The course includes a research paper assignment of twelve pages minimum of
content in APA format, including a Title page, Abstract, Main Body, and Reference
page.
The research paper will require you to choose “a” commercial aviation accident or a
“couple” of accidents to analyze. You need instructor approval for the accident you
choose before you begin. You will need to extract the full accident report
from https://ntsb.gov/_layouts/ntsb.aviation/index.aspx and https://aviationsafety.net/.
The first step in completing the assignment is to give a “brief” overview of the
accident you chose. It will serve as the introduction to your paper. (I am not
looking for a report about the accident). The goal is to use the concepts introduced
in the course via the textbook and other sources to analyze the accident to answer
the following questions. You may choose a maximum of two accidents. You must
consider at least three accident models while answering the following questions.
Give a brief summary of the accident(s). The research paper, at a minimum, needs
to answer the following questions in your discussion of the accident:
What were the contributing factors, findings, and probable cause(s),
including the recommendations for the accident(s) you chose?
What were the active causes?
What were the root causes?
Discuss how human error played a role in the accident.
How could the current safety programs, such as SMS, change or impact the
outcome of the accident you chose?
Where within the accident chain could there have been an intervention that
could have changed the outcome?
Which proactive and predictive safety concepts could prevent similar
accidents in the future?
How can the human element in the accident be an agent to prevent an
accident like this in the future?
The goal is to apply the concepts you have learned in the textbook to an accident
using critical analysis to offer insight into the cause and prevention of similar accidents. This exercise may save your life one day.
Ask yourself these additional questions about your accident.
Can you identify any Latent errors using Reason’s “Swiss Cheese” Model?
Using the Shell Model, how did the software contribute to the accident?
How did Hardware play into the accident?
How did the Environment play into the accident?
Using the 5-Factor model, how do the five factors play into the accident?
Was there an element of luck involved in the accident?
How did human error contribute to the accident? Would implementing better “soft Skills” positively influence the outcome?
Was there a loss of SA or SSA that played a role?
Was “Miller’s Law” in play during the accident?
What was the error chain? At what level did the error chain begin?
Was the error chain discussed in the accident report?
If the error chain was not discussed in the accident narrative, can you
identify some of the error chain’s links?
Was this a genuine case of “Pilot Error”? How so?
Is there evidence of cognitive errors?
If SA was lost, explain how or when, etc.
Was there evidence of human performance failures?
Was the crew fit for duty?
Were there communication issues?
Was there an element of humans and automation not working and playing
well together?
Did fatigue play a role in the accident?
Were there lapses in professionalism that played a role in the accident?
What were the CRM or lack thereof issues, failures… etc.?
Go through the textbook and ask yourself these questions. There is plenty of
material in the textbook to analyze the accident and offer reflections, observations,
suggestions, etc. Your research paper should result in a “what-if” reflection of the
accident you chose against the backdrop of all the concepts, programs, elements,
etc., found in the textbook.
Pick the accident apart and use the wealth of information in the textbook to offer
observations, analysis, suggestions for prevention, etc.
References:
https://www.abul.org.br/biblioteca/79.pdf
https://www.faa.gov/lessons_learned/transport_airplane/accidents/N62AF
https://www.ntsb.gov/investigations/accidentreports/reports/aar8208.pdf
https://www.faa.gov/lessons_learned/transport_airplane/accidents/N388US
https://www.faa.gov/sites/faa.gov/files/2022-11/aar91-08.pdf
