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As aircraft have become more reliable, humans have played a progressively more important causal role in aviation accidents. Consequently, a growing number of aviation organizations are tasking their safety personnel with developing accident investigation and other safety programs to address the highly complex and often nebulous issue of human error. Yet, many safety professionals are illequipped to perform these new duties. The purpose of the present book is to remedy this situation by presenting a comprehensive, userfriendly framework to assist practitioners in effectively investigating and analyzing human error in aviation. Coined the Human Factors Analysis and Classification System (HFACS), its framework is based on James Reason's (1990) well-known \"Swiss cheese\" model of accident causation. In essence, HFACS bridges the gap between theory and practice in a way that helps improve both the quantity and quality of information gathered in aviation accidents and incidents. The HFACS framework was originally developed for, and subsequently adopted by, the U.S. Navy/Marine Corps as an accident investigation and data analysis tool. The U.S. Army, Air Force, and Coast Guard, as well as other military and civilian aviation organizations around the world are also currently using HFACS to supplement their preexisting accident investigation systems. In addition, HFACS has been taught to literally thousands of students and safety professionals through workshops and courses offered at professional meetings and universities. Indeed, HFACS is now relatively well known within many sectors of aviation and an increasing number of organizations worldwide are interested in exploring its usage. Consequently, the authors currently receive numerous requests for more information about the system on what often seems to be a daily basis.

Why would highly skilled, well-trained pilots make errors that lead to accidents when they had safely completed many thousands of previous flights? The majority of all aviation accidents are attributed primarily to human error, but this is often misinterpreted as evidence of lack of skill, vigilance, or conscientiousness of the pilots. The Limits of Expertise is a fresh look at the causes of pilot error and aviation accidents, arguing that accidents can be understood only in the context of how the overall aviation system operates. The authors analyzed in great depth the 19 major U.S. airline accidents from 1991-2000 in which the National Transportation Safety Board (NTSB) found crew error to be a causal factor. Each accident is reviewed in a separate chapter that examines events and crew actions and explores the cognitive processes in play at each step. The approach is guided by extensive evidence from cognitive psychology that human skill and error are opposite sides of the same coin. The book examines the ways in which competing task demands, ambiguity and organizational pressures interact with cognitive processes to make all experts vulnerable to characteristic forms of error. The final chapter identifies themes cutting across the accidents, discusses the role of chance, criticizes simplistic concepts of causality of accidents, and suggests ways to reduce vulnerability to these catastrophes. The authors' complementary experience allowed a unique approach to the study: accident investigation with the NTSB, cognitive psychology research both in the lab and in the field, enormous first-hand experience of piloting, and application of aviation psychology in both civil and military operations. This combination allowed the authors to examine and explain the domain-specific aspects of aviation operations and to extend advances in basic research in cognition to complex issues of human performance in the real world. Although The Limits of Expertise is directed to aviation operations, the implications are clear for understanding the decision processes, skilled performance and errors of professionals in many domains, including medicine. Dr Dismukes is Chief Scientist for Human Factors in the Human Factors Research & Technology Division at NASA Ames Research Center. His current research addresses cognitive issues involved in the skilled performance of pilots, their ability to manage challenging situations, and their vulnerability to error; prospective memory; and management of attention in concurrent task performance. Captain Berman is a senior research associate at San Jose State University/NASA Ames Research Center and flies the Boeing 737 for a major air carrier. He is the former Chief of Major Investigations of the U.S. National Transportation Board, where he previously led the Operational Factors Division, served as a member of the major accident go-team responsible for flight operations, and managed safety studies. Dr Loukopoulos is a Senior Research Associate at NASA's Human Factors Research and Technology Division. She currently resides in Athens, Greece where she serves as a human factors consultant to the Greek Air Accident Investigation and Safety Board and where she served on the Helios Airways 2005 accident investigation. She also continues her collaboration with NASA through the San Jose State University Foundation. Contents: Foreword; Preface; Introduction; USAir 1016 - windshear encounter; TWA 843 - the power of suggestion; American 1572 - accumulation of small errors; American International 808 - the strobe light that wasn't there; Southwest 1455 - unstabilized approach at Burbank; FedEx 14 - pilot-induced oscillations in the landing flare; Ryan 590 - a minute amount of contamination; Tower 41 - loss of control during a slippery runway takeoff; Continental 1943 - gear-up landing in Houston; American 102 - runway excursion after landing; Continental 795 - high-speed takeoff decision with poor information; USAir 405 - snowy night at LaGuardia; ValuJet 558 - 2 missing words and a hard landing short of the runway; Air Transport International 805 - disorientation, loss of control and the need to intervene; American 903 - loss of control at altitude; Simmons 3641 - over the gates and into forbidden territory; American 1340 - autopilot deviation just prior to landing; Delta 554 - undershot landing at LaGuardia; American 1420 - pressing the approach; Flightcrew-related accident data: comparison of the 1978-1990 and 1991-2001 periods; Converging themes: the deep structure of accidents; Bibliography; Index.

Safety in the Skies: Personnel and Parties in NTSB Aviation Accident Investigations The National Transportation Safety Board (NTSB) bears a significant share of the responsibility for ensuring the safety of domestic and international air travel. The NTSB relies on teamwork to resolve accidents; the parties that participate in an investigation may include manufacturers and operators, as well as the Federal Aviation Administration. This arrangement works well under most circumstances, despite inherent conflicts of interest that may jeopardize, or be perceived to jeopardize, the integrity of the NTSB investigation. The NTSB's ability to lead investigations and to form expert teams is also seriously threatened by a lack of training, equipment, and facilities; by poor control of information; and inadequate aids to project management. Additionally, the need to modernize investigative practices and procedures is particularly acute. In this report, RAND outlines a comprehensive set of recommendations intended to help the NTSB strengthen the party process, create a more expansive statement of causation, modernize investigative procedures, streamline internal operating procedures, better manage resources, maintain a strategic view of staffing, streamline training practices, improve facilities for engineering and training.

\"The gripping true tale of a devastating plane crash, the investigation into its causes, and the race to prevent similar disasters in the future.\"--Provided by publisher.

The International Civil Aviation Organisation (ICAO) audits its Member States for safety oversight and monitors its Effective Implementation (EI). The global average EI was 68.83% in 2019, with 46% audited Member States achieving 75% EI (2022 target); however, an ICAO (2016 – 2018) audit highlighted six Annex 13 non-compliance issues. One issue was that more than 60% of Member States do not have a comprehensive and detailed investigator training program, contributing to many shortcomings that include a lack of essential and volatile evidence preservation, investigation management, investigation reporting and/or safety recommendations. This paper proposes an Expert System that captures knowledge in aircraft accident investigation generated over many years and allows aircraft investigators to share, access and interrogate accumulated knowledge to support the aircraft accident investigation process. The Expert System will improve the evidence analysing timeline, conclusion consistency and accuracy and support the on-the-job “field” training of evidence analysis through self-discovery.

During a flight, pilots must rigorously monitor their flight instruments since it is one of the critical activities that contribute to update their situation awareness. The monitoring is cognitively demanding, but is necessary for timely intervention in the event of a parameter deviation. Many studies have shown that a large part of commercial aviation accidents involved poor cockpit monitoring from the crew. Research in eye-tracking has developed numerous metrics to examine visual strategies in fields such as art viewing, sports, chess, reading, aviation, and space. In this article, we propose to use both basic and advanced eye metrics to study visual information acquisition, gaze dispersion, and gaze patterning among novices and pilots. The experiment involved a group of sixteen certified professional pilots and a group of sixteen novice during a manual landing task scenario performed in a flight simulator. The two groups landed three times with different levels of difficulty (manipulated via a double task paradigm). Compared to novices, professional pilots had a higher perceptual efficiency (more numerous and shorter dwells), a better distribution of attention, an ambient mode of visual attention, and more complex and elaborate visual scanning patterns. We classified pilot’s profiles (novices—experts) by machine learning based on Cosine KNN (K-Nearest Neighbors) using transition matrices. Several eye metrics were also sensitive to the landing difficulty. Our results can benefit the aviation domain by helping to assess the monitoring performance of the crews, improve initial and recurrent training and ultimately reduce incidents, and accidents due to human error.