Reasons For The Swiss Cheese Model

One of the most controversial and important air crash linked to human error of the modern world happened on the night of February 12, 2009. Colgan air flight 3407, operated by Continental Connection, was on final approach to runway 23 at Buffalo-Niagara International Airport as it disappeared from radar. The aircraft was a Bombardier Dash 8, a popular twin engine medium range turboprop Airliner used by many regional carriers. The aircraft entered an uncontrollable stall crashing into to a neighborhood 5 miles northeast of the airport killing all everyone on souls on board. The Captain, Marvin Resnlow and first officer Rebecca Lynne were behind the controls the night of the accident. The NTSB report determined error by both pilots cause the aircraft to crash. Thus, pilot fatigues, improper recovery form a stall were contributing factors. The victim’s family members pushed for congress to overhaul airline regulations. The NTBS investigation delivery multiple findings that eventually led to a modernization of airline operations and pilot training.

Reason (2000) opines that the safeguards in the system are likened to slices of Swiss cheese and that the presence of holes in one piece does not invariably lead to a bad outcome but only when the holes in the other slices align to allow a trajectory which results in an unsatisfactory outcome. He further alluded that the breach in the barrier may result from both active and latent failures.

Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root

Crashes are rare, and most of the time are consequences of many unrelated factors. Many believe that airplane crashes are the cause of bad piloting or harsh weather; but other factors are overlooked. Suren Ratwatte have been studying airplane

The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from

The SHELL Model has proven to be an useful tool when it comes to using the human factors and aviation safety. On this case study, we will use the details from the NTSB report from the American Airlines Flight 1420 NTSB to study all the factors of the SHELL Model that were contributed to the accident.

First of all, a causal argument focuses on causes and effects. In this article, authors have discussed how accidents happen while

The study of traffic crashes is a relatively new disciple in the forensic forum. This could be due to the progressive number of deaths resulting from wrecks. Although the idea of ‘Forensic Engineering’ may still be fresh to the public, it has been widely accepted and implemented by law enforcement. Technology is still being created to assist in furthering this field. Simultaneously, law enforcement agencies are working diligently to prove that although fatal crashes are not intentional, the underlying primary contributing factors are negligent, thus adding a homicidal element to most traffic homicide investigations. This mission became more urgent to me, after reading that fatal crashes where only considered accidental. This paper will attempt

On Saturday, August twenty-second, a stunt plane at an air show in England crashed and killed seven people. It was said that the pilot of the stunt plane was attempting to do a loop, but lost control and crashed onto a highway. The seven people that were killed in this accident were people just driving on highway and were caught in the accident. The plane model that crashed was called a “Hawker Hunter”, and it was a plane model from the Cold War. Along with the seven people that were killed in the accident, there are around fourteen people that were injured.

The terrorist attacks on September 11 2001 will have a permanent affect on the global culture. Nearly every decision, process, design in the aviation community will be affected from these attacks. The masterminds behind these attaches could not have envisioned how much the world would change from these acts.

On June 1st, 1999 American Airlines flight 1420 experienced a tragic accident that claimed many lives and made an impact on aviation worldwide. The event and it subsequent investigation shed

The science of human factors in aviation has a come along way since the days of the Wright brothers in 1913 but it did not actually start with them. According to Dr. Bill Johnson, Chief Scientist at the Federal Aviation Administration, human factors “dates back to the 1600s when Leonardo da Vinci drew the Vitruvian Man, with all the anthropometric measures, [when] he was trying to decide if a human was strong enough to propel an aircraft” (FAA, 2012). Long after the work of da Vinci, human factors has brought advancements to aircraft design while creating a greater understanding of the human role in mishaps.

I will take Three Mile Island (TMI) nuclear accident as an example to further understand how these two models work for recognizing the causations of accidents.

There are several events that contributed to this incidents occurring. Some of them are related in the form of chain events for instance the second event occur because of the effect from the first event and the third event occur because of the effect from second event and so on until the incident occur. By using SHELL Model, base on the Aircraft Accident Report 3/96 which was provided and presented by Air Accidents Investigation Branch, Department of Transport, under the report title of “Report on the Incident to Boeing 737-400, G-OBMM near Davontry on 23 February 1995, the analysis of the contribution events to the incident can be reveal and the appropriate recommendations from competence authority was been made to ensure the same incident will not occur in the future.

As a ramification, it is difficult for human operators to anticipate faults within the system and prevent and manage the risks incurred by an operational accident accordingly, making them “incomprehensible”. Therefore, organisational accidents in complex systems are inevitable as despite defensive measures implemented to mitigate their risk, such as the training of operators and regular maintenance, the fragile design of the systems is the core reason why accidents occur.