Root cause analysis in aircraft accidents: Tenerife airplane crash examination

Although the aviation sector is considered one of the safest modes of transportation due to its high safety standards, it is still prone to major accidents caused by systemic weaknesses. In this thesis, the Tenerife air disaster of 1977—known as the deadliest accident in aviation history—is examined through a multidimensional analysis using the Bow Tie and FRAM methods. The aim of the study is to provide a more holistic evaluation of aviation safety by comparatively applying traditional cause-effect approaches and functional variation analyses. The hypothesis suggests that such accidents occur not only due to human errors, but also due to contextual factors, system-level interactions, and control failures. The case study is the Tenerife accident scenario, with the main analytical units being the core functional components involved in the event. The FRAM diagram was created using the FRAM Model Visualiser (v3.1.0), and then a Bow Tie diagram was developed to model causal and barrier relationships. The findings reveal that communication failures, low visibility, ambiguous air traffic instructions, and human factors combined to create a cascading sequence leading to the accident. The combined use of both methods enabled a systematic and contextual analysis of the incident; as a result, multi-layer preventive strategies were developed to enhance aviation safety.