Aviation Accident Analysis: Safety Management System Perspective

Assignment brief:

The objective of this assignment is to produce a report analysing on a significant aviation accident. Emphasis should be given to the identification and analysis of the key deficiencies and weaknesses from a Safety Management System’s perspective.

Details:

Choose one significant aviation accident that occurred in the world, and submit a paper on the accident.

With this assignment, students will reinforce their capabilities, improve their communication skills, critical judgment as well as consolidating their knowledge on key areas in Safety Management Systems.

The report is to provide a brief outline of what occurred and discuss salient gaps and deficiencies identified from a safety management system perspective. If appropriate, the paper should also indicate any resultant changes to aviation regulations and legislation. Please note that this is not intended to be a formal report resulting from the investigation to the accident/incident, but rather a critical paper on the safety deficiencies impacting the different elements of an SMS.

You may choose an accident which involves an organization(s) with or without an implemented SMS at the time of the accident. There are numerous examples of accidents prior to the SMS era that illustrate well the need to have an integrated and systematic approach to safety as a proactive means to minimize risks. On the other hand, recent accidents involving organisations with a fully implemented SMS prove that a safety system per se might not be an effective answer to a risk free scenario, thereby demonstrating the need to use the lessons learnt from bad experiences as a means to improve existing SMS. In summary, and whichever accident you decide to choose, your analysis should be focused on the deficiencies spanning all elements of a standard SMS (existing or not) with an aim to prevent similar occurrences in the future.

The paper should be in your own words as much as possible; where you need to quote from other sources you must properly acknowledge and reference those sources. Furthermore, in your report you will need to:

· Select a significant aviation accident;

· briefly describe the accident;

· identify the key safety issues and risks;

· analyse key  gaps  and  weaknesses  in  the  safety  management system that may have led to the accident occurring;

· determine if  there  has  been  any  resultant  changes  to  aviation legislation, regulations and/or safety practices; and

· from the lessons learnt, explain how an effective SMS could contribute to prevent analogous situations in the future;

· write up a report outlining your analysis and conclusions.

IMPORTANT: The report is to be developed around the following main headings:

 Introduction

The introduction sets the tone for the report. It has two major aims: to introduce the problem in a suitable context; to stimulate the reader’s interest. A short description of the accident based on factual information should be provided in this section.

 Accident information

Review of relevant sources of information contributing to a better understanding of the problem (e.g., official reports, journal papers, books, technical literature, media, etc). Some accidents have been thoroughly analysed and constitute reference case-studies in literature in the aviation safety domain (e.g., books, papers, articles in specialized media), whereas other accidents may benefit from resorting to main references in key areas pertaining to SMS (e.g., Human Factors, organizational issues, etc).

 Analysis and discussion

Presentation and critical analysis of findings should be included in this section. Notwithstanding the use of other references, an effort should be made to present your own argumentation and critical analysis of facts (e.g. comparison with conclusions obtained from other sources). In this section, you should aim to address the following questions in particular: 1) what were the key gaps and weaknesses in the organisation(s) Safety Management System that contributed to the accident’s occurrence. If an SMS was not in place at the date of the accident, the discussion should be centred around which elements of a SMS could be impacted if one was to exist assuming the standard structure recommended by ICAO. 2) the resulting industry recommendations and changes to aviation legislation, regulations and/or safety practices.

 Conclusion and recommendations

A list of safety recommendations should be presented in this section based on the discussion of the circumstances of the accident. An attempt should be made to go beyond the recommendations in the official report issued by the investigation authorities and envisaging improving the effectiveness of the SMS. Key ideas may be presented using bullet point format.

Assessment Criteria:

To provide a comprehensive answer to the assessment brief, you will need to achieve the following, as a minimum:

· Display a comprehensive understanding of the topic;

· Demonstrate a wide review of the literature and include practical examples to support your argumentation and analysis (a minimum of two text books and/or technical literature issued by main aviation stakeholders, 2 journal peer-reviewed papers and 2 articles/reports from authoritative industry stakeholders are expected);

· Demonstrate a critical analysis of the literature and research, including your own argumentation based on the facts and circumstances of the incident/accident.

· Present information in a logical, systematic and integrated manner (i.e., structure/format and written quality of the report);

· Appropriately use of a referencing style (e.g. RMIT Harvard Reference style)