The Bombing of Pan Am Flight 103
The bombing of Pan Am Flight 103 occurred on December 21, 1988, when the Boeing 747, flying from London to New York, exploded over Lockerbie, Scotland. All 259 people aboard and 11 people on the ground were killed.
From a common sense management perspective, the tragedy illustrates several failures.
* Threat information was not adequately translated into action. Authorities had intelligence indicating a serious threat to U.S. aviation around the time of the bombing, but the information did not result in sufficiently effective protective measures.
* The system relied too heavily on procedures rather than eliminating vulnerabiities. Security depended on multiple organizations, airlines, airports, governments and intelligence agencies, performing their individual responsibilities correctly.
* Baggage security was inadequate. A dangerous device was able to enter the baggage system and ultimately be loaded onto the aircraft without being detected.
* Information sharing was insufficient. Critical intelligence and security information did not flow effectively among the organizations responsible for protecting the flight.
* Risk was not treated conservatively enough. When credible information suggests a potentially catastrophic threat, common sense says the response should err on the side of protecting passengers, even when the probability of an attack is uncertain.
* The consequences of a single failure were enormous. The aviation-security system allowed one concealed device to defeat multiple layers of protection.
The Common Sense Lesson
The fundamental lesson is “don’t wait for the disaster to prove the vulnerability.”
A good safety system should continually ask:
What can go wrong? What warning signs aleady exist? What is the simplest way to prevent it? And what happens if one protection layer fails?
Pan Am 103 demonstrates the danger of a system in which warnings, security procedures, technology, and organizational responsibilities are treated as separate issues rather than as one integrated safety system.
NO COMMON SENSE
ANALYZE THE EXAMPLE
* Which supports and barriers were in play?
* What were the dynamics?
* Who, or What, won the Tug-of-War?
* Discuss the outcome with your friends and family.
* Use Post #4 as a reference for the dynamics and relationships between supports and barriers.