This case study explores design/manufacturing flaws, often involving errors or faulty assumptions during the design or manufacturing process. While you are only required to conduct your case study analysis on one of the accidents, 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.
USAir Airlines Flight 427, Boeing Model 737-3B7, N513AU/FAALinks to an external site.
https://www.faa.gov/lessons_learned/transport_airplane/accidents/N513AU
British Airways Flight 38, Boeing 777-236ER, G-YMMM/FAALinks to an external site.
https://www.faa.gov/lessons_learned/transport_airplane/accidents/G-YMMM
United Airlines Flight 232, DC-10/FAALinks to an external site.
https://www.faa.gov/lessons_learned/transport_airplane/accidents/N1819U
Note: The links provided herein should serve as a starting point for your research and are not intended to be the only stop to your detailed analysis. You are encouraged to review the final accident report and other records and other sources, too (i.e., the Hunt Library).
Case Study Guidance:
A typewriter that has typed the words case study on a page. Case studies are important learning opportunities for you in this course. They will allow you to see the practical application of the material we are studying. This page is designed to provide you with guidance as you prepare your written analysis.
It is best to include section headers to clearly delineate one section from another. The bulk of your research should be authoritative websites and databases, rather than wikis. Use any resources you wish to complete this activity. Ensure you do a thorough Web search and check the vast database resources available from ERAU’s Hunt Library.
Your case study analysis must include the following sections, sequentially:
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.
Note that your work will automatically be submitted to the Turnitin anti-plagiarism tool. This software checks your writing against a database of millions of written works and provides feedback on originality. Ensure your written work submitted is entirely your own and that you have not plagiarized any material. Properly cite your sources using APA format – especially in the use of direct quotations!
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