On April 1, 2011, about 15:58 mountain standard time (MST), a Boeing 737-3H4, N632SW, operating as Southwest Airlines flight 812
experienced a rapid decompression while climbing through flight level 340. The rapid decompression occurred due to a failure of the outside skin of the aircraft.
Read the NTSB report and data summary on this accident below. Some areas have been highlighted in the Final report that may help you with this case study.
Executive Summary (DOCX)Preview the document
NTSB Summary (PDF)Preview the document
Southwest 812 Final Report (PDF)Preview the document
Now, this is not the first time this has happened in aviation and surely not in the case of the B-737. Those old enough to remember will recall Aloha Airlines flight 243 in 1988. A flight attendant was lost in that accident when the entire top half of the fuselage (about a 20 foot section) ripped off the aircraft in flight. In 2009, another Southwest B-737 (flight 2294) experienced a similar incident. And as recent as April of 2018, a Southwest Airlines 737 (flight 1380) had a window blow out after an uncontained engine failure resulting in the death of a passenger. Feel free to look these up and use any information on these other accidents if you like.
The reason for this accident came down to a fabrication error from back in 1996 when the aircraft was manufactured. The NTSB found that the crown skin was replaced during the manufacturing process, and is was done improperly.
After what you have learned about the cause of this accident, and the others if you want to incorporate or use them, use one of the methods of analysis that you learned about in this module to complete an analysis of the possible failures that could happen in this process and the outcomes if that failure were to happen.
Now, it is important to note here that the human operator can be part of the system. In other words, the human can be a subsystem too. If that operator has some form of interface that can affect the overall operation of the system (like when the holes were drilled), they can be one of the nodes used in the analyzing technique. Provide your analysis and a narrative of your findings in an analysis to your boss. Use any other sources of information you need to research the accident further, but be sure to cite them accordingly.
This assignment has two requirements that must be completed.
A chart presenting the data you selected to analyze in your chosen technique (examples are found in the Ericson text).
A short narrative to the boss telling them why the items you show in your chart are important and need to be addressed.
Both of these must be turned in for this case study.
Your Instructor will evaluate your analysis based on the Case Study Rubric.
Save your assignment using a naming convention that includes your first and last name and the activity number (or description). Do not add punctuation or special characters.
Your paper will automatically be evaluated through Turnitin when you submit your assignment in this activity.
Most of the modules in this class contain case studies that you will complete. As mentioned in the intro video, this class uses a building block process to introduce you to the techniques used by systems safety professionals to completely analyze a system. The specific directions for accomplishing these case studies are contained in each module.
General rules for all case studies – The case studies are designed to allow you to use the techniques you have read about each of the module readings. There are two basic requirements for each case study:
Every one of the case studies requires some form of a chart to be done. For example, in Module 2, you must construct a Preliminary Hazard List (PHL) just like the one shown in the samples in the class textbook. In Module 6, you must construct a full Fault tree analysis chart, again just like what is shown in the textbook. Now, if you don’t have a program that allows for building an FTA chart and are having a hard time formatting it, then there is nothing wrong with drawing it out legibly and submitting it that way. Realize that sometimes rapidly getting the information presented to the boss for action is more important than taking the time to make it pretty.
A report to your boss outlining what you have found and your thoughts on it. Your report should include sections that tell the boss what you found, and analysis of why what you found is important and needs to be addressed, and finally what needs to be done to correct the issues you found or what is needed to bring it into compliance. This report should be a minimum of 1 to 2 pages in length and double spaced. These reports may require correctly APA formatted references and citations depending upon what information you used to draft your report.
Your assignment will automatically be evaluated through Turnitin when you submit your assignment in this activity. Turnitin is a service that checks your work for improper citation or potential plagiarism by comparing it against a database of web pages, student papers, and articles.
from academic books and publications. Ensure that your work is entirely your own and that you have not plagiarized any material!
Hazard Analysis Techniques for System Safety
Edition: 2nd
Year: 2015
ISBN: 978-1-118-94038-9
Author: Clifton Ericson II
Publisher: John Wiley & Sons
Publication Manual of the American Psychological Association
Edition: 6th
Year: 2010
ISBN: 978-1-4338-0561-5
Author: American Psychological Association
Publisher: American Psychological Association
Note: For further information, see the APA website.
Note: The following materials are available for free. Links to these items are also located in the
activities within the course which require the specific sources.
Basic Guide to System Safety
Edition: 3rd
Year: 2014
ISBN: 978-1-1184-6020-7
Author: Clifton Ericson II
Publisher: John Wiley & Sons
Note: This ebook is free through the ERAU Hunt Library.
Air Force System Safety Handbook (PDF)
Note: Available through the Air Force Safety Agency