Part 4/8:
This incident illustrates what aviation safety professionals refer to as the "Swiss Cheese model" of accidents: that is, multiple latent failures must fuse together for a mishap to occur. John added that it’s imperative to understand what holes in the system lined up to cause this incident. It raises the question: What is the role of Crew Resource Management (CRM) in ensuring both the controller and pilots maintain acute awareness of their surroundings, especially in busy air traffic?