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Systematic Investigation of the Asiana Airlines 214 Air Crash Using the AcciMap Methodology

2019; SAGE Publishing; Volume: 63; Issue: 1 Linguagem: Inglês

10.1177/1071181319631055

2169-5067

Maryam Tabibzadeh, Vivek Shapeti, Mohammad Mokhtari,

Human-Automation Interaction and Safety

This paper utilizes the AcciMap methodology, which was originally developed by Rasmussen in 1997, to systematically investigate the unfortunate aviation accident of Asiana Airlines 214 in San Francisco on July 6, 2013, which resulted in 3 fatalities and the complete loss of the aircraft. This paper captures the associated socio-technical factors into a hierarchical map that correlates the multiple levels of interaction between different categories and key involved players that ultimately resulted in this air crash. In most accidents, including the Asiana Airlines 214, majority of the blame is laid on front-line operators. In this accident, the pilots are blamed for not adhering to standard operating procedures and training guidelines of Asiana Airlines. This is while accidents do not occur as the act of individuals, but rather due to highly responsive and combined processes that involve decisions of several layers of key players. Some of the other significant contributing factors to this accident are lack of overseeing and enforcing regulations; insufficient training provided by the airline company to pilots; no specific requirements by the company to mandate physical/manual, instead of only simulated, line training; cockpit culture; and complex flight control manuals. The AcciMap methodology has been applied to analyze accidents in different industries, such as railroad, offshore drilling and chemical processing. It is, however, noteworthy that due to our knowledge, this methodology has been used for the analysis of very few aviation accidents.