Accident Analysis: KLM Boeing 747 Rijn and PANAMA Boeing 747 Clipper Victor

This report analyses the KLM Boeing 747 Rijn and PANAMA Boeing 747 Clipper Victor accident, highlighting human factors, training, teamwork, and the Shell and Swiss cheese models. Recommendations are provided to avoid such accidents in the future.

Running head: ACCIDENT ANALYSIS
ACCIDENT ANALYSIS
Name of the student
Name of the university
Author note

1ACCIDENT ANALYSIS
Executive summary
In this study, it has been identified that Aviation or flight accidents are one of the most terrified
form of accidents that have occurred to the history of mankind. The accident concerned here is
the KLM Boeing 747 Rijn which killed 583 people and rendered 46 people wounded. It is
discussed in this report that the airport runway was covered with heavy fog due and also due to
the lack of communication between the airport officials and the plane crew, the accident took
place with the collision of the two flights and their exploding into flames. It has been identified
that training is being considered as the systematic proves in which the knowledge is being
developed. Team work is very important in achieving the vision and mission in an organization.
It is important for maintaining the collaboration in the aviation industry. In case of analyzing the
risk management in the aviation industry the report has shed list on the Swiss cheese model and
Shell model.

2ACCIDENT ANALYSIS
Table of content
1. Introduction..............................................................................................................................3
2. Discussion................................................................................................................................3
2.1 Accident analysis...................................................................................................................3
2.2 Human Factors influence.......................................................................................................4
2.3 Training..................................................................................................................................5
2.4 Teamwork..............................................................................................................................6
2.5 Shell model............................................................................................................................6
2.6 Swiss cheese model................................................................................................................7
2.7 Impact.....................................................................................................................................8
3. Recommendation.....................................................................................................................8
4. Conclusion...............................................................................................................................9
Reference list.................................................................................................................................10
Appendix........................................................................................................................................12
Appendix 1.................................................................................................................................12
Appendix 2.................................................................................................................................12
Appendix 3.............................................................................................................................13

3ACCIDENT ANALYSIS

4ACCIDENT ANALYSIS
1. Introduction
Accidents are not desirable in any form as it involves harming of human beings along
with financial loss which often is very big to replenish. According to The worst crash in aviation
history, (2018), Aviation or flight accidents are one of the most terrified form of accidents that
have occurred to the history of mankind which is the base of the report. The accident concerned
here is the KLM Boeing 747 Rijn which killed 583 people and rendered 46 people wounded. The
report here analyses the analysis of the accident on aviation human factors, usability and design
of training, team work leadership of the crew resource management of the airport and flight. The
factors are analysed using the SHELL and SWISS CHEESE model for the better approach. The
following paragraph also highlights the impact of the factors on the accident analysis and also
the recommendations needed for the betterment and avoidance of this kind of situations in future
(refer to Appendix 1).
2. Discussion
2.1 Accident analysis
The accident of KLM Boeing 747 Rijn and PANAMA Boeing 747 Clipper Victor is one
of the most dangerous of all times as it involved the clash of two of the biggest passenger planes
of the time. The accident took place on March 27, 1977 at The Canary Island of Tenerife
(Raudys, 2014). The airport runway was covered with heavy fog due and also due to the lack of
communication between the airport officials and the plane crew, the accident took place with the
collision of the two flights and their exploding into flames. There are a number of causes behind
the collision and explosion which can be segmented into both natural and man-made causes.
After the investigation of the transcript that is being used for the plane and for the purpose of
flight attending, it was found that the manmade error contributed most of the places in the overall

5ACCIDENT ANALYSIS
accident. The accident is one of the most dangerous in the aviation history as it is a perfect
example of a happening that is an amalgamation of wrong airport instruction that is being given
to the flight cabin crew as well as the dense fog that engulfed the whole runway track resulting in
extremely poor visibility and lack of vision. The bombing threat that is being given to the nearby
airport due to which heavy traffic diversion to the small airport of Canary Island is one of the
prime reasons that led to the disastrous accident.
2.2 Human Factors influence
In the accident which led to the loss of approximately 600 lives and immense finance,
there are a number of human errors that are being involved. According to Skalle, Aamodt and
Laumann, (2014), Human factors are defined as the study of both the human strength and
weakness which in turn enhances the safety and operational performance of human beings.
Human Factors are defined as the eclectic field of human behaviour including the fields of
psychology, engineering and branches of science and technology. The safe and effective use of
the organization through the use of the human factors is essential for the working. In the aviation
industry, the welfare as well as the human factor plays a vital role in the overall matter
(Wiegmann & Shappell, 2017). The history of human factor employs the selection of pilots and
training them along with dealing with the entire organization and aircraft system. The human
factor is actively involved in the KLM accident in which the lack of communication and
miscommunication is deliberately involved in the whole incident. In addition, the wrong
information given by the airport authorities is also an example of human errors that are there in
the KLM accident case analysis. According to Shappell et al., (2017), the errors in the case are
not random and they are not caused due to their inefficiency. With the fact that human errors are
natural and occur without any deliberation, the fact is also to be considered that many of the

6ACCIDENT ANALYSIS
occupations such as the authority case as well as the pilot and crew is involved in the human
errors of the case.
2.3 Training
According to Holt (2016), training is being considered as the systematic proves in which
the knowledge is being developed. In the recent aviation industry the process of experimental
learning is being applied. The process has become more scientific. It has been identified that
depending on the statistical analysis, scientific experiments and interviews. Training process
plays a significant role in case of developing the pre career, beginning career and mid-career
(Littlepage et al., 2016). In this process the learning skills of the participants are being
developed. In case of aviation industry, the training is essential for achieving the goals. It is also
very important in case of risk management practices (Henle, 2017). In this study, the KLM
incident has been highlighted. After analyzing the issue, it has been identified that lack of proper
training of the employees, the incident has been occurred. It has been identified in the analysis
that lack of coordination among the crew members and the pilots, the situation happened. It has
been identified that lack of air traffic control clearance is another important reason behind the
accident. Lack of understanding between the air traffic controller and the pilot, the disaster
happened. In this situation, it has been identified that if proper training would have been
provided to the employees, the accident may not be happened. In case of avoiding the further
risks, the proper training regarding the motor skill and automated technologies are needed to be
provided to the employees. In case of the KLM Report, it has been discussed that the lack of
coordination between the flying and field staffs, the air field disaster happened.

7ACCIDENT ANALYSIS
2.4 Teamwork
Team work is very important in achieving the vision and mission in an organization. It is
important for maintaining the collaboration in the industry (Littlepage et al., 2015). By working
in a team the problem solving skills of the team members can be improved. On the other hand, it
plays influential role for increasing the social and self-awareness. In case of an organization, the
team work can help to accept the challenges. As stated by McDaniel and Salas (2018), through
the effective team initiative the innovation can be introduced in the workplace. In case of
aviation industry, the team work is also very important. It is true that if the coordination between
the field and air employees can be maintained, it becomes easier to handle any kind of situation
(cDaniel & Salas, 2018). It is also true that depending on the coordination among the employees,
the organizational goals can be achieved in the easier way. In case of KLM disaster, it has been
identified that lack of understand the commands and lack of activeness are the major reason
behind the disaster. It cannot be said that one person or one department is responsible for the
disaster. It is true that lack of coordination between the Air clearance department, Pilots, air
commander and crew members the disaster happened.
2.5 Shell model
In the year 1972 the Shell model was developed and after the 1080, the framework of
shell model has been implemented in the industry (Patankar & Taylor, 2017). The Shell model is
conceptual that highlights the human factors which clarifies the scope of the factors of human
aviation. This is very important in case of understanding the relationships between human
component and the aviation system resources. In the shell model the sole cause of the accident is
being analyzed. In the Shell model 5 components are being highlighted. Software, Hardware,

8ACCIDENT ANALYSIS
Environment, Liveware of individuals and Liveware of groups are being highlighted in the Shell
model (refer to Appendix 2).
In the above diagram, the interface between the people and 5 components of the Shell
model is being discussed. In the model, various task related contextual factors are being
interacted with the human operators who are involved in the system of aviation. Through the
shell model both the failure and gaining in the aviation system. In the words of YANG andFAN
(2016), the modern transportation system is being represented through the Shell model. By
relating the shell model with the limitations and general capabilities the general human
components are being understood.
2.6 Swiss cheese model
The Swiss chess model was introduced by Jams reason, for introducing the systems for
human defense so that the randomly arranged holes can be set by keeping the selective gaps
between the each slice (Underwood & Waterson, 2014). The Swiss chess model is being
considered as the accident causation model in which the risk is being analyzed. In the words of
Stein and Heiss (2015), in this model the safety of the aviation, health care, engineering,
computer security, defense and emergency service of the organizations are being discussed (refer
to Appendix 3).
In the above diagram the method of Swiss chess model has been described. It is being
considered as the tonic for procrastination. In the model, different hoes of the four different was
have been shown. It is the way which is being started for achieving its goals by poking the holes
in the wall. In the words of Underwood and Waterson (2014), in most of the cases, it has been
identified that accidents are being traced to four domains. It is true that supervision,
organizational influence, specific acts and preconditions are the major influential factors in the

9ACCIDENT ANALYSIS
case of the analyzing the unsafe acts in the aviation industry. Analyzing the influence of Swiss
chess model in the aviation industry, Swiss chess model plays an influential role in terms of
developing the investigation and safety thinking in the aviation industry. In the words of Stein
and Heiss (2015), in case of analyzing accident in the aviation industry, the proper
implementation of the theoretical framework of Swiss chess model as well as the illusion
management is required.
2.7 Impact
The impact of the overall analysis of all the factors as well as the models comes to the
summation that the accident though was not deliberate and had a number of environmental and
natural factors associated with it. However, along with the natural causes, the involvement of the
human causes and lack of proper developmental facilities cannot be ignored and the lack of such
resources is also contributed to the fact. The impact of the overall case is therefore summed in
the fact that the accident is caused due to a number of human and other related factors which
could have been avoided to make sure that such massive accidents would not have occurred
again.
3. Recommendation
The following recommendations can be levied to the case to make sure that in future,
such massive accidents do not happen again –
 One of the primary recommendations is to make sure that adequate amount of
training and developmental facilities have been provided to avoid such
circumstances.

10ACCIDENT ANALYSIS
 The next recommendations is to make sure that the teamwork and leadership
qualities of the authorities is enough to motivate and direct the employees for
better working and good communication system.
 The third recommendation is to avoid the potential human errors as much as
possible and also to make sure that each and every error done either deliberately
or not deliberately is being maintained and not done in the concerned span of
time.
 The fourth recommendation is to improve the technology of the airport to make
sure that the people communicating have everything heard clear and not a single
information is missed.
 The fifth recommendation is to make sure that the runway numbers need to be
improved. In cases of emergencies, it is being stated that the change of runway is
essential which can sometimes run to collision of flights in small airports. The
development of airport infrastructure is must in such cases.
4. Conclusion
At the end, it can be concluded that the accident which took place between the two flights
on 1977 is one of the most dangerous in the history of aviation accident calendar. The report has
mentioned the analysis of the accident along with certain factors that have affected the overall
happening of the accident in the concerned span of time. The impact of the overall analysis has
been done along with the recommendations that are to be maintained in the aviation and airport
industry. The report is an assessment of the flight accident that occurred in 1977 and the
subsequent effects of the case which are being discussed in details.

11ACCIDENT ANALYSIS
Reference list
Collins, S. J., Newhouse, R., Porter, J., & Talsma, A. (2014). Effectiveness of the surgical safety
checklist in correcting errors: a literature review applying Reason's Swiss cheese
model. AORN journal, 100(1), 65-79.
Henley, I. M. (2017). Aviation education and training: Adult learning principles and teaching
strategies. Routledge.
Holt, T. B. (2016). The Problem with Postsecondary Aviation Safety Training, as Voiced by
Aviation Industry Professionals.
Littlepage, G. E., Hein, M. B., Moffett III, R. G., Craig, P. A., & Georgiou, A. M. (2016). Team
training for dynamic cross-functional teams in aviation: Behavioral, cognitive, and
performance outcomes. Human factors, 58(8), 1275-1288.
Littlepage, G. E., Hein, M. B., Moffett III, R. G., Craig, P. A., & Georgiou, A. M. (2016). Team
training for dynamic cross-functional teams in aviation: Behavioral, cognitive, and
performance outcomes. Human factors, 58(8), 1275-1288.
McDaniel, S. H., & Salas, E. (2018). The science of teamwork: Introduction to the special
issue. American Psychologist, 73(4), 305.
Miller, M., & Holley, S. (2017, July). SHELL Revisited: Cognitive Loading and Effects of
Digitized Flight Deck Automation. In International Conference on Applied Human
Factors and Ergonomics (pp. 95-107). Springer, Cham.
Patankar, M. S., & Taylor, J. C. (2017). Risk management and error reduction in aviation
maintenance. Routledge.

12ACCIDENT ANALYSIS
Raudys, J. (2014). Review of Aviation Accidents and Incidents Caused by Miscommunication.
Aviation technologies, 2(2), 41-44
Shappell, S., Detwiler, C., Holcomb, K., Hackworth, C., Boquet, A., & Wiegmann, D. A. (2017).
Human error and commercial aviation accidents: an analysis using the human factors
analysis and classification system. In Human Error in Aviation (pp. 73-88). Routledge.
Skalle, P., Aamodt, A., & Laumann, K. (2014). Integrating human related errors with technical
errors to determine causes behind offshore accidents. Safety science, 63, 179-190.
Stein, J. E., & Heiss, K. (2015, December). The Swiss cheese model of adverse event occurrence
—closing the holes. In Seminars in pediatric surgery (Vol. 24, No. 6, pp. 278-282). WB
Saunders.
Bbc.com, (2018). Retrieved from https://www.bbc.com/news/av/magazine-35695521/the-co-
pilot-who-survived-the-tenerife-aircraft-disaster
Tong, P. C., Chau, H. T., & Wong, T. T. (2015). A shelf-swiss cheese model for aviation safety.
Underwood, P., & Waterson, P. (2014). Systems thinking, the Swiss Cheese Model and accident
analysis: a comparative systemic analysis of the Grayrigg train derailment using the
ATSB, AcciMap and STAMP models. Accident Analysis & Prevention, 68, 75-94.
Wiegmann, D. A., & Shappell, S. A. (2017). A human error approach to aviation accident
analysis: The human factors analysis and classification system. Routledge.
YANG, K., & FAN, Y. (2016). “Peart” Human Factors Model for Aviation Maintenance.
Zwaailichten.org: Tenerife ramp. (2018). Retrieved from
http://www.zero-meridean.nl/c_tenerife_270377_en.html

13ACCIDENT ANALYSIS
Appendix
Appendix 1
Figure – Clash of KLM Boeing 747 Rijn and PANAM's Boeing 747 Clipper Victor
(Source – BBC News 2018)
Appendix 2
Figure:

14ACCIDENT ANALYSIS
(Source: Miller & Holley, 2017)
Appendix 3
Figure: Swiss chess model
(Source: Collins et al., 2014)