The Vulnerable System: An Analysis of the Tenerife Air Disaster
分析了特内里费空难中系统脆弱性如何导致危机，指出相互依赖系统中断、认知效率下降和沟通失真等因素共同引发了多重小错误的快速扩散。
The Tenerife air disaster, in which a KLM 747 and a Pan Am 747 collided with a loss of 583 lives, is examined as a prototype of system vulnerability to crisis. It is concluded that the combination of interruption of important routines among interdependent systems, interdependencies that become tighter, a loss of cognitive efficiency due to autonomic arousal, and a loss of communication accuracy due to increased hierarchical distortion, created a configuration that encouraged the occurrence and rapid diffusion of multiple small errors. Implications of this prototype for future research and practice are explored.