Error-proofing Lubrication

The world’s worst air disaster occurred in 1977 on the Spanish Island of Tenerife. The accident which claimed the lives of 583 people onboard two Boeing 747s was attributed to a series of unfortunate coincidences and mistakes, the most heinous being the decision by one of the pilots to initiate an unauthorized takeoff on a runway where the second plane was taxiing. As a result of this accident, new rules were established for cockpit communication between pilot and first officer, which until 1977, allowed for a dogmatic style of command where the second officer was not permitted to challenge or second-guess any pilot decision. This, along with other changes, was immediately implemented in an attempt to prevent a similar catastrophe from recurring.

 

Error-proofing Lubrication