I think it will be helpful to start the course with reviewing an accident scenario, with the intent of helping you understand how many aviation accidents happen. While this is not a “flight safety” or even an “aviation safety” course, but instead is about how specifically to manage aviation safety, it is still important for you to get a sense of the error chain that is typically experienced in the lead up to an accident. Very rarely is an accident “cause” a singular event. There is typically a trail of problems that culminate in that event, and many of those problems lie deep under the surface. To avoid the tendency to simply blame accidents on an “operator” (pilot, controller, mechanic) error, the key to understanding these deep-rooted issues is to keep questioning why a particular operator error was committed. When you get to these root causes, then, as managers, you can start working on eliminating those causes. Don’t forget to use APA citations and provide references; several paragraphs will be necessary to cover this topic appropriately.
You will once again take a look at a particular accident – Comair 5191. Much like last week, as we are in the beginning stages of this course, the key to understanding organizational causes of accidents is to keep questioning “why” a particular operator error was committed. When you get to these root causes work can begin on eliminating those causes.
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