
@HorsleyCarl "the crew did not realise Manawanui remained in autopilot"
So, nothing whatsoever to do with the autopilot <eye roll>.
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Ken Catchpole
3.8K posts

@KenCatchpole
Clinical Human Factors Research Practitioner. Disrupting conventional views of error, safety and performance improvement in healthcare. https://t.co/eTOnJDc6L7

























It's tragic and frustrating how healthcare continues to ignore the lessons of safety science, human factors, joint cognitive systems, and complex adaptation, instead doubling down on simplistic notions of "error", blame, trying harder, person vs system, and linear determinism.


