It has been argued by many experts that the “culture” at NASA was to blame for the accident.

Assignment Brief

3000 words; (Academic essay with Introduction , conclusion and references)

Answer the Five Questions ,the majority of the Investigation is on analysis, not decisions/recommendations, therefore this assignment should  reflect  ability to analyse not decide. Make sure you consider multiple points, positions and possibilities for each circumstance; investigations often take years of deep analysis in order to justify a conclusion.

Question 1 Space Shuttle Columbia Report

It has been argued by many experts that the “culture” at NASA was to blame for the accident.

• Please analyse the culture at the time of the accident (15 marks)
• Why was this not listed as the official “cause” of the accident (5 Marks)

 Question 2 British Airways Flight 268

Assume you are tasked with an investigation of Flight 268;

• Analyse the crew’s decisions from the time of the fire to the eventual landing (10 Marks)
• Based on the discussion in class do you think the Captain should have been charged by the FAA, explain? (5 Marks)

Question 3 Valujet 592

Assume you are part of a multi-disciplinary investigation team, the IIC (Investigator in Charge) has asked you to analyse the rapid growth of Valujet as it may have played a role in the accident;

• Prepare a high level analysis of Valujet’s growth, and how rapid growth affects safety in general (do not make any recommendations/decisions only analyse the growth) for the IIC to decide if this is an area worth exploring (15 marks)
• Assume there is pressure from the highest office to not explore growth any further. Based on your analysis the IIC asks you if you’re ok dropping this and moving onto another part of the investigation. How would you respond to that? (5 Marks)

Question 4 Alaska Airlines 261

• Analyse the CVR data and the crews actions (5 Marks)
• Analyse the FAA’s oversight of Alaska Airlines (10 Marks)
• Why would the NTSB allow the board member statements to be included towards the end of the report? (5 Marks)
• What recommendation would you make to the FAA (5 Marks)

Question 5 Japan Airlines Boeing 787-8 JA829J

• Critically analyze the role of the manufacturing process for the 787? (15 Marks)
• What recommendation would you make to the FAA, explain? (5 Marks)

Sample Answer

Critical Analysis of Aviation and Aerospace Incidents: Lessons from High-Profile Cases

Introduction

Accident investigations in aviation and aerospace demand careful, multifaceted analysis. While technical causes may be clear, deeper systemic issues, such as organisational culture or regulatory oversight, often contribute significantly. This essay examines five high-profile incidents: the Space Shuttle Columbia disaster, British Airways Flight 268, ValuJet 592, Alaska Airlines 261, and the Japan Airlines Boeing 787-8 battery fire. Using official investigation data, crew communications, and regulatory decisions, this paper focuses on analysing events, decisions, and possible systemic failures, without drawing final conclusions or recommendations.

Question 1: Space Shuttle Columbia

NASA’s Culture and the Columbia Disaster 

NASA’s organisational culture in the early 2000s was marked by hierarchy, complacency, and pressure to maintain mission schedules. Decision-making often followed rigid chains of command, and open dissent from lower-level engineers was discouraged. There was a culture of normalisation of deviance, where abnormal occurrences became acceptable over time. Foam strikes on shuttle launches had happened before and did not lead to catastrophe, leading management to underestimate the risk. Communication was also heavily bureaucratised, and mission urgency overrode safety warnings.

This culture led to a disconnect between engineers and decision-makers. For instance, engineers who suspected that foam damage could be catastrophic were unable to get their concerns properly addressed. The Flight Readiness Review process failed to prioritise safety assessments, instead relying on previous successful missions to justify risk tolerance.

Why Culture Was Not Listed as the Official Cause 

Culture was not listed as the official cause likely because accident reports focus on tangible, actionable failures, technical faults, procedural errors, or specific organisational oversights. Culture, being intangible and systemic, is harder to define legally or technically. While the Columbia Accident Investigation Board (CAIB) strongly highlighted cultural issues, it chose to list technical causes officially, such as foam strike damage and lack of in-orbit inspection capability. This allowed NASA to be held accountable for specific actions rather than abstract traits.

Question 2: British Airways Flight 268

Crew Decisions from Fire to Landing 

Flight 268 experienced an engine fire shortly after take-off from Los Angeles. The crew chose to continue flying across the Atlantic rather than return or divert. The decision seemed based on procedures that did not explicitly require a return if one engine was lost, as long as the aircraft could fly safely. The crew communicated with engineers and believed it was safer to continue rather than dumping fuel and risking other complications during an immediate return.

However, critics argue that the choice increased risk, as the flight had to continue with one engine for a long period over water and remote areas. There were also concerns about fuel leaks and potential structural damage. The crew’s adherence to protocols was technically valid, but the judgment to prioritise the transatlantic journey raised ethical and operational concerns.

Should the Captain Have Been Charged? 

While the FAA did investigate the matter, they did not charge the captain. Many experts believe this was the right decision. The crew acted within the boundaries of training and regulations, and no passengers were harmed. Charging the captain could have set a precedent where pilots become hesitant to make decisions during emergencies for fear of legal action. However, it also sparked debate on whether current protocols allow for too much subjective judgment in emergency scenarios.

Question 3: ValuJet 592

Rapid Growth and Safety Risks 

ValuJet was one of the fastest-growing budget airlines in the U.S. during the 1990s. It expanded aggressively, using older aircraft and relying heavily on outsourced maintenance. This strategy reduced operating costs but compromised control over safety procedures. The airline’s growth rate outpaced the development of its internal safety infrastructure. Maintenance contracts with third-party providers meant quality assurance was inconsistent.

The company’s culture placed financial growth ahead of safety. This environment created a risk where critical issues were overlooked. The incident involving ValuJet 592, a crash caused by improperly stored oxygen generators that ignited a fire, highlighted gaps in training, oversight, and cargo management.

Rapid growth, especially in cost-cutting environments, can stretch resources and encourage risky decisions. In ValuJet’s case, reliance on subcontractors and minimal internal audits led to inadequate safety checks.

Response to Political Pressure to Drop the Issue 

As an analyst, if I were told to move on despite clear signs of safety compromises due to rapid growth, I would raise my ethical concerns with the IIC. Investigations must be impartial. If growth had a potential link to safety failings, ignoring it could compromise the integrity of the investigation and public trust. I would respectfully insist on documenting my findings so that the final report reflects all areas worth exploring.

Continued...