Alaska Airlines Flight 261: Understanding the Systemic Contributors to Organizational Accidents
| Autor: | Christian G.W. Schnedler, Steven J. Stumpp, Daniel Murphy, Frantz St. Phar |
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| Rok vydání: | 2007 |
| Předmět: | |
| Zdroj: | Systems Research Forum. :42-51 |
| ISSN: | 1793-9674 1793-9666 |
| DOI: | 10.1142/s1793966607000078 |
| Popis: | On January 31, 2000, at approximately 16:21 Pacifi c Standard Time, Alaska Airlines Flight 261 crashed into the Pacifi c Ocean off the California coast just west of Los Angeles. The crash killed all 88 passengers and crew members onboard. After an extensive investigation by the National Transportation Safety Board (NTSB), the cause of the accident was attributed to a failed jackscrew assembly controlling the horizontal stabilizer in the tail section of the airplane. This caused the plane to pitch nosedown, rendering it completely uncontrollable once the jackscrew failed. Factors leading to the crash of Alaska Airlines Flight 261 uncovered in the NTSB report included Federal Aviation Administration (FAA)-approved lengthened inspection intervals; the use of unapproved tools and methods of measurement for checking the jackscrew assembly and assessing it for wear (endplay check); falsifying maintenance reports to show work had been completed when none took place; receiving approval for maintenance manual and procedural changes without consent from the FAA, director of base maintenance, or the director of maintenance planning and production control; and various interpretations by mechanics at different repair/inspection facilities without regards to proper inspection procedures of the jackscrew assembly. We will analyze this crash, utilizing principles and organizational theories described by Reason (1997) which focus not on the technical failure of the mechanical components, but on the roles played by the human infl uence from upper management of Alaska Airlines and the FAA down to the culture of the maintenance crew involved. This analysis paints a clear picture of how minimal importance was given to safety in this organization and how unmonitored practices eventually breached the wellintentioned, but unjustifi ably neglected, systemic defenses in place. We summarize that the root cause of Flight 261’s tragic end was not the failure of the jackscrew assembly, but rather the cumulative effect of both economic and organizational pressures acting on all levels of Alaska Airline’s organizational hierarchy. We further propose that the true value of the lessons learned from Flight 261 lies in the importance of taking a comprehensive, systems perspective of organizational risks. Finally, we cite the Tripod-Delta Model as an example of a systems-based risk mitigation tool, though we also note that the need remains for more advanced tools capable of systematically mitigating core organizational risks identifi ed. |
| Databáze: | OpenAIRE |
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