Module 2 - Causes of Incidents and Accidents

• Causes of Aircraft accidents or incidents:

  -       Actions

  -       Omissions

  -       Events

  -       Conditions

  -       A combination
• 20 links - no. of links regarding investigations of some hull loss accidents in the United States
• Under 4 links – average no. of links involved in an accident or incident
• Subdividing – by doing this, an incident or accident leads into a chain of events reveals important information
• Consequences - the only meaningful difference between many incidents and accidents
• CFIT - controlled flight into terrain
• “Loss of Control” Accidents – a classification of accidents that include collisions caused by engine failure, icing, stalls, or other circumstances that interfere with the ability of the flight crew to direct the motion of the aircraft
• QAR – quick access recorders
• Quick Access Recorders – use to monitor stopping distance would provide operators with an independent means of detecting potentially hazardous abnormalities
• Accident rates can be computed in terms of accidents per:

  -        Passenger-trip

  -        Passenger-mile

  -        Passenger-flight hour
• Proactive Approach – an approach that could eliminate risks before they cause accidents and requires an effective means of tracking the chains of events in both incidents and accidents
• Corrective Action - use to prevent one or more of the events and is one approach to preventing other accidents that might involve the same events
• Human factors - include mistakes caused by voluntary acts, failure to act, and other factors associated with actions or inaction
• Maintenance-related cause factors - include improperly performed maintenance and inadequate maintenance procedures and plans
• Environmental Cause - factors include hazardous weather, volcanic ash, sand, dust, and birds.
• Primary Cause - defined as the most critical cause factor associated with a particular incident or accident, can be deceiving and is often subject to interpretation
• FOQA - flight operations quality assurance
• BASIS - British Airways Safety Information System
• Traps - common factors that are easier to identify and eliminate than a unique, extremely rare factor that may be labeled the "primary cause" in a given accident
• Methodical Approach – an important approach to the process of accident investigation we must ensure
• Investigation of accidents consists of three distinct principles:

   

  -        Data Collection (Physical, Documentation, & Photographic)

  -        Analysis of Data

  -        Presentation of Findings
• Accident investigation - a systematic process whereby all of the possible causes of an adverse event are evaluated and eliminated
• Accident investigation – considered as both Art and Science