On 27 March 1977, two Boeing 747's collided at a small airfield in the Canary Islands, causing the most deadly aircraft mishap to date. 583 souls perished and 61 survivors suffered injuries.
THE SWISS CHEESE MODEL
The four overarching categories in the Swiss Cheese Model:
- Organizational Influences
- Unsafe Supervision
- Preconditions for Unsafe Acts
- Unsafe Acts
HOLES IN THE CHEESE
- Explosion at Gran Canaria Airport: Bomb forced diversion to Los Rodeos
- Small Airport: Los Rodeos was a one-runway regional airport
- Dense Fog: Visibility less than 100m (330 ft)
- No Ground Radar: ATC couldn't visualize aircraft positions
- KLM Fully Refueled: Added weight required more runway
- Pan Am Missed Turn: Taxiway C-3 was poorly marked
Questions about pilot medical certification?