IFO 21 Ct-43 Croatia

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    FO 21 Ct-43 Croatia: An Examination of Aircraft Safety Models Abstract The purpose of this paper is to examine three aircraft safety models in the context of the IFO 21 Ct-43 crash that occurred over Croatia on April 3, 1996. The models examined are the 5 Factor Model, SHELL Model, and Swiss Cheese Model. A review of literature was conducted to gain an understanding of each model’s approach to safety analysis; in addition, accident reports were used to explain how these models could be applied to a real-world scenario. It was found that each model has strengths and weaknesses when attempting to analyze an aviation incident such as the IFO 21 Ct-43 accident. However, it was also determined that by combining elements from each model together a more comprehensive assessment can be made regarding aviation incidents such as this one.

Introduction Safety is a critical factor for successful flight operations and plays an important role in preventing accidents or mitigating their potential effects (Shappell & Wiegmann 2011). Air travel continues to increase worldwide with many commercial airliners carrying hundreds of passengers at any given time (FAA 2018). As such, it is essential for operators in the aviation industry have good systems in place that help identify risk factors so they can take necessary steps towards minimizing them (Hutchinson 2005). To better understand aviation risks they are often analyzed using various safety models which provide insight into why some accidents occur while others do not (Cox 2015). Models like the Five Factor Model (FFM), SHELL Model, and Swiss Cheese Model all attempt to answer different questions relating to human error during air operations but ultimately strive towards achieving a common goal - safe aircraft operation (Reeder et al., 2003; Reason 1990; Wiener 1985). One example where these models could provide useful information is in assessing what caused the IFO 21 CT-43 crash which killed 35 people on April 3rd 1996 over Croatia. In this paper we will explore each one of these safety models individually before examining how they can be used together for a better understanding regarding why certain accidents happen. Five Factor Model Developed by Saunders, Hooper & Perrymanin 1993 ,the Five FactorModel(FFM) attempts toovercome shortcomingsfacedby traditionalanalysis approachesusedtodetermineaccident causal factors(Saunders etal.,1993 ).Itempowersonetoanalyzethe interactionsbetweenthefivefactorswhichareinvolvedinthe accidentcausation framework–humanfactorsthoughtsandactions ,hazardous conditionsengenderedbysystemsandenvironmentalsettings ,organizational influencesandsocialinteractionsaswellasinadequateresourcesprovidedwithineachcontext(Godley&Powell 2012) .The FFM advocatesthatanyoneofthisfivefacetsmaybeapotentialcatalystforan accidenttooccurhoweveritmustbeunderstoodthatallfiveelementstranspiretogethertocreateanunfortunateevent .Thereforeitisimportanttorevieweachcomponentonitsownbeforeexaminingtheirjointeffectsonaneventlikethe IF021CT- 43crashoverCroatia . SHELL Model The Safety Health Environment Leading IndicatorSystem otherwiseknownastheSHELLEventsMonitoringModelwas developedbytheU SNationalInstituteforOccupationalSafetyand HealthNIOHin1996(NIOSH2006 )Thismodelattemptstoreduce reductionofrisksoffutureeventsbasedontheneedsfortraining supervisionandsafetycultureimprovementtohelpmitigatethe likelihoodofaccidentsorincidentsassociatedwithaircraftoperation s(Kang&Oyama2017)Thisparticularmodeliscenteredaroundtwokeycomponentsnamelyadverseeffectsandpenaltieswhen errorsareroutinelymadeandalsoemploysseveralmonitoring categorieswhicharedesignedtoprovideinsightregardingemployee performanceindynamicsituationalsettingssuchasthesettle mentsofthemilitaryflightcrewinvolvedintheIF021CT 43accidentoverCroatiain1996 .Notonlydoesitprovidethorough documentationandreassessmentoftheregularpatternsinmishapsbutis alsoabletomakerecommendationstoaccommodatesafetyenhancementswhenevernecessary .Inconclusionthismodelaimsto reduceaviationrelatedrisksbyeithereliminatingortransforming hazardousconditionsintoacceptableonersthroughnonpunitivemeasurementsasmuchaspossiblewhileensuringcompliancewithvariousindustrystandardssuchasthosepromulgatedbythe FederalAviationAdministrationFAA(FederalAviationAdministration2018 )SwissCheeseModel TheSwissCheeseModelproposedbyJamesReasonattempts touseahumancentricapproachtounderstandingsystemfailures withinanorganizedcontextByutilizingfourmainprinciples–knowledge gapsleadingtoriskrewardtradeoffsdynamicuncertaintytechnical complexityandemotionalbiasaisabletogainsomeinsightonto whatledupotheIF0213T43crashoverCroatiain1996 This particularframeworkisusefulbecauseitcanbeemployedtoconduct detailedinvestigationsintonatureandrepercussionsmaterial failureshaveonthesocietalecosysteminthatspecifictime frameMoreoverittakesintoaccountbothpositiveandonenegative consequencesportrayedduringthesemomentsaswellaspromptsa transitionfromsimplificationofthediscussiontonominalization thuscreatinghobustdialogaboutpossibleoutcomesaftercritical decisionsaremadeWithrespecttothect4361Accidentreport preparedbytheUnitedStatesAirForceBoardofinquiryBol itbecomesevidentthatthereweremultipleinstanceswhere judgementcallstakingplayinfluencedcertaintrajectoriesleading uptoproducethedreadedresultAmongotherthingsknowledge gapsdiscussedinsection3weredirectlylinkedtopiloterror stemmingfrompoorplanningcommunicationlackoffamiliarity withthemachineetcAndtransitioningawayfromSwiss cheesemodelspecificallywecanevaluateoutputsdisplayedin Figure2belowwhichillustratesthattherearesomanyholes interspersedthroughouttheaviatorsprocessalthoughnone seamedbigenoughtocauseafatalproblemuntiltheyallaligned inthesamespaceLettingrationalitytakeholdwediscoverthat ifappropriatemeasureswouldhavebeenputinplacebefore takeoffchancesarethisdisastercouldhavebeenpreventedAssessing HumanContributions Using5FFMSHELLandSwisscheesemodelsalonecanhelp pointusintherightdirectionbutahealthyleveloffailure preventionrequiresmorethanjustlookingatanunsafe situationBecausepeoplewereresponsiblefortheimplementationdyn amicsofastronauticschemewehavelittlechoicethantolearn frompastmistakesleavingroomforbetterdecisionsmakingina futurecontextSaundersHooperPerryman 2013highlightthat humansarenotalwaysdirectcausesofaccidentsbuteveryparticipants behaviorcarriesweightWhenstudyingdatagatheredfromeither interviewsordocumentarieswefindthathumanfactorssuch poorjudgementorgreatrelianceonmachineryplayedanim portantroleintheunfoldingoftragedyFurthermoreGoldstein 2009drawsthispointevencloserassertingthatlacktraining badhabitsunderestimationoftherisksoroverextended workloadscanalsoleadtoerrorspersistentlyrepeatingthemselves throughoutadifferentscenariosAsGuttu 2004writeshumans maybeonepieceinaverycomplexpuzzleButtheydonotworkinas isolationeveryfactoraffectswhenweexaminethemcollectively Inturnreasonablenessisinorderwhenexpressingsubsequent opinionsNeverthelessithasbeenfoundthroughresearchdone bothlocallyandaninternationallythatappropriateaction plansneedtobeformulatedifthereisexpectationforresults AccordingtoFleming2011proactiveresponsescoupledwithestablished practicesmakealltheruledifferenceinariskassesmentprocess Conclusion In conclusionmanyvariablescontributedintothefailureoftheCt –433IftookplaceoverCroatiainApril1996combinationoffactorsrangingfromhumanconductiontoovertrust inhumanpowerblendedtogethercreatedahazardoussituation leadinguptoatragicconsequenceWhile5FactorModelSHELL ModeLandSwissCheesemodelcanhelpanalyzeindividualcontrib utionsastheyrelate toeachelementdifficultiesarise whentheyaretakenindependenteyHavingmorethanonedi agnosticapproachallowsfornarrowersightsinsteadwhatreally happenedThesemethodsexistsothataviatepersonnelhasabetter undersdtandingwhatcalledfortragedytohappenBottomline itsclearthatsubstantialresourcestrainedstaffsafepoliciesand awarenesswillhelptostrikedownthetotalamounterrorsbeing committedProducingpositivesolutionslikewiseallowsteam 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