Report 1 - FIRE AT SCHIPHOL AIRPORT PRISON COMPLEX...

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FIRE AT SCHIPHOL AIRPORT PRISON COMPLEX Maastricht University Faculty of Economics and Business Administration Maastricht, 8 September 2011 Name : Caroline Ulrici ID numbers : 623261 Study : International Business Economics Course : Crisis Management in Organizations Group number : 1 Tutor name : B.Scheurs Introduction In the night of October 26, a prisoner lit a fire in his cell in a detention center at Amsterdam's Schiphol airport causing 11 deaths and 15 injured. Analyzes and investigations demonstrated that this accident have had multiple sources. Failures in defense mechanisms, unsafe acts, psychological precursors, failure types and decisions that night of October eventually have led to the Schiphol Airport disaster. With the help of the general accident scenario and the Swiss cheese model of system accidents, this paper will try to answer the questions: What were the specific failures and lacks during that
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night, which lessons can be drawn from this event? What could have been done to prevent this from happening? The general accident scenario As Wagenaar, Hudson and Reason (1990) explained in their article, with the help of the general accident scenario, an accident is always the result of an unsafe act. Every developed organization uses defense mechanisms to prevent those unsafe acts. However, accident keeps on happening every year because of holes in the defense layers (Reason, 2000). The Swiss cheese model of system accidents focuses on those defensive layers deficiencies. Indeed, each defensive mechanism is represented by a slice of the Swiss cheese full of holes (Reason, 2000). When, by
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This note was uploaded on 10/20/2011 for the course SBE 204 taught by Professor Furneaux during the Spring '11 term at Maastricht.

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Report 1 - FIRE AT SCHIPHOL AIRPORT PRISON COMPLEX...

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