For this activity, you will pick one of the following accidents related to aircraft operation, maintenance, and inspection issues:
Aloha Airlines Flight 243, Boeing 737-200, N73711/FAA (Links to an external site.) https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=20
American Airlines Flight 587, Airbus A300-600, N14053/FAA (Links to an external site.) https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=35
Alaska Airlines Flight 261, McDonnell Douglas MD-83, N963AS/FAA (Links to an external site.) https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=23
In this module you will discover factors related to nondestructive inspection (NDI) and nondestructive testing (NDT), such as visual, borescope, liquid (dye) penetrant, magnetic particle, ultrasonic, eddy current, and radiographic (X-rays and Gamma rays) inspections.
An accident case study analysis is included as research for this module to allow an opportunity to apply what you’ve learned in the course up to now.
This case study explores aircraft operation or maintenance/inspection flaws, often involving errors or faulty assumptions during the operation or maintenance process. Feel free to explore each of the accident descriptions to help you decide if there is a particular accident you wish to study over the other two. As you study and research the accident you chose, be sensitive to discover what the flaws, errors, and faulty assumptions were.
Again, this site and its database hold a wealth of data and useful information pertaining to these case study analyses of this course. Use this case study to become acquainted with the information and resource layout on the FAA website. Graphics, actual documents, and final accident reports are all included in the accidents provided in this database, which makes it a great starting point. Try to be as specific as you can while expressing your analysis in your own words, so try to limit your use of jargon.
Case Study Guidance
Title or Cover Page – Include title, activity number, course number, and your name at a minimum.
Introduction or executive summary – include a brief paragraph to introduce your reader to your approach to this analysis and what to expect.
Primary Causal Factor(s) of the Accident – Include one to two paragraphs identifying the probable cause(s) of the accident. Usually, it is hard to narrow an accident event down to a single cause, especially if two related or intertwined systems or system components are involved simultaneously, referred to as ‘coupling’ in the context of safety analysis. This content must be evidence-based and factual in nature.
Contributing Factors to the Accident – Include two to four paragraphs identifying what the contributing factors were causal to the accident. These factors contributed to the accident, even though they weren’t primary. These factors could be links in the ‘accident chain’ of events leading up to the mishap. These factors may reduce or exacerbate the accident conditions and resulting severity. A thorough analysis in this section should aid you in formulating potential risk mitigation or reduction strategies in a subsequent section. This content must be evidence-based and factual in nature.
Structural and Mechanical Factors Related to the Accident – Include two to four paragraphs identifying the structural and mechanical factors involved in this accident. This portion should entail the bulk of your analysis. Use this section to detail any strengths and weaknesses of the applicable aviation system(s), whether aircraft design, construction, maintenance, component reliability, etc. This content must be evidence-based and factual in nature.
Relevant Human Factors and/or Organizational Factors Related to the Accident – Include two to four paragraphs identifying what the relevant human/organizational factors were involved in this accident. Be sure to include how these deficiencies led to or exacerbated the situation. This content must be evidence-based and factual in nature.
Outcomes of the Accident – Include two to four paragraphs stating what happened subsequent to the accident (this may be months or years later). Although a bulleted list of outcome items may be provided, there should be sufficient explanations to describe any disparities between the investigation board’s proposed solutions (i.e., recommendations) versus ‘real-world’ eventual actions by the various governmental and industry groups. Examples may include possible airworthiness directives (ADs) issued, new regulations or rules adopted or amended, redesign standards, etc. Consider which recommendations were suggested by the investigation board. Were these recommendations followed or complied with? What recommendations were left unheeded? If so, why? This content must be evidence-based and factual in nature.
Risk Mitigation or Reduction Strategies – Include two to four paragraphs explaining, from your analysis, any risk mitigation or reduction strategies or methods that you believe may have either prevented this accident or lessened its severity. This is your opportunity to demonstrate and integrate your knowledge learned up to this point of the course and apply learned facets in analyzing this accident. This is where you can interject your opinions, suggestions, any differences you may have regarding investigation board results, and any differences toward eventual outcomes related to this accident. This section should prepare you for your Discussion – Case Study Reflection
Conclusion or Summary – Include one or two paragraphs to explain your main take-aways from this case study. This is your opportunity to demonstrate and integrate your knowledge learned up to this point of the course and apply learned facets in analyzing this accident. This is also where you can interject your opinions, suggestions, or differences regarding investigation board results related to this accident. This section should prepare you for your Discussion – Case Study Reflection
Reference Page – Include all references cited in the paper of information sources, in current APA edition format.