Risk Management and Quality Improvement Ia
Risk Management and Quality Improvement
Individual Written Assignment
Case Study 2: Tenerife Airport Disaster
Name: Tam Chuen Fung (Panda)
SID: 10485559
Mind Map:
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.
* P-Pilot 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.
2) Recency
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.
* A-Aircraft 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.
* V-Environment 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
Individual Written Assignment
Case Study 2: Tenerife Airport Disaster
Name: Tam Chuen Fung (Panda)
SID: 10485559
Mind Map:
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.
* P-Pilot 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.
2) Recency
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.
* A-Aircraft 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.
* V-Environment 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