Streetlights and Shadows

I've been reading Gary Klein's new book: Streetlights and Shadows. It's a great, research-based foray into the nature of expertise exercised within the real world. It also doesn't read like an academic paper. You can learn about the pilot who managed to land the "Gimili Glider" when it ran out of jet fuel at 41,000 feet and both engines quit, shutting down the crt displays and hydraulic controls. You can also learn about the nuclear power plant operators who got tired of being written up for not following procedures. So they did. And got written up for "malevolent procedure following" when following procedures put them into an endless loop.

The "Gimili Glider" that Klein discusses was an interesting convergence of a succession of improbable events coupled with an improbable expertise that saved the day. It reconstructs how a brand new (in 1983) 767 ran out of fuel in mid-flight, You see both a good example of adaptive expertise and a good model for learning from hazards so that one can make changes to prevent them. The steps for hazards control involve investigating exactly what occurred, determining the failures of knowledge, procedure, or equipment that led to the failure, and implementing changes to minimize the likelihood of future such events. When people talk about hazards, but I don't see that series of conceptual links, then I know they have no actual concept of hazard mitigation.