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Chain Of Events (accident Analysis)
In accident analysis, a chain of events (or error chain) consists of the contributing factors leading to an undesired outcome. Aviation In aviation accidents and incidents, these contributing actions typically stem from human factor-related mistakes and pilot error, rather than mechanical failure. A study conducted by Boeing found that 55% of airline accidents between 1959 and 2005 were caused by such human related factors, while only 17% of accidents were caused by mechanical issues with the aircraft. The Tenerife airport disaster, the worst accident in aviation history, is a prime example of an accident in which a chain of events and errors can be identified leading up to the crash. Pilot error, communications problems, fog, and airfield congestion (due to a bomb threat and explosion at another airport) all contributed to this catastrophe. See also *Swiss cheese model The Swiss cheese model of accident causation is a model used in risk analysis and risk management, i ...
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Accident Analysis
Accident analysis is carried out in order to determine the cause or causes of an accident (that can result in single or multiple outcomes) so as to prevent further accidents of a similar kind. It is part of ''accident investigation or incident investigation .'' These analyses may be performed by a range of experts, including forensic scientists, Forensic engineering#Forensic engineering, forensic engineers or health and safety advisers. Accident investigators, particularly those in the aircraft industry, are colloquially known as "tin-kickers". Health and safety and patient safety professionals prefer using the term "incident" in place of the term "accident". Its retrospective nature means that accident analysis is primarily an exercise of directed explanation; conducted using the theories or methods the analyst has to hand, which directs the way in which the events, aspects, or features of accident phenomena are highlighted and explained. Sequence Accident analysis is performed in ...
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Jeppesen
Jeppesen (also known as Jeppesen Sanderson) is an American company offering navigational information, operations planning tools, flight planning products and software. Jeppesen's aeronautical navigation charts are often called "Jepp charts" or simply "Jepps" by pilots, due to the charts' popularity. This popularity extends to electronic charts, which are increasingly favored over paper charts by pilots and mariners as mobile computing devices, electronic flight bags, integrated electronic bridge systems and other display devices become more common and readily available. Jeppesen is headquartered in Inverness, Colorado, a census designated place in Arapahoe County. The postal designation of Englewood is used in the company's mailing address. Jeppesen has offices in locations around the world, including Neu-Isenburg (Germany), Massa (Italy), Crawley (United Kingdom), Gothenburg (Sweden), Canberra (Australia) and Gdańsk (Poland). The company employs approximately 3,200 people.< ...
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Englewood, Colorado
The City of Englewood is a home rule municipality located in Arapahoe County, Colorado, United States. The town population was 33,659 at the 2020 United States Census. Englewood is a part of the Denver–Aurora–Lakewood, CO Metropolitan Statistical Area and the Front Range Urban Corridor. Englewood is located immediately south of Denver in the South Platte River Valley. History The recorded history of Englewood began in 1858, when gold was discovered on what came to be called Little Dry Creek by William Green Russell, an early settler of the High Plains. Two years later, Thomas Skerritt, considered to be the founder of the city, established a home in the area, which was called Orchard Place. Four years later, the first road connecting Denver and Orchard Place was created by Skerritt himself, using his own plough. In 1879, the first telephone arrived in the area. In 1883, the Cherrelyn horsecar path was laid. The Cherrelyn trolley was and is an important city icon, being c ...
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Aviation Accidents And Incidents
An aviation accident is defined by the Convention on International Civil Aviation Annex 13 as an occurrence associated with the operation of an aircraft, which takes place from the time any person boards the aircraft with the ''intention of flight'' until all such persons have disembarked, and in which a) a person is fatally or seriously injured, b) the aircraft sustains significant damage or structural failure, or c) the aircraft goes missing or becomes completely inaccessible. Annex 13 defines an aviation incident as an occurrence, other than an accident, associated with the operation of an aircraft that affects or could affect the safety of operation. A hull loss occurs if an aircraft is damaged beyond repair, lost, or becomes completely inaccessible. The first fatal aviation accident was the crash of a Rozière balloon near Wimereux, France, on June 15, 1785, killing the balloon's inventor, Jean-François Pilâtre de Rozier, and the other occupant, Pierre Romain. Th ...
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Human Factors
Human factors and ergonomics (commonly referred to as human factors) is the application of psychological and physiological principles to the engineering and design of products, processes, and systems. Four primary goals of human factors learning are to reduce human error, increase productivity, and enhance safety, system availability, and comfort with a specific focus on the interaction between the human and the engineered system. The field is a combination of numerous disciplines, such as psychology, sociology, engineering, biomechanics, industrial design, physiology, anthropometry, interaction design, visual design, user experience, and user interface design. Human factors research employs methods and approaches from these and other knowledge disciplines to study human behavior and generate data relevant to the four primary goals above. In studying and sharing learning on the design of equipment, devices, and processes that fit the human body and its cognitive abilities, the ...
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Pilot Error
Pilot error generally refers to an Aviation accidents and incidents, accident in which an action or decision made by the Aircraft pilot#Airline, pilot was the cause or a contributing factor that led to the accident, but also includes the pilot's failure to make a correct decision or take proper action. Errors are intentional actions that fail to achieve their intended outcomes. Chicago Convention on International Civil Aviation, Chicago Convention defines accident as "An occurrence associated with the operation of an aircraft [...] in which [...] a person is fatally or seriously injured [...] ''except when the injuries are [...] inflicted by other persons."'' Hence the definition of the "pilot error" does not include deliberate crash (and such crash is not an accident). The causes of pilot error include psychological and physiological human limitations. Various forms of threat and error management have been implemented into pilot training programs to teach crew members how t ...
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Boeing
The Boeing Company () is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, telecommunications equipment, and missiles worldwide. The company also provides leasing and product support services. Boeing is among the largest global aerospace manufacturers; it is the third-largest defense contractor in the world based on 2020 revenue, and is the largest exporter in the United States by dollar value. Boeing stock is included in the Dow Jones Industrial Average. Boeing is incorporated in Delaware. Boeing was founded by William Boeing in Seattle, Washington, on July 15, 1916. The present corporation is the result of the merger of Boeing with McDonnell Douglas on August 1, 1997. Then chairman and CEO of Boeing, Philip M. Condit, assumed those roles in the combined company, while Harry Stonecipher, former CEO of McDonnell Douglas, became president and COO. The Boeing Company's corporate headquarters is in Chicago, Illi ...
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Tenerife Airport Disaster
The Tenerife airport disaster occurred on March 27, 1977, when two Boeing 747 passenger jets collided on the runway at Los Rodeos Airport (now Tenerife North Airport) on the Spanish island of Tenerife. The collision occurred when KLM Flight 4805 initiated its takeoff run while Pan Am Flight 1736 was still on the runway. The impact and resulting fire killed everyone on board KLM 4805 and most of the occupants of Pan Am 1736, with only 61 survivors in the front section of the aircraft. With 583 fatalities, the disaster is the deadliest accident in aviation history. A bomb set off by the Canary Islands Independence Movement at Gran Canaria Airport had caused many flights to be diverted to Los Rodeos, including the two aircraft involved in the accident. The airport quickly became congested with parked airplanes blocking the only taxiway and forcing departing aircraft to taxi on the runway instead. Patches of thick fog were drifting across the airfield, so visibility was greatly r ...
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Swiss Cheese Model
The Swiss cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of Swiss cheese, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure. The model was originally formally propounded by James T. Reason of the University of Manchester, and has since gained widespread acceptance. It is sometimes called the "cumulative act effect". Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subjec ...
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