Is this project an undergraduate, graduate, or faculty project?
Undergraduate
group
What campus are you from?
Daytona Beach
Authors' Class Standing
Kevin Batz, Senior Scott Masse, Senior William Taylor, Senior Matthew Soja, Senior Trevor Todd-Stone, Senior
Lead Presenter's Name
Kevin Batz
Faculty Mentor Name
Flavio Antonio Coimbra Mendonca
Abstract
James Reason’s Swiss-Cheese Model contends that complex systems are protected by multiple defensive layers designed to prevent hazards and system failures from evolving into accidents. These overlapping barriers protect complex technological systems, such as the aviation industry, against accidents. This model proposes that all accidents include a combination of both active failures and latent conditions. Active failures are unsafe acts, including errors and violations, that are generally associated with front-line personnel (e.g. pilots) which could result in injuries and/or damage to equipment. Latent conditions are those that exist in the aviation system well before a damaging outcome is experienced and are usually the result of fallible decisions made by people far removed from the situation. The Swiss-Cheese model was utilized to identify the latent conditions and active failures contributing to the tragedy of Air France flight 447 on June 1st, 2009. The results of this case study indicate that incorrect airspeed measurements and sudden changes in the aircraft’s automation led to inappropriate control inputs that destabilized the flight path. The flight crew then failed to follow procedure for the loss of indicated speeds, failed to identify the approach to stall, and failed to correct the flight path. These discoveries led to the illumination of major deficiencies in both human factors, such as the interaction with Airbus’ automation system, and crew resource management, such as Air France’s pilot training program, that ultimately led to organizational improvements.
Did this research project receive funding support from the Office of Undergraduate Research.
No
Organizational Accidents and the Swiss Cheese Model: Learning from Air France flight 447
James Reason’s Swiss-Cheese Model contends that complex systems are protected by multiple defensive layers designed to prevent hazards and system failures from evolving into accidents. These overlapping barriers protect complex technological systems, such as the aviation industry, against accidents. This model proposes that all accidents include a combination of both active failures and latent conditions. Active failures are unsafe acts, including errors and violations, that are generally associated with front-line personnel (e.g. pilots) which could result in injuries and/or damage to equipment. Latent conditions are those that exist in the aviation system well before a damaging outcome is experienced and are usually the result of fallible decisions made by people far removed from the situation. The Swiss-Cheese model was utilized to identify the latent conditions and active failures contributing to the tragedy of Air France flight 447 on June 1st, 2009. The results of this case study indicate that incorrect airspeed measurements and sudden changes in the aircraft’s automation led to inappropriate control inputs that destabilized the flight path. The flight crew then failed to follow procedure for the loss of indicated speeds, failed to identify the approach to stall, and failed to correct the flight path. These discoveries led to the illumination of major deficiencies in both human factors, such as the interaction with Airbus’ automation system, and crew resource management, such as Air France’s pilot training program, that ultimately led to organizational improvements.