Literatuur

Diepe analyse

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Benjamin Berman et al

“Although no airline we are familiar with would knowingly compromise safety to cut costs, it is extremely difficult to know a priori whether changes designed to improve efficiency of operations and training will affect safety.” (p. 1)

“It is important to recognize that the scripts provided by FOMs [Flight Operations Manuals] represent an ideal. Actual line operations present complex situations not fully provided for by FOMs (…) and the norms of actual line operations sometimes diverge from the ideal because of sociocultural, professional, and organizational factors.” (p. 2)

“Many people assume that if an expert in some domain (aviation, medicine, or any other) makes an error, this is evidence of lack of skill, vigilance, or conscientiousness. This assumption is both simplistic and wrong” (p. 4)

“Computers have extremely limited capability for dealing with unexpected and novel situations, for interpreting ambiguous and sometimes conflicting information, and for making appropriate value judgments in the face of competing goals. These functions are appropriately reserved for human experts.” (p. 4)

“Experts typically do what seems reasonable to them at the time, given their understanding of the circumstances.” (p. 6)

“[W]e must start by recognizing that it is unrealistic to assume that humans will perform any task with perfect reliability, no matter how important the task.” (p. 292)

“It is natural for society to want to understand what caused an accident, and because crew actions and omissions are often proximal to the final events of an accident it is tempting to identify those actions and omissions as 'the probable cause'.” (p. 300)

“It is highly unrealistic to expect crews - no matter how well trained, skilled, and conscientious  – to never make errors. " (p. 302)

“An airline can reduce the risk of an accident by establishing (and enforcing) extremely conservative criteria but at the cost of expensive fuel, delays, and passenger dissatisfaction in an extraordinarily competitive market.” (p.308)

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Christopher Chabris / Daniel Simons

"The structure of the human body doesn’t permit us to fly, just as the structure of the mind doesn’t permit us to consciously perceive everything around us." (p. 39)

"This is the illusion of memory at work: most people firmly believe that they will notice unexpected changes, when in fact almost nobody does." (p. 55)

"In other experiments, Kruger and Dunning showed that this unskilled-and-unaware effect can be measured in many areas besides humor, including logical reasoning and English grammar skills. It probably applies to any area of human experience." (p. 89)

"We tend to think that our good performances reflect our superior abilities, while our mistakes are “accidental,” “inadvertent,” or a result of circumstances beyond our control, and we do our best to ignore evidence that contradicts these conclusions." (p. 90)

"Almost every report claiming to identify the key factors that lead companies to succeed (…) errs by considering onIy companies that succeeded and then analyzing what they did. They don’t look at whether other companies did those same things and failed." (p. 171)

"You’ll recognize that the confidence people express often reflects their personalities rather than their knowledge, memory, or ability." (p.241)

"(…) and new ways of understanding why people act the way they do. Often, it’s not because of stupidity, arrogance, ignorance, or lack of focus. It’s because of the everyday illusions that affect us all. Our final hope is that you will always consider this possibility before you jump to a harsher conclusion." (p. 242)

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Sidney Dekker

"When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure." (back cover)

"The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production)." (back cover)

"It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language." (back cover)