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
Application of systems theory for analysing the sustainability foci and practices of the Faculty of Economics and Information Technology Systems: (A Case Study of Walter Sisulu University: Komani campus)
- Authors: Klishi, Konwaba Bomikazi
- Date: 2022-10-14
- Subjects: Sustainable development Study and teaching (Higher) South Africa Mthatha , System theory , Curriculum evaluation South Africa Mthatha , Community engagement , Walter Sisulu University for Technology and Science
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/405281 , vital:70157
- Description: Sustainable development is a global concern that intertwines several factors, including poverty, biodiversity, inequality, water, and energy. This interconnection does not only affect the current generation but may have long term implications for future generations as we see the rapid spread of environmental risk in our local communities. In this study, systems theory was adapted for analysing the sustainability focus of the Faculty of Economics and Information Technology Systems (FEITS) at Walter Sisulu University. A qualitative research method was used during this research, and data collected from a purposive sample of staff, activities and documentation. In this study, Von Bertalanffy’s systems theory is applied to analyse the sustainability foci and practices of the FEITS. The study describes sustainability practices and concerns that emerge from research activities, community engagement activities and work-integrated learning. The theory is also used to analyse the connection between various subsystems of the faculty when addressing emerging local sustainability concerns. Education for sustainable development is an important aspect of this study as it considers the sustainability concerns in the curriculum from the perspective of current and future alternatives for the economy and socio-ecological aspects of communities. The following findings have emerged from the study: Contextual realities related to inequality were foci of discussion and concern in various qualifications. Socioecological issues and risks were found to be related to water and sanitation, food security and climate change. Sustainability discourse is related to health and wellbeing, peace, and security. There is an alignment of green skills to the curriculum of the faculty and pedagogical practices which relate to sustainability. The faculty participates in stakeholder platforms to respond local sustainability challenges and is developing courses in response to local development needs. This study has implications for the faculty’s curriculum in terms of the content of various qualifications, future research, and community engagement activities of the university. , Thesis (MEd) -- Faculty of Education, Education, 2022
- Full Text:
- Date Issued: 2022-10-14
- Authors: Klishi, Konwaba Bomikazi
- Date: 2022-10-14
- Subjects: Sustainable development Study and teaching (Higher) South Africa Mthatha , System theory , Curriculum evaluation South Africa Mthatha , Community engagement , Walter Sisulu University for Technology and Science
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/405281 , vital:70157
- Description: Sustainable development is a global concern that intertwines several factors, including poverty, biodiversity, inequality, water, and energy. This interconnection does not only affect the current generation but may have long term implications for future generations as we see the rapid spread of environmental risk in our local communities. In this study, systems theory was adapted for analysing the sustainability focus of the Faculty of Economics and Information Technology Systems (FEITS) at Walter Sisulu University. A qualitative research method was used during this research, and data collected from a purposive sample of staff, activities and documentation. In this study, Von Bertalanffy’s systems theory is applied to analyse the sustainability foci and practices of the FEITS. The study describes sustainability practices and concerns that emerge from research activities, community engagement activities and work-integrated learning. The theory is also used to analyse the connection between various subsystems of the faculty when addressing emerging local sustainability concerns. Education for sustainable development is an important aspect of this study as it considers the sustainability concerns in the curriculum from the perspective of current and future alternatives for the economy and socio-ecological aspects of communities. The following findings have emerged from the study: Contextual realities related to inequality were foci of discussion and concern in various qualifications. Socioecological issues and risks were found to be related to water and sanitation, food security and climate change. Sustainability discourse is related to health and wellbeing, peace, and security. There is an alignment of green skills to the curriculum of the faculty and pedagogical practices which relate to sustainability. The faculty participates in stakeholder platforms to respond local sustainability challenges and is developing courses in response to local development needs. This study has implications for the faculty’s curriculum in terms of the content of various qualifications, future research, and community engagement activities of the university. , Thesis (MEd) -- Faculty of Education, Education, 2022
- Full Text:
- Date Issued: 2022-10-14
A systems thinking approach to e-government strategy formulation for water service delivery in South African local municipalities
- Authors: Osah, Umeoniso Joshua
- Date: 2017
- Subjects: Internet in public administration South Africa , Electronic government information South Africa , Communication in public administration South Africa , Municipal services South Africa , Municipal services Information technology , System theory
- Language: English
- Type: Doctoral theses , text
- Identifier: http://hdl.handle.net/10962/64471 , vital:28547 , DOI 10.21504/10962/64471
- Description: E-Government deployments by stakeholders within the South African water service sector, provide certain benefits for the sector. While deemed beneficial and of considerable value, e-Government deployments and implementations in the water sector of local governments of South Africa have not always been successful. One important reason for e-Government failures, among several others, is the lack of coherent strategies, informed by key representing stakeholder views, to guide implementation and deployment of e-Government tools. Without strategies, it is highly likely that ICT integration will be conducted haphazardly. As a point of note, more than the deliverable (strategy document) that represents the output of the strategy development process, it serves more purpose to understand the process that results in the strategy. Importantly, understanding the process helps to account for the formed relationships between the various stakeholders that need to buy into the strategy. The research study develops an e-Government strategy formulation framework based on a systems thinking approach, intended to support the strategy formulation process of e-Government strategies – to underpin the effective integration, deployment and sustained use of ICT solutions for water service delivery at the local government level. A systems thinking approach is considered due to its emphasis on the strategy being informed by a holistic assessment. Where there is some knowledge about the processes by which a strategy is formulated – over time ideas may be derived on the types of processes that may produce efficient e-Government strategies. The research is conducted using the Design Science research paradigm. The Design Science paradigm is comprised of two processes – build and evaluate (Hevner et al., 2004). The build process, as related to this research concentrates on the progression through which the theoretical e-Government strategy formulation framework is derived. Weick’s (1989) theorizing approach is ascribed, supporting the design of the theoretical framework. In applying Weick’s theorizing approach, firstly, the lack of knowledge on how e-Government strategies should be formulated in South African local municipalities – is explicated in an intelligible manner. Once the problem is properly articulated, a trial and error selection process is undertaken of existing approaches on strategy formulation – thought to possess the potential to contribute to the development of an e-Government strategy formulation framework, suited to local governments in South Africa. With good reason, 10 (ten) strategy approaches are selected from, e-Government programmes in developed countries, Non-Governmental organizational strategy approaches, and business related strategy formulation approaches. Lastly, as all possible approaches that may contribute to the framework development process cannot be selected, criteria is specified to limit the number of possible selections. Furthermore, in deriving the framework, foundations for systematically dealing with unstructured problems, such as, strategy formulation are consulted. This foundation along with the research goals, informs the development of a template used to comparatively analyse the 10 selected approaches on strategy formulation. This analysis aids in revealing the components of an e-Government strategy formulation process. With the developed framework, the evaluation process of the design science research commences, seeking to determine the utility of the framework (suitability and shortcomings). The framework is applied to the procedural formulation of a strategy for a tentative e-Government project called MobiSAM, which aims to enhance citizen engagement with local government through the use of mobile phones. The strategy formulation application process in the project environment and local government reveals lessons that inform revisions to the framework. The e-Government strategy formulation framework, therefore represents a fundamental tool for e-Government strategy development in local municipalities, and may be customized to fit the requirements of varying local municipalities. , Thesis (PhD) -- Faculty of Commerce, Information Systems, 2017
- Full Text:
- Date Issued: 2017
- Authors: Osah, Umeoniso Joshua
- Date: 2017
- Subjects: Internet in public administration South Africa , Electronic government information South Africa , Communication in public administration South Africa , Municipal services South Africa , Municipal services Information technology , System theory
- Language: English
- Type: Doctoral theses , text
- Identifier: http://hdl.handle.net/10962/64471 , vital:28547 , DOI 10.21504/10962/64471
- Description: E-Government deployments by stakeholders within the South African water service sector, provide certain benefits for the sector. While deemed beneficial and of considerable value, e-Government deployments and implementations in the water sector of local governments of South Africa have not always been successful. One important reason for e-Government failures, among several others, is the lack of coherent strategies, informed by key representing stakeholder views, to guide implementation and deployment of e-Government tools. Without strategies, it is highly likely that ICT integration will be conducted haphazardly. As a point of note, more than the deliverable (strategy document) that represents the output of the strategy development process, it serves more purpose to understand the process that results in the strategy. Importantly, understanding the process helps to account for the formed relationships between the various stakeholders that need to buy into the strategy. The research study develops an e-Government strategy formulation framework based on a systems thinking approach, intended to support the strategy formulation process of e-Government strategies – to underpin the effective integration, deployment and sustained use of ICT solutions for water service delivery at the local government level. A systems thinking approach is considered due to its emphasis on the strategy being informed by a holistic assessment. Where there is some knowledge about the processes by which a strategy is formulated – over time ideas may be derived on the types of processes that may produce efficient e-Government strategies. The research is conducted using the Design Science research paradigm. The Design Science paradigm is comprised of two processes – build and evaluate (Hevner et al., 2004). The build process, as related to this research concentrates on the progression through which the theoretical e-Government strategy formulation framework is derived. Weick’s (1989) theorizing approach is ascribed, supporting the design of the theoretical framework. In applying Weick’s theorizing approach, firstly, the lack of knowledge on how e-Government strategies should be formulated in South African local municipalities – is explicated in an intelligible manner. Once the problem is properly articulated, a trial and error selection process is undertaken of existing approaches on strategy formulation – thought to possess the potential to contribute to the development of an e-Government strategy formulation framework, suited to local governments in South Africa. With good reason, 10 (ten) strategy approaches are selected from, e-Government programmes in developed countries, Non-Governmental organizational strategy approaches, and business related strategy formulation approaches. Lastly, as all possible approaches that may contribute to the framework development process cannot be selected, criteria is specified to limit the number of possible selections. Furthermore, in deriving the framework, foundations for systematically dealing with unstructured problems, such as, strategy formulation are consulted. This foundation along with the research goals, informs the development of a template used to comparatively analyse the 10 selected approaches on strategy formulation. This analysis aids in revealing the components of an e-Government strategy formulation process. With the developed framework, the evaluation process of the design science research commences, seeking to determine the utility of the framework (suitability and shortcomings). The framework is applied to the procedural formulation of a strategy for a tentative e-Government project called MobiSAM, which aims to enhance citizen engagement with local government through the use of mobile phones. The strategy formulation application process in the project environment and local government reveals lessons that inform revisions to the framework. The e-Government strategy formulation framework, therefore represents a fundamental tool for e-Government strategy development in local municipalities, and may be customized to fit the requirements of varying local municipalities. , Thesis (PhD) -- Faculty of Commerce, Information Systems, 2017
- Full Text:
- Date Issued: 2017
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