Risk Management and Quality Improvement
Individual Written Assignment
Case Study 2: Tenerife Airport Disaster
Name: Tam Chuen Fung (Panda)
For the key events or hazards that led to the occurrence of the disaster, 9 points are included in this part. PAVE would be used in the hazard identification as a tool.
1) Experience level
Captain of the KLM, Jacob van Zanten is an experienced pilot of KLM. But he gave a disadvantage in the cockpit that, no one would bravery enough to remind him.
The recent flies that Jacob van Zanten drove before the disaster were 3 months. Therefore, there was a potential recency hazard existed in the disaster.
3) Fully fuelled
When the Tenerife Airport disaster occurred, the KLM is fully fuelled, so that longer runway was needed to takeoff. The resulting conflagration was that much more terrible.
4) Too big aircraft
The B747 was the biggest type of aircraft on that time. The airport was too small to handle two jumbo aircraft in the same time at the same place.
5) Sudden Fog
The weather of Tenerife Airport had been changed suddenly. Due to the High-altitude of the airport, it is usual to change the weather. The sudden fog is one of the examples. The fog would affect the visibility of ATC, also the aircrafts.
6) Too small airport
Because of a bomb exploded in the Las Palmas Airport, aircrafts were diverting to the Tenerife Airport, but it was too small for so many aircrafts
7) Jamming radio between ATC to aircrafts
Due to the lack of radio equipment in the Tenerife Airport, the communication makes confusion between ATC and aircrafts. In the accident, two simultaneous messages generated feedback and a loud squeal drowned out most of both messages
* E-External Pressure
8) Think with self-common sense
ATC had called the PAN AM to exit the runway at exit C3, but PAN AM thought that was not reasonable to make an over 90 degrees turn in case. Therefore, the PAN AM kept moving on the runway, without telling ATC.
9) Goal Focused
For the time aimed captain of KLM, he did not want to be late and punished, so that the captain throttled up again the engines in the middle of his request. For providing an analysis of the causal and contributory factors of the disaster, SHELL Model would be used as a tool.
S – Software
1) Takeoff without clearance
Captain of KLM takeoff without clearance and throttled up the engines. 2) Lack of ground collusion avoiding system
The ground collusion avoiding system would avoid the collusion of two B747. 3) Information blocked by Radio jam
Due to the recovery of radio signals, information is lost and blocked. 4) Think with self-common sense
PAN AM flight crews thought that was not reasonable to make an over 90 degrees turn to exit in C3 exit.
H – Hardware
1) Too small airport
Aircrafts were diverting to the Tenerife Airport due to the bomb exploded in the Las Palmas Airport, but it was too small for so many aircrafts. 2) Two aircrafts use the same runway at the same time
Due to the simple design, size and taxiway jamming of the airport, PAN AM and KLM were used to taxi in the same runway at the same time. 3) Lack of radio equipment
Due to the old radio equipments, radio was being jammed and the whole information could not transfer to the aircrafts. 4) Full filled KLM B747
The full filled KLM B747 need longer runway to takeoff, so that when KLM flight crews saw the PAN AM and pull up the aircraft, it was too late to avoid the collusion. 5) Non-stop engines and Fuel leakage after the collusion
The leaked fuel went into the engines and being burnt and exploded. This is the main reason of so many people being killed and injured. E – Environment
1) Sudden Fog
Due to the High-altitude of the airport, it is usual to change the weather. The affected the...
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