Instructions

Further recommendations for an enhanced report:

a. Select an accident or incident that you find interesting but also one that has multiple sources of original research material, including the original accident/incident investigation report. Do not report on an act of sabotage or terrorism.

b. The accident or incident can be drawn from any area of aviation (e.g. flight operations, maintenance, customer service, ground handling, security etc).

c. When analysing the accident or incident using the SH(C)EL/L model look at the liveware (operator) as the focus when analysing the error(s) but be aware that that the liveware (operator) may change depending the aspect you are analysing. For instance, if an accident involves both a PF (pilot flying) and an ATC error, you need to look at both the PF and the ATC operator separately as the centre of their own SHEL system.

Learning Outcome 1 Assess the regulatory framework behind Safety requirements

Learning Outcome 2

Examine safety measurements and systems in airlines, aircraft and airports.

Learning Outcome 3

Assess contemporary challenges related to safety management and recommend solutions.

TASK:

(LO1, LO2 and LO3) Select two aircraft accidents for examination, and report your findings based on the guidelines provided (define “accident” as stipulated in ICAO Annex 13). The report must focus on the findings of the investigation by considering which of these findings are causal and which findings are not considered causal.

Specific mark allocation guide:

1. Application and defence of an appropriate organisational accident causation model (James Reason’s Swiss Cheese, 5-M, SH(C)EL/L, HFACS): Learning Outcome 1 and 2 (25 marks).

2. Identification of specific latent weaknesses within the accident causal linkages (layers of defence) and issues related to the outcome of the accident or incident (Learning Outcome 2 and 3): 50 marks.

3. Compare and contrast the investigation’s probable causes with other contributory factors. What recommendations would you support or offer based on your analysis of the accident or incident? (Learning Outcome 1 and 3): 25 marks.

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