View the following YouTube videos:
- Air Disasters – Terror in San Francisco (Asiana Airlines Flight 214) (6:32)(Links to an external site.)
- NTSB “Animation of Asiana Flight 214 accident sequence” (3:55)(Links to an external site.)
- ABC news update: “Aircraft Accidents Investigation: Asiana Airlanes Flight 214 Crash” (3:15)(Links to an external site.)
- Asiana 214: Full Crash And Rescue Footage – Airport Camera Video C225 (47:42)(Links to an external site.)
- Tower camera video of crash, evacuation, and emergency response
Read the following:
- Board Meeting: Crash of Asiana Flight 214 Accident Report summary (NTSB)(Links to an external site.)
- Asiana airlines crash caused by pilot error and confusion, investigators say (The Guardian)(Links to an external site.)
The crash of Asiana Flight 214 on July 6, 2013 was one of the most widely publicized crashes up to that point that dealt primarily with automation. Of the 307 people on board the B-777 aircraft, 3 were killed and 187 injured, of which 49 were serious injuries. The weather was clear and perfect for the visual approach the pilots elected to fly that day. But what should have been a routine approach and landing for these highly experienced pilots took a dramatic turn. So, what went wrong? Let’s see what can we learn using systems safety techniques about this crash? Based on the videos and anything else you researched, use one of the techniques you learned about in this module to conduct an analysis of one of the system malfunctions that happened and led to this crash. Take this analysis and draft a one to two-page report to show your boss the findings and how to correct this problem before it happens again.
As with every case study, don’t feel limited to just the video and reading posted here. Feel free to use any credible sources you wish to complete this assignment but be sure to cite them accordingly.
This assignment has two requirements that must be completed. The first is a chart presenting the data you selected to analyze in your chosen technique (examples are found in the Ericson text). The second is a short narrative to the boss telling them why the items you show in your chart are important and need to be addressed. Both of these must be turned in for this case study.
Your Instructor will evaluate your analysis based on the Case Study Rubric.
Save your assignment using a naming convention that includes your first and last name and the activity number (or description). Do not add punctuation or special characters.
Your paper will automatically be evaluated through Turnitin when you submit your assignment in this activity.
tools
Software Hazard Analysis
Sneak Circuit Analysis
Barrier Analysis
Management Oversight Risk Tree Analysis