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This sounds quite interesting. Any books you could recommend on the "pilot error" topic.


When I was getting my pilots license I used to read accident reports from Canada's Transportation Safety Board [1]. I'm sure the NTSB (America's version) has similar calibre reports [2].

There is also Cockpit Resource Management [3] which addresses the human factor in great detail (how people work with each other, and how prepared are people).

In general what you learn from reading these things is that its rarely one big error or issue - but many small things leading to the failure event.

1 - https://www.tsb.gc.ca/eng/rapports-reports/aviation/index.ht...

2 - https://www.ntsb.gov/investigations/AccidentReports/Pages/Ac...

3 - https://en.wikipedia.org/wiki/Crew_resource_management


The old "they write the right stuff" essay on the On-Board Shuttle Group also talked about this mindset of errors getting through the process as being first and foremost a problem with the process to be examined in detail and fixed.


"The Checklist Manifesto", by Atul Gawande, dives into how they looked at other sectors such as aviation to improve healthcare systems, reduce infections, etc. Interesting book.


Just bought the audiobook. About to give it a listen now. Thanks.


The Design of Everyday Things by Donald A. Norman. He covers pilot error a lot in this book in how it falls back on design and usability. Very interesting read.


Not sure about books, but the NTSB generally seems to adopt the philosophy of not trying to assign blame, but instead to figure out what happened, and try to determine what can be changed to prevent this same issue from happening again.

Of course trying to assign blame is human nature, so the reports are not always completely neutral. When I read the actual NTSB report for Sullenburger's "Miracle on the Hudson", I was forced to conclude that while there were some things that the pilots could in theory have done better, given the pilots training and documented procedures, they honestly did better than could reasonably be expected. I am nearly certain that some of the wording in the report was carefully chosen to lead one to this conclusion, despite still pointing out the places where the pilots actions were suboptimal (and thus appearing facially neutral).

The "what can we do to avoid this ever happing again?" attitude applies to real air transit accident reports. Sadly many general aviation accident reports really do just become "pilot error".


This is also one of the core tenets of SRE. The chapter on blameless postmortems is quite nice: https://landing.google.com/sre/sre-book/chapters/postmortem-...


Anything by Sidney Dekker. https://sidneydekker.com/books/ I would start by The Field Guide to Unterstanding 'Human Error'. It's very approachable and gives you a solid understanding of the field.


Not sure about books but look up the Swiss cheese model. It is widely used approach and not only in aviation. Most industrial accidents and incidents are investigated with this in mind.


As a GA pilot I know people that had accidents with planes and I know that in most cases what is the the official report and what really happened are not the same, so any book would have to rely on inaccurate or unreal data. For airliners it is easy because there are flight recorders, for GA it is still a bit of Wild West.


It's part of the Human Performance subject in getting an ATPL (airline license), it was one of the subjects that I didn't hate as much when studying. You can probably just buy the book on Amazon, they're quite accessible.




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