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The curious cases of the Tenerife plane crash and medical errors: What we see through the Swiss cheese model

Both the Tenerife plane collision and the medical error at a community hospital were caused by the accumulation of multiple lapses, including communication and authority gradients, and the lack of a system to catch human errors, which can be prevented by implementing crew resource management, cross-checks/checklists, and improved communication skills.
Van Zanten Donald Norman Bob Wachter Canary Islands Air Traffic Controller Swiss Cheese Model

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