What Happens When Knowledge Isn’t Documented? Lessons from Aviation for Knowledge Management

In aviation, every checklist, every cockpit manual, and every post-flight log exists for one reason: to make sure knowledge gets passed on and doesn’t get lost at 35,000 feet.

But if that system breaks down? The results can be catastrophic.

While your workplace might not involve jet engines or transponders, the consequences of undocumented knowledge can still cause serious turbulence. During Aviation History Month, we’re looking at some haunting real-life aviation incidents where gaps in documentation and communication played a fatal role, and what that teaches us about the importance of knowledge management.

Tenerife Airport Disaster (1977) – When Assumptions Replace Documentation

Two Boeing 747s collided on a foggy runway in Tenerife, killing 583 people in what remains the deadliest accident in aviation history. While weather and congestion were contributing factors, investigators zeroed in on a critical communication breakdown between the KLM pilot and air traffic control.

The KLM captain believed he had been cleared for takeoff. He hadn’t.

The takeaway? Critical procedures must be unambiguous, consistent, and documented.
In the KLM crew’s case, vague verbal protocols and lack of standardized phraseology created deadly confusion.

Today, aviation relies on standardized communication — documented, rehearsed, and reinforced — to eliminate ambiguity. In business? We still hear “I thought you meant…” far too often.

Air Florida Flight 90 (1982) – When Tribal Knowledge Isn’t Enough

On a freezing day in Washington, D.C., the crew of Air Florida Flight 90 attempted takeoff with ice on the wings and faulty engine readings. The first officer questioned the readings, but the captain dismissed the concern. Moments later, the plane stalled and crashed into the Potomac River.

The investigation revealed a culture where informal knowledge (aka, “we always do it this way”) overrode formal training and documentation.

Lesson learned: “We know how it works” isn’t the same as “It’s written down.”

Without documentation, informal knowledge can become outdated, misunderstood, or dangerously wrong.
In the workplace, relying on memory or “how Jim always did it” can lead to mistakes, inefficiency, or total knowledge loss when key staff leave. This is especially true if Jim retires and takes the metaphorical flight data recorder with him.

United Airlines Flight 173 (1978) – When Everyone’s Waiting for Someone Else to Say It

This Portland-bound flight ran out of fuel while the crew was preoccupied with landing gear issues. Why? Because while team members noticed the fuel concern, no one escalated it clearly. There was no established documentation protocol (or culture) to flag and prioritize that life-threatening problem in real time.

The crew’s knowledge existed; it just wasn’t transferred or acted upon.

KM takeaway: Knowledge management isn’t just storage, but structured, timely communication.

If knowledge doesn’t move to the right person at the right time, it’s functionally useless. A well-structured knowledge base or communication system ensures that what someone knows gets used, not just remembered.

Ground Control to HR: This Isn’t Just a Pilot Problem

Before you breathe a sigh of relief that your office doesn’t involve flight plans or jet fuel, remember:

• Every undocumented process is a risk.
• Every siloed team creates a fog of miscommunication.
• Every “we’ll just wing it” moment is a missed opportunity to build safety and clarity.

Whether it’s onboarding, client handoffs, or IT system recovery, lack of documentation slows us down and confuses our teams. In high-stakes industries, it can literally cost lives.

Lessons from the Flight Deck

Here’s what the aviation industry gets right—and what every organization should adopt:

• Checklists – Standardized, step-by-step instructions reduce reliance on memory
• Post-incident reviews (aka postmortems) – Documented, shared, and used to prevent recurrence
• Clear communication protocols – Phraseology is standardized, reviewed, and documented
• Simulated training with feedback – Scenarios are debriefed, lessons learned captured
• Human error is assumed—and accounted for

Documentation Is the Black Box of Business

In aviation, the black box records everything—not to assign blame, but to learn from failure. In business, good documentation does the same. It captures what went wrong, what worked, and what the next crew (or team) needs to know to land safely.

During Aviation History Month, let’s take a page from the flight manual: If knowledge matters, it must be documented. Otherwise, you’re just flying blind.

Related Blogs

From Newbie to Pro: Top Knowledge Management Practices

Knowledge Management and Workplace Transitions

Get Organized, Get Productive: 5 Ways Leaders Can Stay Efficient Without Losing Their Minds  

References

“Air Florida Flight 90, N62AF.” Federal Aviation Administration. 3/7/23. Accessed 10/13/25. https://www.faa.gov/lessons_learned/transport_airplane/accidents/N62AF

“Aircraft Accident Report.” National Transportation Safety Board. 6/7/79. Accessed 10/13/25. https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7907.pdf

“Dorothy Kelly — The Tenerife Air Disaster.” Confessions of a Trolley Dolly. 3/26/17. Accessed 10/13/25. https://confessionsofatrolleydolly.com/2017/03/26/angels-of-the-sky-dorothy-kelly-the-tenerife-disaster