Department of Electronic Engineering Lecture
John Guest, a retired British Airways training captain, talks about the Kegworth Boeing 737 crash (1989). He reveals what happened on the flight, the lessons that were learned and the changes to airline training and practice which followed. The wider importance of an “error chain” analysis of accidents, human factors training in safety critical environments and the problem of “authority gradients” are discussed. These concepts have lessons for all organisations, whether safety critical or not. The talk presents a brief introduction into measures which can be taken to mitigate their malign affects, including incident reporting, a no blame culture and requiring senior employees to encourage challenge. There might be particular lessons for hierarchical organisations, notably the church, the military, the medical profession, and even some parts of academia and government.