Speaker

Shawn Pruchnicki

Captain Shawn Pruchnicki was director of human factors for the Air Line Pilots Association and is now a human performance specialist.

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Themes

The Lexington air disaster

Key Messages

  • What may seem an extremely basic error can be often be due to error cascading of smaller incidents leading to a major failure.
  • Do not make snap judgements with ‘hindsight bias’ following adverse events until you have reviewed all the facts.

Video Description

The Lexington air disaster

Mr Pruchnicki describes the Lexington air disaster and how it was analysed. They found numerous small problems that contributed to the accident rather than a “smoking gun”. He tried to work out why the crew made the decisions that led to the crew taking off on the wrong runway, rather than what they “failed” to do.

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