The vulnerable system: an analysis of the Tenerife air disaster.
Material type:
TextLanguage: ENG Publication details: 1990Description: 24p., 56 refsSubject: 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 interpretation of important routines among interdependant systems, interdependancies that become tighter, a loss of cognititive efficiency due to autonomic arousal, and a loss of communication accuracy due to increased heirarchical 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
| Item type | Current library | Collection | Call number | Status | Date due | Barcode | |
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Books
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Australian Emergency Management Library | BOOK | 363.1241 WEI (Browse shelf(Opens below)) | Available | 005266201 | ||
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Books
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Australian Emergency Management Library | BOOK | 363.1241 WEI (Browse shelf(Opens below)) | Available | 005323746 |
Reprinted from Journal of Management; 1990; Vol 16 No 3; pp571-593
Reprint
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 interpretation of important routines among interdependant systems, interdependancies that become tighter, a loss of cognititive efficiency due to autonomic arousal, and a loss of communication accuracy due to increased heirarchical 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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