- Title
- Applying human factors and ergonomics system analysis methods to the V5-NRS Cessna 441 Conquest II aviation accident
- Creator
- Fischer, Jordan Daena
- ThesisAdvisor
- Davy, Jonathan Patrick
- ThesisAdvisor
- Doull, David
- ThesisAdvisor
- Todd, Andrew I
- Subject
- Ergonomics
- Subject
- Human engineering
- Subject
- Accident investigation
- Subject
- Aircraft accidents Investigation
- Subject
- AcciMap Approach
- Subject
- System theory
- Subject
- Study of complex systems
- Date
- 2023-10-13
- Type
- Academic theses
- Type
- Master's theses
- Type
- text
- Identifier
- http://hdl.handle.net/10962/424245
- Identifier
- vital:72136
- Description
- Intro: Accidents are complex in nature with multiple contributing factors. The way in which accidents are investigated is important and using system-based analysis tools assists in understanding and mapping these contributing factors to learn from them. There has been an increase in the number of accidents that have occurred within the general aviation industry in South Africa and while accident investigations have been undertaken, these have not included the application of system-based analysis tools. This led to a collaboration between Rhodes University and the Accident and Incident Investigations Division (AIID) of the South African Civil Aviation Authority where it was agreed that two systems-based analysis tools will be applied to a previously investigated accident that occurred in 2015. Aims: The first aim of this thesis was to identify if, through the implementation of these systems-based tools, the systemic contributory factors could be determined using the existing report by the AIID. The second aim of this thesis was to identify if, using the two systems-based tools, the actors and levels involved in the accident could be identified and the third aim was to identify if the implementation of these tools generates the same or different recommendations to that of the AIID. Methods: The two systems-based analysis tools applied were AcciMap and Causal Analysis using Systems Theory (CAST). These tools were applied to the V5-NRS Cessna 441 Conquest II accident report which captured the details of how the aircraft flew into the Tygerberg mountain on its descent into the Cape Town International Airport in August 2015. Results: Through the application of these two systems-based analysis tools the major contributing factors elucidated throughout this analysis were: visual and lighting conditions, pilot experience, training, lack of terrain warning equipment, fatigue, inadequate oversight, and inadequate risk management. In line with these findings, the analysis revealed various actors across various levels (the crew; South African Air Traffic Control, the SACAA, WestAir (the operator) and the Namibian Civil Aviation Authority Through the elucidation of these factors at various levels, 14 to 15 different recommendations were generated which was more than the one recommendation that was generated by the AIID. Discussion: Even when applied to an existing report, both the CAST and Accimap tools were able to bring to light the systemic contributing factors to this accident and importantly, highlight the role that various actors and levels within the system had in this unfortunate event. Consistent with previous literature, most of the contributing factors were found at the lowest level (the crew in this case) and fewer, but key factors were identified at higher levels (management and regulator level). Importantly, the application of the systems tools facilitated a systematic and systemic analysis of this accident, which allowed for the generation of recommendations at all levels, not just at the operator level. Conclusion: This study demonstrates the benefits and importance behind implementing a systems-based analysis method to an accident as these tools generate more useful recommendations which allows for important lessons to be learned following accidents, with the intention of re-designing systems to prevent them from happening again.
- Description
- Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2023
- Format
- computer, online resource, application/pdf, 1 online resource (116 pages), pdf
- Publisher
- Rhodes University, Faculty of Science, Human Kinetics and Ergonomics
- Language
- English
- Rights
- Fischer, Jordan Daena
- Rights
- Use of this resource is governed by the terms and conditions of the Creative Commons "Attribution-NonCommercial-ShareAlike" License (http://creativecommons.org/licenses/by-nc-sa/2.0/)
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | SOURCE1 | FISCHER-MSC-TR23-120.pdf | 1 MB | Adobe Acrobat PDF | View Details Download |