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Organizational processes
Activities over which any organization has a reasonable degree of direct control
1- Resource allocation and management: This
includes financial, human and other resources
2- Compliance with laws and regulations:
Ensuring that the organization's activities are in
compliance with legal and regulatory
requirements
3- Employee management: Recruiting, training,
and supervising employees, setting goals and
performance expectations
4- Health and safety practices: Implementing
policies, procedures and training to ensure a safe
working environment.
5-Work processes: The way work is performed,
including standard operating procedures, work
flows and quality controls
6- Information management: Management of
information systems and data, including security
and privacy
8- Performance monitoring and improvement:
Regularly monitoring and evaluating
performance and implementing improvement
initiatives
7- Supply chain management: Overseeing and
managing the activities of suppliers and partners
Workplace conditions
Latent conditions
Factors that directly influence the efficiency of people in
aviation workplaces
Conditions present in the system before the accident,
made evident by triggering factors
The workplace is The environment
Tenerife Airport is not typically equipped to
handle larger aircraft and is better suited for
smaller planes.
The noise and vibration levels in the cockpits
of Boeing 747 planes are quite high
Las Palmas airport received bomb threats from
terrorists.
Noise and vibration levels are quite high in
cockpits of Boeing 747 aircraft.
Communication problems arose due to two
people speaking on the same time, causing a
loud, noisy sound.
During the accident, a dense fog had
descended from the volcano and settled over
the airport.
Instead of waiting for verbal clearance, the
pilot told the co-pilot to request
frequency at the same time, causing a loud,
noisy sound.
AERO 346
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clearance and began the takeoff process by
increasing the throttle.
There was a management/organizational
emphasis on cost and reputation
rather than safety culture.
The emergency plans and procedures at the
airport were not adequate for
handling a scenario like this.
Active failures
Defences
Actions or inactions by people (pilots, controllers,
maintenance engineers, aerodrome staff, etc.) that have
an immediate adverse effect
Resources to protect against the risks that organizations
involved in production activities must confront
The KLM engineer and co-pilot did not
intervene when the pilot increased
the throttle and took off without receiving
clearance from the radar tower.
The KLM pilot ignored information suggesting
that the Pan Am plane was
still on the runway.
Pilots should be willing to consider the
decisions made by their co-pilots
The KLM co-pilot remained silent and did not
object to the pilot's actions, believing that the
pilot is always right.
Communication training can be useful for
pilots to enhance their skills in
exchanging information with their colleagues
and air traffic control.
Crew resource management training should be
incorporated into a
company's culture to minimize failures due to
human factors.
Air traffic control instructed the Pan Am flight
to move from the runway to taxiway 3, but the
angle of the taxiway was not suitable for a
large Boeing747 to maneuver.
The KLM flight engineer questioned the pilot's
decision to take off after
hearing advice from the traffic tower that the
Pan Am flight may not have
yet cleared the runway.
AERO 346
Stress training may be berleficial for pilots to
learn how to manage and
cope with stress effectively during flights.
Protocols need to be established that mandate
that co-pilots possess
enough proficiency to challenge the decisions
made by their captains.
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The pilot told the co-pilot to request clearance
and immediately began the
takeoff process without waiting for verbal
clearance.
The Pan Am aircraft missed the third taxiway.
AERO 346