Anatomy of a system accident: the crash of Avianca Flight 052. Helmreich, R L The International journal of aviation psychology, 4(3):265--84, January, 1994.
Anatomy of a system accident: the crash of Avianca Flight 052. [link]Paper  doi  abstract   bibtex   
On January 25, 1990, Avianca Flight 052 crashed after running out of fuel following a missed approach to New York's John F. Kennedy Airport. Weather was poor on the East Coast of the United States that day, and the flight had experienced several holding patterns enroute from Medellín, Colombia, to New York. The accident is analyzed in terms of Helmreich and Foushee's (1993) model of crew performance and Reason's (1990) model of latent pathogens in system operations.
@article{Helmreich1994,
abstract = {On January 25, 1990, Avianca Flight 052 crashed after running out of fuel following a missed approach to New York's John F. Kennedy Airport.  Weather was poor on the East Coast of the United States that day, and the flight had experienced several holding patterns enroute from Medell\'{\i}n, Colombia, to New York.  The accident is analyzed in terms of Helmreich and Foushee's (1993) model of crew performance and Reason's (1990) model of latent pathogens in system operations.},
author = {Helmreich, R L},
doi = {10.1207/s15327108ijap0403\_4},
issn = {1050-8414},
journal = {The International journal of aviation psychology},
keywords = {Accidents, Aviation,Accidents, Aviation: prevention \& control,Aerospace Medicine,Aircraft,Behavior,Colombia,Communication,Cultural Characteristics,Group Processes,Human Engineering,Humans,Inservice Training,Safety Management,Safety Management: methods,Task Performance and Analysis},
month = jan,
number = {3},
pages = {265--84},
pmid = {11539174},
title = {{Anatomy of a system accident:  the crash of Avianca Flight 052.}},
url = {http://www.ncbi.nlm.nih.gov/pubmed/11539174},
volume = {4},
year = {1994}
}

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