Learning from Disaster
summary
1978 United Flight 173 runs out of fuel after a 47‑minute hold, killing 10 and triggering adoption of crew resource management to force clear delegation and assertive cross‑checks; 2009 Air France 447 loses pitot tube airspeed input, enters alternate law and stalls, killing 228 and leading to replacement pitot models and new manual high‑altitude training (recorders found in 2011); 2018–19 Lion Air and Ethiopian crashes expose MCAS single‑sensor failure and force redesign and certification changes; 2008 Qantas 72 suffers a mislabelled 19‑bit data spike, causing sudden nose‑down commands and 119 injuries, prompting stricter data validation and testing.
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chapters (11)
- 0:00Start
- 1:40United Airlines Flight 173
- 17:22Corrective Course of Action
- 28:50Victim Identification
- 31:33Lion Air Flight 610
- 39:06Quick Fixes to a Failing Culture
- 39:47A Culture of Discipline
- 40:16The Delicate Art of Bureaucracy
- 41:26Why Understanding Risk Is Important
- 43:5619-Bit Data Section
- 52:49What Made the Failure of the Iou Dangerous
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