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Image of the BlackHawk wreckage courtesy of NTSB On the evening of 29 January 2025, a regional jet on approach to Washington Ronald Reagan airport and a US Army Black Hawk helicopter collided over the Potomac River. Sixty-seven people lost their lives. Both aircraft were operating legally with crews who were trained and experienced. Air traffic control was in place and functioning. On paper, this is most definitely what a safe system is supposed to look like. However, it stil

A busy bridge This blog is sort of a sequel to the blog published a fortnight ago. If you haven't read the last blog, you can do so here . If you haven't, don't worry, you can read this one first which is aimed at explicitly discussing BRM. The Story On the evening of 5 October 2024, HMNZS Manawanui  was conducting survey operations off the southern coast of Upolu, Samoa. The ship was operating in challenging conditions, in close proximity to a reef, while attempting to maint

HMNZS Manawanui sinking. Image courtesy of Tom Udall The story On the evening of 5 October 2024, HMNZS Manawanui was conducting survey operations off the southern coast of Upolu, Samoa. The conditions were far from benign. Winds were sitting at around 20–25 knots, the sea state was elevated, and the ship was operating in close proximity to a reef. This was routine work for the ship. The task was to collect hydrographic survey data in support of an upcoming international event

F-35 at RAAF TIndal. Image taken by SGT David Gibbs In August 2025, a light aircraft and a military fast jet came alarmingly close to each other over northern Australia. A Piper PA-28, part of an air race, lost electrical power while heading to Royal Australian Air Force Base Tindal. Simultaneously, two F-35s were preparing to land. Without radio communication, a transponder, or radar visibility, the PA-28 continued its approach. Both aircraft, unaware of each other, lined up

KC-135 after the accident. Image courtesy of the USAF Lessons from the KC-135 maintenance explosion In 1999, a KC-135 tanker was undergoing depot-level maintenance at Tinker Air Force Base in Oklahoma. As part of the maintenance process, technicians needed to conduct a fuselage pressurisation test, a routine procedure designed to simulate the conditions the aircraft experiences during flight and confirm that the structure and sealing systems can safely withstand those loads.

The F-35A. Image courtesy of the USAF This post is about what happens when complexity, distraction and assumptions collide. On the night of 19 May 2020, an F-35A Lightning II was returning to Eglin Air Force Base in Florida after a routine training sortie. The landing should have been uneventful. Instead, within five seconds of touching down, the aircraft bounced, became unstable, and the pilot ejected as the F-35A departed the runway and burst into flames. The aircraft, wort

F-16C. Image courtesy of US Air Force During a routine training sortie at the end of a low-level practise intercept of a light aircraft, an F-16 entered what the pilot believed was an unrecoverable state and crashed shortly afterwards. The pilot safely ejected. What began as a manageable situation escalated rapidly. The pilot was faced with conflicting cues, time pressure, and narrowing margins. The investigation that followed did what investigations often do: it identified c

USAF F-16 of the 8th Fighter Wing. Image courtesy of Cpl Tyler Harmon, USMC Some failures arrive slowly. We see them coming. This gives us time to think, adapt, and recover. Others arrive suddenly, at precisely the wrong moment, compressing decision-making, overwhelming cognition, and leaving little margin for recovery. This accident I'm about to discuss belongs firmly in the second category. A routine flight. A subtle technical failure. A moment of uncertainty. Coming togeth

Sam monitoring the teams during an Interlab mission Recently, Sam and I delivered a training session for a large team. It was built around detailed discussion, rich storytelling, and two missions using the Interpersonal Skills Lab (Interlab) software to show the value of and teach briefing and debriefing. There were 36 participants in total. The energy was high and the engagement was strong. The room was buzzing, and that included us, not just the participants! The feedback w

F-35 on takeoff. Image courtesy of 354th Fighter Wing Public Affairs On 28 January 2025, a USAF F-35A was destroyed during operations at Eielson Air Force Base, Alaska. The pilot ejected safely. There was no hostile action and no single, obvious technical failure that immediately explains what happened. Instead, the Accident Investigation Board (AIB) describes a complex, unfamiliar problem involving landing gear abnormalities, contaminated hydraulic fluid, frozen components,

Renee Good, moments prior to being shot. Image courtesy of CNN. In the aftermath of tragedy, one thing happens almost immediately these days: video footage appears. Phone recordings, CCTV clips, body-worn cameras; all fragments of reality, replayed millions of times. And almost just as quickly, opinions harden. People watch the same footage and arrive at radically different conclusions about what they’ve seen, what it means, and where to point fingers. The recent fatal shooti

Final resting place of the B-1B that crashed at Ellsworth AFB in January 2024. Image courtesy of the US Air Force On 4 January 2024, a USAF bomber was destroyed during operations at Ellsworth Air Force Base. No hostile action. No mechanical failure in the traditional sense. No dramatic chain of obvious errors. Instead, the Accident Investigation Board (AIB) describes a sequence of events shaped by crosschecking breakdowns, ineffective crew coordination, supervision gaps, and

Image courtesy of @visagrad24 on X captures the moment the fire started. When the recent bar fire in Switzerland killed 40 people, public attention moved quickly to accountability and blame. Within days, one person had been arrested: the bar owner. At first glance, that feels reasonable. The owner operated the venue. Modifications had been made. The fire started there. If someone must be held responsible, surely it’s the person “closest” to the event. The issue with this log

Image courtesy of Ventura County Fire Department In September 2019, the dive vessel MV Conception  caught fire off the coast of California, killing 34 people as they slept below deck. It remains one of the deadliest maritime disasters in modern US history. In the aftermath, public attention quickly narrowed. One individual, the captain, was prosecuted. The narrative became familiar: lack of crew training, dereliction of duty, and failure to enforce standards. And yet, when we

AI image of a Cessna 206 over Brisbane On 24 July 2025, a Cessna 206 departed Archerfield airport, Queensland, Australia just minutes before last light. It was a routine training flight planned under instrument flight rules (IFR). The instructor and student had submitted an IFR flight plan with a 17:30 departure time, comfortably before last light at 17:39. As aviation often reminds us, routine creates the perfect space for small shifts to grow into real hazards. The aircraft

AI image of a Qantas Link Dash 8 on the runway at Wagga Wagga On 15 July 2024 at Wagga Wagga Airport (Australia), a QantasLink Dash 8 and a Piper PA-28 came dangerously close to occupying the same runway at the same time. No one behaved recklessly.Both aircraft made all the required calls. Both crews believed they had a good picture of what was happening. Both operated exactly as their procedures expect. And yet, they still converged. The ATSB’s report explains the timeline,

Image of the crashed helicopter courtesy of ATSB On 5 October 2025, a Schweizer 269C-1 helicopter departed Lake Macquarie Airport for what should have been a simple ferry flight to Duri, New South Wales. The pilot had just collected the aircraft after its annual service. This was to be a routine flight, one they’d done many times before. Before take-off, the pilot looked at the fuel gauge: 92 litres. The number matched expectations, and the aircraft had just come from mainten

On the night of June 1, 2009, Air France Flight 447, an Airbus A330 flying from Rio de Janeiro to Paris, vanished over the Atlantic Ocean. The aircraft crashed after entering an aerodynamic stall from which it never recovered, killing all 228 people on board. What intrigued investigators wasn’t just that a modern, sophisticated airliner could fall out of the sky, it was how it fell out of the sky. There was no explosion, no catastrophic mechanical failure, no storm that shoul

The Wreckage of Asiana Flight 214. Image courtesy of the NTSB On July 6, 2013, Asiana Airlines Flight 214, a Boeing 777 from Seoul, approached San Francisco International Airport under clear skies. As the aircraft neared the runway, it was far too low and too slow. The tail struck the seawall, the fuselage broke apart, and three passengers died. Miraculously, 304 others survived. At first glance, it looked like yet another a classic case of “pilot error”, a failure to monitor

Depiction of the Tenerife Airport Disaster On March 27, 1977, two Boeing 747 Jumbo Jets, one operated by KLM, the other by Pan Am, collided on a fog-covered runway at Los Rodeos Airport in Tenerife. Five hundred and eighty-three people were killed. This is still the deadliest accident in aviation history and it was essentially caused by humans trying to do their jobs in difficult conditions. By communicating, making decisions and managing pressure in a system that allowed mis