Sample Answer
Aviation Accident Investigations
Introduction
Aviation accidents often reveal complex interactions between human, technical, and organisational factors. Investigations typically take years, as analysts sift through layers of evidence, decision-making, and systemic weaknesses to understand not only what happened but why. This essay analyses five major aviation cases, the Space Shuttle Columbia, British Airways Flight 268, ValuJet Flight 592, Alaska Airlines Flight 261, and Japan Airlines Boeing 787-8 JA829J, with a focus on identifying systemic patterns, cultural influences, oversight dynamics, and manufacturing challenges. The aim is not to deliver verdicts but to examine multiple points of analysis that contribute to understanding how these incidents evolved.
Question 1: Space Shuttle Columbia Report
NASA’s Organisational Culture
The loss of Columbia in February 2003 exposed deep-rooted cultural and organisational issues within NASA. Analysts such as Diane Vaughan (1996) and the Columbia Accident Investigation Board (CAIB, 2003) highlighted a phenomenon termed the “normalisation of deviance.” This describes how deviations from safety standards become normalised over time when they do not immediately lead to failure. NASA had experienced foam strikes on previous shuttle launches, yet none had caused disaster, which led to a dangerous acceptance that such incidents were within operational tolerance.
The culture at NASA in this period was marked by hierarchical communication, time pressure, and a risk-tolerant mindset shaped by political and budgetary constraints. Engineers often felt unable to challenge management decisions. Organisational silos also restricted information flow, resulting in technical concerns being filtered before reaching top decision-makers. According to the CAIB (2003), NASA’s culture had shifted from one valuing technical excellence to one driven by schedule and cost compliance. This erosion of safety culture mirrored patterns seen in Challenger seventeen years earlier, indicating systemic cultural persistence.
Why Culture Was Not Listed as the Official Cause
While the CAIB explicitly described cultural failures, the official “cause” of the Columbia accident remained the physical event, foam insulation striking the left wing and breaching the thermal protection system. The distinction lies in investigation standards. The official cause in technical accident reporting typically refers to the proximal cause rather than latent organisational contributors. Cultural and managerial factors are addressed in “contributing causes” or “findings,” but the final “cause” in official terms must be physical and verifiable. This separation prevents ambiguity in accountability, even though many experts argue that NASA’s culture was the true underlying cause (Dekker, 2011).
Question 2: British Airways Flight 268
Crew’s Decisions During the Incident
British Airways Flight 268, a Boeing 747 departing Los Angeles in 2005, suffered an engine fire shortly after take-off. The crew shut down the affected engine but chose to continue the 10-hour flight to the UK rather than return to LAX. Analysing their decisions requires balancing procedural compliance, operational judgment, and situational awareness.
From an analytical standpoint, the captain’s decision can be viewed as an exercise in risk assessment under uncertainty. The aircraft remained controllable, and performance data showed it could safely continue on three engines. However, continuing over the North Atlantic with reduced redundancy introduced cumulative risk, particularly with fuel management and potential diversions. The crew’s actions complied with certain operational parameters but arguably contradicted the precautionary principle underpinning flight safety.
From a human factors perspective, cognitive biases such as “plan continuation bias” may have influenced the crew. After extensive preparation for a long-haul flight, diverting so soon could have felt disproportionate. Moreover, the crew operated under a cultural assumption of technical reliability within British Airways, known for its strong maintenance record.
Should the Captain Have Been Charged by the FAA?
Analytically, opinions diverge. Some argue the captain’s decision contravened the spirit of safety-first procedures and should have warranted FAA scrutiny. Others note that aviation decision-making is context-driven; the aircraft remained within operational limits, and no injuries or damage occurred. The FAA ultimately declined prosecution, viewing the incident as a matter for procedural revision rather than disciplinary action. This reflects a preference for systemic learning over punitive responses, consistent with modern safety management frameworks (Reason, 1997).
