Slide 14
Slide 14 text
Lessons Learned
● Unclear communications between teams.
● Junior team member noticed the mistake, but was ignored.
● If you do not have observability, you should not make decisions.
● Cockpit procedures were also changed after the accident.
● The course of action was later expanded into what is known today as crew
resource management (CRM), which states that all pilots, no matter how
experienced they are, are allowed to contradict each other.
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