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When “They Broke the Rules” Stops Us Learning Anything. The Worst Ever Diving Accident in The Maldives.
The Five Italians Who Died in The Maldives Five divers entered a cave system in the Maldives on the 14th May 2026 and never came back. A sixth person — a Maldivian rescue diver — died in the days after during the recovery operation. Almost immediately, the conversation online became frustratingly predictable. “They shouldn’t have been in there.” “They broke the rules.” “They were unqualified.” Maybe. However..... Those sorts of conclusions are also where learning pretty much
Mike Mason
May 255 min read


The Aircraft Was Flying Perfectly. Until Nobody Was Flying It. Lessons from Eastern Air Lines Flight 401
The wreckage of E401. Image by Ron Infantino It started with a light bulb. On December 29, 1972, Eastern Air Lines Flight 401 was approaching Miami at night. The Lockheed L-1011 TriStar was one of the most advanced airliners of its time and the approach itself was routine. The crew lowered the landing gear and something small happened. The indicator light confirming that the nose landing gear was locked down failed to illuminate and that quickly became the focus. The crew beg
Mike Mason
May 184 min read


LaGuardia, JFK, Potomac. These Aren’t Isolated Events. They’re Signals.
These are signals more than just individual incidents In the recent past, aviation has produced a series of events that, on the surface, appear unrelated. At LaGuardia, a fire truck and an aircraft ended up colliding on the runway. At JFK, two passenger aircraft came within 350 feet of each other before TCAS alerts forced evasive action. Over the Potomac, a regional jet and a military helicopter collided with fatal consequences. We've published blogs on all 3 of these acciden
Mike Mason
May 114 min read


JFK Airport, April 2026. The System Worked. That’s Not the Point.
The point of closest approach. Image courtesy of Flightradar24 Just a few weeks ago at New York's JFK Airport, two passenger jets narrowly avoided a mid-air collision when an American Airlines regional jet deviated from its approach path and flew within 350 feet of a landing Air Canada jet. Both flight crews successfully aborted their landings, triggered onboard collision avoidance alarms, and landed safely. Right up until the moment the TCAS alerts go off, everything looks u
Mike Mason
May 44 min read


When the System Can’t See the Risk. Lessons From the LaGuardia Runway Collision
The Air Canada Express Jet, the morning after the collision. Image courtesy of Reuters. It all starts routinely. It was March 22, 2026 and at 23:35, Air Canada Flight 8646 is cleared to land on Runway 4 at LaGuardia airport, New York. It’s on about a five-mile final on a normal descent profile. At roughly the same time, fire vehicles are responding to an unrelated emergency. Their route will take them across that same runway. They call the tower. The first call is blocked and
Mike Mason
Apr 276 min read


When Everyone Is Doing Their Job and it Still Goes Wrong. Lessons from the Potomac midair collision
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
Mike Mason
Apr 205 min read


Why Didn’t We Talk About Bridge Resource Management? More lessons from the loss of HMNZS Manawanui
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
Mike Mason
Apr 136 min read


Was This Always Going to Happen? Lessons from the loss of HMNZS Manawanui
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
Mike Mason
Mar 317 min read


The Near Miss at Tindal: Lessons for Corporate Leaders
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
Mike Mason
Mar 236 min read


"We've Always Done it That Way"
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.
mikemason100
Mar 166 min read


Five Seconds to Disaster
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
Mike Mason
Mar 95 min read


What Does Normal Look Like? The Real Lessons From an F-16 Crash.
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
mikemason100
Mar 36 min read


When Failure Hides in Plain Sight: Why Redundancy Only Works If You Trust It
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
mikemason100
Feb 166 min read


When Good Could Still be Better: What a Recent Training Session Taught Us About Feedback, Learning, and Continuous Improvement
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
mikemason100
Feb 96 min read


Were We Lucky, or Were We Good? What an F-35 Crash Reveals About Decision-Making When the Playbook Runs Out
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,
mikemason100
Feb 25 min read


Your Brain Decided What Happened Before You Pressed Play
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
Mike Mason
Jan 275 min read


“The Pilot Failed To...” Why This Accident Still Has Lessons Left Unlearned
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
Mike Mason
Jan 195 min read


The Last Person to Touch It: Why the Swiss Bar Fire Was a System Failure, Not Just the Owner's Failure
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
Mike Mason
Jan 135 min read


When Everyone Thought It Was Safe: What the MV Conception Fire Really Teaches Us About System Failure
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
mikemason100
Dec 9, 20254 min read


Lines in the Sand, Safety Nets, and a Just Culture: Lessons from an Aviation Near-Miss
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
Mike Mason
Nov 24, 20255 min read


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