The Vulnerable System: An Analysis of the Tenerife Air Disaster
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CONTRIBUTORS:
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JOURNAL:
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YEAR:
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1990
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PUB TYPE:
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Journal Article
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SUBJECT(S):
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None
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DISCIPLINE:
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No discipline assigned
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HTTP:
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LANGUAGE:
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English
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PUB ID:
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103-370-844
(Last edited on
2005/10/20 12:51:43 GMT-6)
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SPONSOR(S):
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ABSTRACT:
The Tenerife air disaster, in which a KLM 747 and a Pan Am 747 collided with a loss of 583 lives, is examined as a prototype of system vulnerability to crisis. It is concluded that the combination of interruption of important routines among interdependent systems, interdependencies that become tighter, a loss of cognitive efficiency due to autonomic arousal, and a loss of communication accuracy due to increased hierarchical distortion, created a configuration that encouraged the occurrence and rapid diffusion of multiple small errors. Implications of this prototype for future research and practice are explored.
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