Applying human factors and ergonomics system analysis methods to the V5-NRS Cessna 441 Conquest II aviation accident
- Authors: Fischer, Jordan Daena
- Date: 2023-10-13
- Subjects: Ergonomics , Human engineering , Accident investigation , Aircraft accidents Investigation , AcciMap Approach , System theory , Study of complex systems
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/424245 , 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. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2023
- Full Text:
- Date Issued: 2023-10-13
- Authors: Fischer, Jordan Daena
- Date: 2023-10-13
- Subjects: Ergonomics , Human engineering , Accident investigation , Aircraft accidents Investigation , AcciMap Approach , System theory , Study of complex systems
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/424245 , 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. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2023
- Full Text:
- Date Issued: 2023-10-13
Challenges faced by healthcare professionals in reporting near miss incidents in a hospital, at the Amathole District, Eastern Cape Province, South Africa
- Authors: Ntlanganiso, Lindiwe
- Date: 2022-12
- Subjects: Industrial accidents , Accident investigation
- Language: English
- Type: Master's theses , text
- Identifier: http://hdl.handle.net/10353/27094 , vital:66276
- Description: Background Recording and investigation of NMIs can provide valuable information on monitoring and enhancing patient safety in the healthcare facilities. This in turn, can reduce the likelihood of medico-legal claims. Regardless of attempts to establish efficient incident reporting systems across the entire healthcare industry, underreporting of errors persists worldwide. Therefore, not only do near miss incidents serve as early warning signs of impending potential failure in the healthcare system, but they also provide a chance for patient safety improvement. With that in mind, this study was undertaken to investigate challenges faced by health care professionals in reporting near miss incidents at a hospital in the Amathole District, in the Eastern Cape province of South Africa. Aim The aim of the study was to develop recommendations for healthcare management and healthcare professionals on how to better manage NMIs, and by identifying the challenges faced by health care professionals and the impact they have on the quality of care at one state-funded district hospital. Setting The study was conducted with healthcare professionals at a district hospital in the Amathole District, Eastern Cape Province, South Africa. Methods This study used a mixed method study design. Purposive and convenience sampling were used for participants’ selection for the study. Quantitative data was collected using the WHO Near-Miss Approach while individual and focus group interviews with healthcare professionals were carried out for collecting qualitative data. The maternity and neonatal intensive care units were identified as the two high-risk areas from which most medical negligence claims are lodged. The number of complications that occurred in each month of the year 2019 was determined by using components of the WHO near miss approach. The researcher adopted this approach to serve as a baseline assessment. Data was analysed using both Nvivo Version 10 and SPSS Version 20. Findings The challenges that healthcare professionals face in reporting near miss incidents at the study site included lack of knowledge about the reporting tool and system, inability to identify a near miss incident and healthcare professional attitudes and practices. The document review revealed that the NMIs are existent but not reported on the prescribed reporting system, a total of 210 actual incidents had occurred in the maternity and neonatal units of the hospital, which accounts for 62% of the 357 deliveries in the year 2019. Conclusion Based on the study result and findings, the healthcare system should shift towards a proactive rather than a reactive approach to medical and clinical errors. Continuously reducing the incidence of all patient safety incidents requires improved prevention strategies and effective strategies for recovery from possible medico-legal claims. The study further suggests that additional focus should be placed on NMI reporting and investigation so that operative improvement plans can be developed, implemented, monitored and evaluated. In essence, these improvement plans should be designed to progress patient care, reduce avoidable PSIs and reduce medico-legal claims. , Thesis (MCur) -- Faculty of Health Sciences, 2022
- Full Text:
- Date Issued: 2022-12
- Authors: Ntlanganiso, Lindiwe
- Date: 2022-12
- Subjects: Industrial accidents , Accident investigation
- Language: English
- Type: Master's theses , text
- Identifier: http://hdl.handle.net/10353/27094 , vital:66276
- Description: Background Recording and investigation of NMIs can provide valuable information on monitoring and enhancing patient safety in the healthcare facilities. This in turn, can reduce the likelihood of medico-legal claims. Regardless of attempts to establish efficient incident reporting systems across the entire healthcare industry, underreporting of errors persists worldwide. Therefore, not only do near miss incidents serve as early warning signs of impending potential failure in the healthcare system, but they also provide a chance for patient safety improvement. With that in mind, this study was undertaken to investigate challenges faced by health care professionals in reporting near miss incidents at a hospital in the Amathole District, in the Eastern Cape province of South Africa. Aim The aim of the study was to develop recommendations for healthcare management and healthcare professionals on how to better manage NMIs, and by identifying the challenges faced by health care professionals and the impact they have on the quality of care at one state-funded district hospital. Setting The study was conducted with healthcare professionals at a district hospital in the Amathole District, Eastern Cape Province, South Africa. Methods This study used a mixed method study design. Purposive and convenience sampling were used for participants’ selection for the study. Quantitative data was collected using the WHO Near-Miss Approach while individual and focus group interviews with healthcare professionals were carried out for collecting qualitative data. The maternity and neonatal intensive care units were identified as the two high-risk areas from which most medical negligence claims are lodged. The number of complications that occurred in each month of the year 2019 was determined by using components of the WHO near miss approach. The researcher adopted this approach to serve as a baseline assessment. Data was analysed using both Nvivo Version 10 and SPSS Version 20. Findings The challenges that healthcare professionals face in reporting near miss incidents at the study site included lack of knowledge about the reporting tool and system, inability to identify a near miss incident and healthcare professional attitudes and practices. The document review revealed that the NMIs are existent but not reported on the prescribed reporting system, a total of 210 actual incidents had occurred in the maternity and neonatal units of the hospital, which accounts for 62% of the 357 deliveries in the year 2019. Conclusion Based on the study result and findings, the healthcare system should shift towards a proactive rather than a reactive approach to medical and clinical errors. Continuously reducing the incidence of all patient safety incidents requires improved prevention strategies and effective strategies for recovery from possible medico-legal claims. The study further suggests that additional focus should be placed on NMI reporting and investigation so that operative improvement plans can be developed, implemented, monitored and evaluated. In essence, these improvement plans should be designed to progress patient care, reduce avoidable PSIs and reduce medico-legal claims. , Thesis (MCur) -- Faculty of Health Sciences, 2022
- Full Text:
- Date Issued: 2022-12
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