The Vulnerable System: An Analysis of the Tenerife Air Disaster

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.

Seeking explanation in theory: Reflections on the social practices of organizations that distribute public use microdata files for research purposes

“…The analyses of Weick (1990) and Vaughan (1996) of the Tenerife air disaster and the Challenger disaster, respectively, show that work practices contributed to horrendous technology disasters that were a consequence of inadequate or miscommunication. Robbin (1984) and Siegel (1981a, 1981b) found that the highly bureaucratic decision making structures of state agencies and perceptions of the external environment strongly influenced decisions that staff made to release or deny access to administrative records containing confidential information.…”

The art of measuring nothing: The paradox of measuring safety in a changing civil aviation industry using traditional safety metrics

“…Currently, much of the safety literature on high-risk environments is based on grounded theory from high-profile accident investigations (Perrow, 1984, Shrivastava, 1987Weick, 1993aWeick, . :1993bVaughn, 1996;Snook, 2002;Gehman, 2003;Johnson, 2004) based on dramatic system failures where much of the emphasis is devoted to showing post facto the structural and behavioral causes and precursors of operating failure (La Porte 1996: p. 60).…”

“…In the past, most studies in safety management have been conducted primarily by scientists in the fields of sociology, psychology and engineering, all with their own particular scientific paradigms, and all with their own specific approaches for defining and measuring safety and/or safety culture (Perrow, 1984, Shrivastava, 1987Weick, 1993aWeick, . :1993bVaughn, 1996;Snook, 2002;Gehman, 2003;Johnson, 2004) but without a great deal of interactivity between academic groupings.…”

“…This is also reflected in Reason's (1997) accumulation of latent failures. Still other literature focuses on man-made disasters such as: Bhopal (Shrivastava, 1987), Three Mile Island (Perrow, 1984), the Tenerife air disaster (Weick, 1993a), the Challenger (Vaughn, 1996) and Columbia (Gehman, 2003) space shuttle accidents, the "friendly" downing of two Blackhawk helicopters (Snook, 2002), and the Überlingen mid-air collision (Johnson, 2004), where organizations play a significant contributing role leading to undesired outcomes. The space shuttle accidents, in particular, demonstrate both the importance of organizational soft variables, such as organizational culture in safety outcomes, as well as, the difficulties in changing culture within socio-technical organizations over time (Gehman, 2003).…”

Researching Entrepreneurial Failures

“…Although most organizations and their members believe that learning from failure is important, they generally find doing so to be difficult (Cannon & Edmondson, 2005), as do entrepreneurs who lose their business (Byrne & Shepherd, 2015;. More specifically, while failure reveals important information, organizations and individuals are frequently unsuccessful at fully processing that information (Weick, 1990;Weick & Sutcliffe, 2006). We need to gain a deeper understanding of the costs of failure (project and business) to the entrepreneur (and by extension the organization) and the ways these costs of failure can create obstacles to achieving the benefits of failure-namely, learning from the experience.…”