MORE THAN 100 YEARS OF powered flight have taught the aviation industry one unshakeable truth: Very few accidents are caused by a single event; more often they are the result of a conflux or alignment of multiple contributory system failures. And in aviation, where most accidents have "human error" as a contributing factor, it is imperative that the industry understand as quickly as possible in a free and open exchange what set of circum-stances conspired to cause humans to err. That view is ...

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