Anatomy of a System accident: The Crash of Avianca Flight 052

On January 25, 1990, Avianca Flight 052 crashed after running out of fuel following a missed approach to New York's John F. Kennedy Airport. Weather was poor on the East Coast of the United States that day, and the flight had experienced several holding patterns enroute from Medellín, Colombia, to New York. The accident is analyzed in terms of Helmreich and Foushee's (1993) model of crew performance and Reason's (1990) model of latent pathogens in system operations.