The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents

Customer Reviews:

Breathes life into accident reports.......2007-08-10

The authors have applied insights from cognitive psychology to nineteen flight-crew-related accidents. In place of the dry narratives of accident reports, we are presented with compelling three-dimensional accounts in which pilots are routinely faced with time pressure, the need to make judgments under uncertainty, and rare but potentially lethal system failures. In examining each accident, the authors attempt to reconstruct the mindset of the pilots, and place the actions of the crew in the context of the flow of events. In contrast to other reviews of accidents, the authors avoid the phrase "the pilots should have...". Instead we are gently encouraged to understand how skilled and professional operators can come to make mistakes in circumstances that are unforgiving of error.

Through the lens of cognitive psychology, the aviation industry becomes a massive human performance laboratory, in which hapless operators are faced with situations and problems produced not by experimenters, but by the complexities of the system of which they are a part. The authors take pains to counter the common presumption that catastrophic accidents must somehow result from extreme acts of villainy or incompetence. In this book, we repeatedly see how accidents often arise from combinations of everyday problems and situations.

By the end of the book, some fascinating patterns begin to emerge. A surprising number of the accidents involved apparently simple slips and lapses. Additionally, the majority of accidents occurred on approach and landing, and most of the accident flights were running late. The failure to go-around from an un-stabilized approach is a common theme in the accident scenarios.

On a minor note, a few more illustrations and diagrams would have added some variety to the text, and more extensive quotations from cockpit voice recordings may have helped. Overall however, the book provides a useful compendium of case studies that will be of value to industry and academia. Airline training personnel in particular will find much that is useful in this book.

An excellent confluence of aviation and psychology.......2007-05-25

Out of approximately 10 million air carrier flights annually in the US, only about 50 involve a major accident. That may not sound like much, but those accidents consist of events like these: a Continental Airlines flight that landed without its landing gear deployed in Houston; an American Airlines flight that suffered loss of control at 16000 ft.; and another American Airlines flight that hit some trees while attempting to land, the culmination of a series of small, individually insignificant errors. These are some of the examples scrutinized in detail, drawn from a large population of accidents in which human error was a major factor. This book makes fascinating reading - providing pilots and aviation professionals with a new perspective on crew error, and the general public with a new way of looking at the whole aviation system and how safety issues are considered.

The authors dissect these accidents in a way that the airline industry has not attempted in great depth before. Rather than stopping at the facts and a conclusion of "crew error", they ask why highly skilled flight crews, with thousands of hours of flying experience, make mistakes and erroneous judgments with horrifying consequences. The common reaction after an accident is that the crew was not sufficiently skilled, otherwise they would not have made the error. The authors start with a different assumption: they assume that the crew was as good as any other crew that could have been chosen, and from that starting point, their illuminating analyses lead them to consider some very interesting psychological and operational factors that underlie these accidents.

To do this, the authors draw on their expertise on how the human brain works (memory systems and decision-making apparatus) and their complementary expertise on aviation and operations. The authors are all affiliated with NASA; two of the them are research psychologists, one of them was a major investigator with the primary transportation investigative arm of the government, the National Transportation & Safety Board, and all of them have extensive experience with aviation safety.

The book covers 19 accidents, devoting a chapter to each. Two additional chapters at the end provide statistics and a summary of the common themes and factors the authors uncover as contributing to these accidents, along with some prescription of possible countermeasures. When an airplane is involved in an accident, the National Transportation & Safety Board performs thorough investigations - these include interviews with the survivors, forensic evidence, the data from the black box, etc. The investigators produce a report that lays out the facts and their judgment of the causes of the accident.

The studies in this book take these reports as a starting point, and go down paths that the NTSB never ventures (their charter does not permit that). Each of the accident chapters is constructed to provide first a factual recount of the event and the NTSB conclusions. From here the authors identify the most significant events leading up to the accident, and for each event in turn, provide an analysis that mixes operational knowledge with cognitive functioning.

This is not a Michael Crichton thriller, but those familiar with aviation will easily be able to follow the details as they are stated in factual, non-judgmental manner, and will see into the deep causes of the events that led up to the final accident. Readers who are already familiar with aviation terminology will find the book easy to read (do you know what "LOFT" and "windshear" mean?). At the end, the very helpful glossary covers both aviation and cognitive psychology terms so that readers of all levels of industry expertise or interest can enjoy this useful study.

The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents.......2007-05-13

It reads like a thesis but is full of great analyses beyond the "official" accident reports. Most aircraft accidents are attributed to "pilot error." Here, the authors dissect the human factors in several accidents and delve into human fallibilities and technical traps which make us all prone to error.

The value of rethinking.......2007-05-04

Air travel has become remarkably safe as a result of advances in equipment systems, operating procedures and training. Each year, flight crews deal skilfully with sub-optimal systems and unexpected situations during the course of around 17 million flights world-wide. Yet airlines operate in a highly competitive market with pressures to deliver unprecedented levels of efficiency, so it is now more important than ever to understand what makes the air transport system vulnerable to failure. Since most aviation accidents have been attributed to deficiencies in the performance of flight crews, it is particularly important to understand what makes pilots vulnerable to error.

In this outstanding and original book, the authors argue that human skill and vulnerability to error are closely linked: errors occur because flight crews are expected to perform tasks at which perfect reliability is not possible - either for humans or machines. The authors show that the presence and interaction of factors contributing to error is probabilistic rather than deterministic. Accidents are rarely caused by a single factor, but rather by the complex interaction of many factors that combine in ways driven largely by chance. The authors argue that small, random variations in the presence and timing of those factors can drastically increase the probability of pilots making errors leading to an accident.

Consequently, it is crucial to understand the nature of vulnerability to error in order to reduce that vulnerability. While it is not always possible to determine exactly why accident crews did what they did, the authors demonstrate that it is possible to understand the types of error to which pilots are vulnerable - and to understand the interplay of various factors contributing to that vulnerability. The central questions posed in this book are: why do highly skilled professional pilots make errors, with consequences that are sometimes fatal to themselves and to their passengers? And how should we understand the role of these errors in accidents in seeking to prevent future accidents? The authors apply scientific knowledge of the nature of skilled performance of humans performing complex tasks to address these questions.

The book reviews the 19 major accidents in US airline operations during the period 1991-2000 in which crew errors played a central role, as defined by the US National Transportation Safety Board (NTSB), based on the NTSB reports and associated documents. While the NTSB must determine the probable cause of each specific accident, the authors take a different approach: would other pilots be vulnerable to making the kinds of errors made by the accident crew and, if so, why? This original approach reveals factors that make all pilots vulnerable to specific types of error in certain situations. In adopting this approach, the authors challenge the assumption that, if expert pilots make errors, this is evidence of their lack of skill, vigilance or conscientiousness. Instead, the authors emphasise the interactions of subtle variations in task demands, incomplete information available to pilots, and the inherent nature of skilled performance. The authors go beyond accident investigation, therefore, to explore the common themes and `deep structure' underlying the accidents.

In addition to the stand-alone accident chapters, the authors provide a statistical summary chapter that extends an earlier study by the NTSB and that reviews accident data for a longer period (1978-2001). In the final chapter, the authors identify the main themes and implications of their study, suggesting specific ways to improve aviation safety. Many issues are raised, including the significance of crew familiarity, crew fatigue, first officer experience levels, unstabilized approaches, plan continuation bias, misleading or absent cues, and monitoring/challenging errors. The authors reframe these airline accidents as `system accidents' resulting from the lack of adequate information provided to crews, the inherent difficulties of assessing ambiguous situations, and the less than extremely conservative guidance given to pilots by the air transport industry.

Overall, this is an excellent and innovative text which reflects the authors' original approach to airline safety. The book is outstanding in its identification of common themes that run deeper than in previous analyses of aviation safety, and the final chapter contains clear, pragmatic guidance to the air transport industry and to researchers. In the final sections of the book, the authors sum up the central challenge faced by the industry in reducing vulnerability to error: pilots should be given more information, better interfaces and clearer decision-making guidance - backed up by prioritising adherence to that guidance over commercial pressures such as on-time performance.

The book will be informative for diverse readers in the air transport industry, including operational staff, researchers, safety analysts, accident investigators, designers of systems and procedures, training providers and students. Given the nature and scope of their study, the authors have focused on the US context, yet their approach could valuably be applied to other parts of the world: a comparable study for Europe, for instance, would be revealing. Their approach could also be extended to other parts of the air transport system, such as air traffic management, where the performance of skilled experts is also implicated in some airline accidents.

The main significance of this book is in its re-framing of the causes of airline accidents: the authors argue that, if we must continue to conceive of airline accidents in terms of deficiency, then that deficiency should be attributed to the overall air transport system. Such an approach can contribute to aviation safety by providing a foundation for improving equipment, training, procedures and organisational policy. In so doing, it is possible to reduce the frequency of `system accidents' and to devise adequate protection against the types of errors to which many, if not all, pilots - as well as many other experts - are vulnerable.

Biological Exposure Values for Occupational Toxicants and Carcinogens, Volume 1, Critical Data Evaluation for BAT and EKA Values

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Biological Exposure Values for Occupational Toxicants and Carcinogens, Volume 1, Critical Data Evaluation for BAT and EKA Values
Dietrich Henschler
Manufacturer: Wiley-VCH
ProductGroup: Book
Binding: Hardcover

Industrial & Technical | Chemistry | Science | Subjects | Books

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ASIN: 3527270329

Book Description

The term BAT value describes the greatest permissible quantity of a working material in human biological media. BAT values are derived by monitoring the absorbed concentration of an occupational toxicant in body fluids and by the subsequent determination of a limit at which mo more adverse effects to the worker's health are observed. Therefore BAT values protect the individual against chemically caused diseases; they are required for medical health surveillance.

This is the first Volume in a series of industrial
health/toxicological justifications of BAT values. It is a necessary supplement to the 'Occupational Toxicants' which document and justify the limit setting process of MAK values (maximum concentrations at the workplace). 51 BAT values for 35 substances or groups of substances have been evaluated.

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Can be bought new for $35 at National Motorists Assoc. Web
A must have book for anyone concerned for auto safety
American Autobahn
If you drive on the interstate, you must read this book!
An Intelligent Plan That Would Work if Implemented

American Autobahn
Mark Rask
Manufacturer: Vanguard Non-Fiction Books
ProductGroup: Book
Binding: Hardcover

General | Transportation | Nonfiction | Subjects | Books

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Safety & First Aid | Health, Mind & Body | Subjects | Books
ASIN: 0966913604

Book Description

The automotive enthusiast's "Bible" for fast-and-safe driving. A first-of-its-kind expose that shows how Germany, since 1970, has reduced the number of people killed on its roadways by almost 70 percent--while traffic moves on its Autobahn freeway system at 100 mph. The book also takes an in-depth look at America's failed attempts, since 1940, to slow down "speeders" and save lives. A fascinating comparison between two radically different philosophies of safety, and how Germany's high-speed approach could be adapted to American's interstate. Included are eight color illustrations of tomorrow's cars, trucks and motorcycles by world-famous automotive artist, Mark Stehrenberger. Many rare photos, ads and graphics. Fast-paced, informative and, yes, fun, this is the book the federal government and insurance industry don't want you to read! Hardbound, 61/4" X 91/4", 312 pages, 55 black & white photos, 8 color.

Customer Reviews:

Can be bought new for $35 at National Motorists Assoc. Web.......2004-02-15

Excellent reading for those who suffer on America's HWY systems.

How things could be if we didn't coddle the incompetent!

A must have book for anyone concerned for auto safety.......2002-11-17

This is a very well written book with prooving statistics - a very unbiased and credible book on the reasons behind America's irresponsibility and negligence for auto safety - and why we have failed in lowering death rates due to high-speed related accidents. This book explains in great detail the German philosophy of road safety and accident prevention that has gone to provide the world's safest automobiles and high speed auto networks. I'd recommend this book for a teenager beginning to drive so that he/she breaks the typical American-attitude towards auto safety.

American Autobahn.......2001-07-16

This book tracks the history of our interstate and the autobahn highways and presents compelling statistics that prove that our system of draconian speed enforcement plus artificially low speed limits is not working. There are numerous charts and graphs that show that Germany's fatality rate on the Autobahn has been consistently below ours for a number of years, while speeds have been rising on both systems. The author points out how and why we should be trying to generate support for upgrades to our highway system while conducting an experiment to increase and/or remove speed limits on our less crowded interstates.

If you drive on the interstate, you must read this book!.......2001-06-14

This book should be required reading for all current and future interstate drivers. Rask provides a compelling argument as to why our interstate system is failing us, and what we can do to change it. If I could afford it, I would send a copy to each of my Congressmen.

An Intelligent Plan That Would Work if Implemented.......2001-03-27

With excellent illustrations by Mark Stehrenberger, Mark Rask tells the history of the Interstate Highway system in the U.S. and our silly obsession of "Speed kills," despite all proof it's stupidity that kills. Then he gives the history of the German Autobahn system and how the Germans, rather than try to restrict speed everywhere, made the roads, the drivers, and the cars safer. All three are models. Their fatality rate went down 70% because of their combined efforts (and a cultural abhorrence to drinking and driving). He explains precisely how the autobahns are designed safer, their drivers are better trained, and how safe their cars are. Then he goes on to give a plan for taking the best of their system and Americanizing it. It's a good read. I recommend it. I enjoyed it. Several people to whom I've recommended it have told me they enjoyed it, and it reveals some truths you won't discover if you listen to the U.S. Safety Establishment.

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Two interesting topics
The Limits of Readability would be more accurate
Sagan and organizational theory
Highly recommendable book on systems safety.
Eceeelnt discussion on controlling nuclear weapons

The Limits of Safety
Scott Sagan
Manufacturer: Princeton University Press
ProductGroup: Book
Binding: Paperback

General | Military | History | Subjects | Books

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ASIN: 0691021015

Book Description

Environmental tragedies such as Chernobyl and the Exxon Valdez remind us that catastrophic accidents are always possible in a world full of hazardous technologies. Yet, the apparent excellent safety record with nuclear weapons has led scholars, policy-makers, and the public alike to believe that nuclear arsenals can serve as a secure deterrent for the foreseeable future. In this provocative book, Scott Sagan challenges such optimism. Sagan's research into formerly classified archives penetrates the veil of safety that has surrounded U.S. nuclear weapons and reveals a hidden history of frightening "close calls" to disaster.

Customer Reviews:

Two interesting topics.......2003-03-31

Sagan examines the safety record of the Strategic Air Command, the organization responsible for US land- and air-based nuclear weapons, as a way to contrast two different theories about how organizations that deal with high-risk technologies avoid accidents. The more optimistic theory is known as the High Reliability theory: it holds that organizations can hope to prevent all accidents through a strong organizational emphasis on safety; redundancy (in both the technological and human senses); and a commitment to organizational learning. The pessimistic theory is known as the Normal Accidents theory: it holds that organizations are driven by internal politics, that greater levels of redundancy can actually cause accidents, and that what Sagan calls "tight coupling" between processes can cause small mishaps to rapidly escalate into major disasters. The book is well-written and about as riveting as a book on this topic can be, and I learned a lot about US nuclear weapons history. (It's amazing we survived the Cold War.) Sagan is considerably hampered in his choice of topic - you have to assume that more skeletons are hiding in the military's top-secret closet - and as Sagan admits, it is difficult to draw any conclusions regarding safety from near-accidents. (Is a near accident evidence that redundancy in the system works as designed, or is it evidence that, under slightly different circumstances, a major disaster could have happened? Sagan favors the latter interpretation.) Thought-provoking.

The Limits of Readability would be more accurate.......2002-02-20

I purchased this book because I have a great interest in the most deadly of ordnance; the atomic bomb. I was hoping for a book that was slanted towards the actual weapons system. Instead, this book is a treatment of how the concept of safety applies to the Nuclear Weapons Program.

While interesting, and well researched, it was a bit of a strrrretch to read at times. If you are into nukes, you'll be fatigued. If you are an OSHA or Site Safety Guy, this book will be a good reference for your work.

Sagan and organizational theory.......2001-11-14

With nuclear technology entering its seventh decade of use, one may have surmised that issues surrounding the safety of this technology would be well agreed upon with a consensus view of the potential pitfalls involved in nuclear security. However, as Scott Sagan reveals in his book called The Limits of Safety, the problems surrounding atomic safety lie not in the components of the system, but in the paradigm that structures our view of atomic safety. By highlighting near misses from the Cuban Missile Crisis and other events, Sagan uncovers how close the world may have come to accidental detonations and possible accidental nuclear war. Sagan interprets these events from two different perspectives concerning organizational learning: the high reliability organization learning theory (an optimistic view of nuclear safety) and the normal accident theory (more pessimistic). These perspectives present and interpret the near misses in totally different lights, as this analysis of the competing paradigms of nuclear safety is the essence of his work. Based on his research, Sagan was forced to change his prior view of nuclear safety and concludes with recommendations to make nuclear weapon systems more secure.
High reliability theory holds that accidents can be prevented through good organizational design, that safety is the priority organizational objective (development of a "high reliability culture"), that redundancy enhances safety, and that trial-and-error learning from near misses can be effective (implying use of sophisticated forms of trial-and-error organizational theory). Essentially, this model argues that accidents can be avoided given the proper set of precautions and organizational learning. Given that there have never been any (known) unauthorized detonations of nuclear weapons, one may conclude that the high reliability model accurately describes the realities of nuclear safety thus far. However, the weaknesses in such a perspective concerning nuclear safety do not become evident until examining normal accidents theory.
Greatly influenced by Charles Perrow's book called Normal Accidents and by integrating these ideas with the garbage can theory of organizational behavior creates Sagan's normal accident model of organizations. This view holds that accidents are inevitable in complex and tightly coupled systems, that safety is only one of a number of competing objectives, that redundancy increases the complexity and opaqueness of the system and thereby may compromise safety (indeed the provocative view that redundancy may even cause accidents) and that political infighting is a serious barrier to organizational learning. This model perceives organizations as rational actors capable of mistakes, and it emphasizes the structural and political nature of nuclear safety.
The weaknesses of high reliability theory then become more evident once the alternative is presented. First, inconsistent goals and conflicting interests are inherent in organizations, and this can increase the probability of accidents. Second, redundancies in features of nuclear safety can actually increase risks. This is due to systems that are not independent of each other interacting in unexpected ways. Also, the overlap in systems caused by redundancy makes mistakes less visible. Thus, organizations are unlikely to adjust for mistakes that they do not perceive exist. Third, some accidents cannot be anticipated. Hence, effective contingency plans may not exist. Lastly, the politics of nuclear safety places restrictions on organizational learning. As Sagan asserts, blame for accidents is often misplaced at low levels in the organization (operator error, for example) instead of addressing problems inherent in the system of nuclear oversight. Sagan is also quick to point out that high reliability theory implies a full disclosure of high-risk (or near miss) nuclear incidents that does not exist. He indicates that much of the information he obtained via the Freedom of Information Act is only a partial account of nuclear accidents in the U.S. military.
After having laid out the propositions and assumptions of these competing theories, the books addresses the basic question of which of the two theories is more accurate drawing from analysis of the Cuban missile crisis, the B-52 Thule bomber crash, the performance of US missile warning systems (specifically in false alarms in 1979 and 1980), and others. This selection of case studies is a tough test for normal accident theory. One would expect that the all-pervasive and dreadful consequences of an accidental nuclear war would make nuclear weapons safety a first priority at all levels of all involved organizations. The reader is left un-reassured of this. Scott Sagan provides numerous examples of political infighting, of organized cover-up, of normalization of errors, of reinterpretation of failure as success, and of conflicts over parochial interests that are serious barriers to organization learning. This is unsettling reading, not the least because Sagan's account is limited to U.S. experience only; the Kremlin does not permit access to its records on nuclear safety.
The research presented by Sagan has major implications for the effectiveness of the theory of deterrence to prevent (accidental) nuclear war. To quote the author, "In light of evidence presented here, the belief that nuclear deterrence can prevent nuclear war under all circumstances should be seen as exactly that: a belief, not a fact" (262). Sagan then listed reasons to doubt the effectiveness of intended deterrence. First, even at the height of the Cold War, the US and USSR did not easily control their nuclear forces. Thus problems in command-and-control operations still exist today. Second, given that the superpowers were unable to structure their nuclear systems in such a way to make accidents impossible, states that will develop nuclear weapons in the future are sure to be less stable than the US and USSR were in their nuclear infancy, thus making nuclear accidents more likely. Third, emerging nuclear powers are under pressing security threats and may perceive the need to keep their nuclear arsenals on high state of readiness. Although the book was written before 1998, the emergence of India and Pakistan as nuclear powers represents these threats to intended nuclear deterrence.

Highly recommendable book on systems safety........2001-05-04

Scott Sagan examines the safety of the US nuclear weapons command organisations employing two opposing theoretical lines of thought: the so-called high reliability school and the normal accident school.

High reliability theory holds that accidents can be prevented through good organisational design, that safety is the priority organisational objective, that redundancy enhances safety, and that trial-and-error learning from near-misses can be effective. The contrasting perspective is that of normal accident theory in which the author combines Charles Perrow's system accident theory with theories of bounded rationality, specifically the garbage can theory of organisational behaviour by Cohen, March and Olsen. This view holds that accidents are inevitable in complex and tightly coupled systems, that safety is only one of a number of competing objectives, that redundancy increases the complexity and opaqueness of the system and thereby may compromise safety (indeed the provocative view that redundancy may even cause accidents) and that political infighting is a serious barrier to organisational learning.

After having laid out the propositions and assumptions of these competing theories, the books addresses the basic question of which of the two theories is more accurate drawing from analysis of the Cuban missile crisis, the B52 Thule bomber crash, the performance of US missile warning systems, and others. This selection of case studies is a tough test for normal accident theory. One would expect that the all-pervasive and dreadful consequences of an accidental nuclear war would make nuclear weapons safety a first priority at all levels of all involved organisations. The reader is left un-reassured of this. Scott Sagan provides numerous examples of political infighting, of organised cover-up, of normalisation of errors, of reinterpretation of failure as success, and of conflicts over parochial interests which are serious barriers to organisation learning. This is unpleasant reading, not the least because Sagan's account is limited to US experience only.

The implications of the issues raised in this book go far beyond nuclear weapons safety. Arguments are carefully reasoned, conclusions balanced, the style of writing clear, yet all details appear meticulously researched. 5 stars.

Eceeelnt discussion on controlling nuclear weapons.......2000-02-03

This important and informative book by Dr. Sagan should be must reading for all U.S. policymakers, the leadership of other nuclear nations and those aspiring to be so. His arugments about the dangers involved in trying to prevent accidents with nuclear weapons is eye-opening and gives one reason for concern. New nuclear nations lack the technical infrastructure enjoyed by the West and Russia. This increases the risk of the unintended use of nuclear weapons. The clear message of the book is that we must move more forcefully in reducing the nuclear threat in all its diemsnions.

This ia a must read for all Christians concerned peacemaking that goes beyond mere sentiment.

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Limits to human control over risky technology

Organization at the Limit: Lessons from the Columbia Disaster
William H. Starbuck (Editor)
Manufacturer: Blackwell Publishing Limited
ProductGroup: Book
Binding: Hardcover

General | Business & Investing | Subjects | Books
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Shouldering Risks: The Culture of Control in the Nuclear Power Industry

Resilience Engineering: Concepts And Precepts

The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA

Managing the Unexpected: Assuring High Performance in an Age of Complexity

Managing the Risks of Organizational Accidents

ASIN: 140513108X

Book Description

Tragedies like the Columbia disaster are distressing reminders that things can go wrong in large, highly regarded organizations. Although we embrace new technologies eagerly, we are reluctant to accept the risks of innovation. Moreover, some technologies and organizations may be too complex to control effectively. What makes some organizations more prone to accidents? Do the very measures taken to increase safety contribute to accidents? Can societies, organizations, and individuals learn from failures and reduce risks?Against this backdrop, Professors William H. Starbuck of New York University and Moshe Farjoun of York University have invited diverse experts to contribute insights about the Columbia accident and the organizational lessons it suggests. This book thus presents many viewpoints on the complex behavioral factors that led to disaster.

Customer Reviews:

Limits to human control over risky technology.......2006-10-29

After two horrible disasters, do you think that NASA has learned from its mistakes, and that it will never happen again? If so, you need to read this book! In 18 well-written chapters, the editors have assembled a set of experts on organizations and disasters to analyze lessons from the Columbia disaster. Because the Challenger disaster foreshadowed many of the problems that subsequently turned up in official investigations of the Columbia disaster, it also figures heavily in this edited book. The authors demonstrate the analytic power of an historically informed organizational analysis of a large governmental agency under strong political pressure to produce results with limited resources.

Two points in particular caught my eye. First, after the Challenger disaster, NASA was supposedly reorganized to place greater emphasis on safety. However, because the organization began to define the space exploration program as a problem of meeting production goals and deadlines, "safety" never achieved the priority in the organization than it deserved. Instead of seeing the space shuttle program as a developmental one, exploring the risky frontier of technological knowledge, NASA officials treated it like any other flight program. Second, as anomalies continued to crop up after flights, engineers and officials began to think about deviations from acceptable practices and outcomes as "normal." As deviation was normalized, unusual events were taken for granted and didn't provoke the kind of response than one would expect from life threatening occurrences.

Scholars interested in organization studies, organizational learning, systems theory, and other academic disciplines will learn much from this book. However, one can also hope that public officials will take its lessons to heart and look more closely at the design of other risky systems that are operating close to the limits of our scientific knowledge.

Almost A Revolution: Mental Health Law and the Limits of Change

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Almost A Revolution: Mental Health Law and the Limits of Change
PAUL APPELBAUM
Manufacturer: Oxford University Press
ProductGroup: Book
Binding: Hardcover

Legal System | Government | Nonfiction | Subjects | Books

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ASIN: 0195068807

Book Description

Doubts about the reality of mental illness and the benefits of psychiatric treatment helped foment a revolution in the law's attitude toward mental disorders over the last 25 years. Legal reformers pushed for laws to make it more difficult to hospitalize and treat people with mental illness, and easier to punish them when they committed criminal acts. Advocates of reform promised vast changes in how our society deals with the mentally ill; opponents warily predicted chaos and mass suffering. Now, with the tide of reform ebbing, Paul Appelbaum examines what these changes have wrought. The message emerging from his careful review is a surprising one: less has changed than almost anyone predicted. When the law gets in the way of commonsense beliefs about the need to treat serious mental illness, it is often put aside. Judges, lawyers, mental health professionals, family members, and the general public collaborate in fashioning an extra-legal process to accomplish what they think is fair for persons with mental illness. Appelbaum demonstrates this thesis in analyses of four of the most important reforms in mental health law over the past two decades: involuntary hospitalization, liability of professionals for violent acts committed by their patients, the right to refuse treatment, and the insanity defense. This timely and important work will inform and enlighten the debate about mental health law and its implications and consequences. The book will be essential for psychiatrists and other mental health professionals, lawyers, and all those concerned with our policies toward people with mental illness.

1993-1994 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

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1993-1994 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

Manufacturer: American Conference of Governmental Industria
ProductGroup: Book
Binding: Paperback

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ASIN: 1882417038

1994-1995 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

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1994-1995 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

Manufacturer: American Conference of Governmental Industria
ProductGroup: Book
Binding: Paperback

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ASIN: 1882417062

1999 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

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1999 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices

Manufacturer: Amer Conf of Governmental
ProductGroup: Book
Binding: Spiral-bound

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ASIN: 1882417321

2000 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indice

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2000 TLVs and BEIs

2000 Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indice
American Conference of Governmental Industrial Hygienists
Manufacturer: Amer Conf of Governmental
ProductGroup: Book
Binding: Spiral-bound

General & Reference | Chemistry | Science | Subjects | Books

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ASIN: 1882417364

Customer Reviews:

2000 TLVs and BEIs.......2000-11-01

The information of this pocket-size publication is used world-wide as a guide for evaluation and controlling workplace exposures to chemical substances and physical agents. Threshold Limit Value (TLV) occupational exposure guidelines are recommended for more than 700 chemical substances and physical agents. There are more than 50 Biological Exposure Indices (BEI) which cover more than 80 chemical substances. Chemical Abstract Service (CAS) registry numbers are listed for each chemical. Introductions to each section and appendices provide philosophical bases and practical recommendations for using TLVs and BEIs.

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