Applying human factors and ergonomics system analysis methods to the V5-NRS Cessna 441 Conquest II aviation accident
- Authors: Fischer, Jordan Daena
- Date: 2023-10-13
- Subjects: Ergonomics , Human engineering , Accident investigation , Aircraft accidents Investigation , AcciMap Approach , System theory , Study of complex systems
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/424245 , vital:72136
- Description: Intro: Accidents are complex in nature with multiple contributing factors. The way in which accidents are investigated is important and using system-based analysis tools assists in understanding and mapping these contributing factors to learn from them. There has been an increase in the number of accidents that have occurred within the general aviation industry in South Africa and while accident investigations have been undertaken, these have not included the application of system-based analysis tools. This led to a collaboration between Rhodes University and the Accident and Incident Investigations Division (AIID) of the South African Civil Aviation Authority where it was agreed that two systems-based analysis tools will be applied to a previously investigated accident that occurred in 2015. Aims: The first aim of this thesis was to identify if, through the implementation of these systems-based tools, the systemic contributory factors could be determined using the existing report by the AIID. The second aim of this thesis was to identify if, using the two systems-based tools, the actors and levels involved in the accident could be identified and the third aim was to identify if the implementation of these tools generates the same or different recommendations to that of the AIID. Methods: The two systems-based analysis tools applied were AcciMap and Causal Analysis using Systems Theory (CAST). These tools were applied to the V5-NRS Cessna 441 Conquest II accident report which captured the details of how the aircraft flew into the Tygerberg mountain on its descent into the Cape Town International Airport in August 2015. Results: Through the application of these two systems-based analysis tools the major contributing factors elucidated throughout this analysis were: visual and lighting conditions, pilot experience, training, lack of terrain warning equipment, fatigue, inadequate oversight, and inadequate risk management. In line with these findings, the analysis revealed various actors across various levels (the crew; South African Air Traffic Control, the SACAA, WestAir (the operator) and the Namibian Civil Aviation Authority Through the elucidation of these factors at various levels, 14 to 15 different recommendations were generated which was more than the one recommendation that was generated by the AIID. Discussion: Even when applied to an existing report, both the CAST and Accimap tools were able to bring to light the systemic contributing factors to this accident and importantly, highlight the role that various actors and levels within the system had in this unfortunate event. Consistent with previous literature, most of the contributing factors were found at the lowest level (the crew in this case) and fewer, but key factors were identified at higher levels (management and regulator level). Importantly, the application of the systems tools facilitated a systematic and systemic analysis of this accident, which allowed for the generation of recommendations at all levels, not just at the operator level. Conclusion: This study demonstrates the benefits and importance behind implementing a systems-based analysis method to an accident as these tools generate more useful recommendations which allows for important lessons to be learned following accidents, with the intention of re-designing systems to prevent them from happening again. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2023
- Full Text:
- Date Issued: 2023-10-13
- Authors: Fischer, Jordan Daena
- Date: 2023-10-13
- Subjects: Ergonomics , Human engineering , Accident investigation , Aircraft accidents Investigation , AcciMap Approach , System theory , Study of complex systems
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/424245 , vital:72136
- Description: Intro: Accidents are complex in nature with multiple contributing factors. The way in which accidents are investigated is important and using system-based analysis tools assists in understanding and mapping these contributing factors to learn from them. There has been an increase in the number of accidents that have occurred within the general aviation industry in South Africa and while accident investigations have been undertaken, these have not included the application of system-based analysis tools. This led to a collaboration between Rhodes University and the Accident and Incident Investigations Division (AIID) of the South African Civil Aviation Authority where it was agreed that two systems-based analysis tools will be applied to a previously investigated accident that occurred in 2015. Aims: The first aim of this thesis was to identify if, through the implementation of these systems-based tools, the systemic contributory factors could be determined using the existing report by the AIID. The second aim of this thesis was to identify if, using the two systems-based tools, the actors and levels involved in the accident could be identified and the third aim was to identify if the implementation of these tools generates the same or different recommendations to that of the AIID. Methods: The two systems-based analysis tools applied were AcciMap and Causal Analysis using Systems Theory (CAST). These tools were applied to the V5-NRS Cessna 441 Conquest II accident report which captured the details of how the aircraft flew into the Tygerberg mountain on its descent into the Cape Town International Airport in August 2015. Results: Through the application of these two systems-based analysis tools the major contributing factors elucidated throughout this analysis were: visual and lighting conditions, pilot experience, training, lack of terrain warning equipment, fatigue, inadequate oversight, and inadequate risk management. In line with these findings, the analysis revealed various actors across various levels (the crew; South African Air Traffic Control, the SACAA, WestAir (the operator) and the Namibian Civil Aviation Authority Through the elucidation of these factors at various levels, 14 to 15 different recommendations were generated which was more than the one recommendation that was generated by the AIID. Discussion: Even when applied to an existing report, both the CAST and Accimap tools were able to bring to light the systemic contributing factors to this accident and importantly, highlight the role that various actors and levels within the system had in this unfortunate event. Consistent with previous literature, most of the contributing factors were found at the lowest level (the crew in this case) and fewer, but key factors were identified at higher levels (management and regulator level). Importantly, the application of the systems tools facilitated a systematic and systemic analysis of this accident, which allowed for the generation of recommendations at all levels, not just at the operator level. Conclusion: This study demonstrates the benefits and importance behind implementing a systems-based analysis method to an accident as these tools generate more useful recommendations which allows for important lessons to be learned following accidents, with the intention of re-designing systems to prevent them from happening again. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2023
- Full Text:
- Date Issued: 2023-10-13
Application of systems theory for analysing the sustainability foci and practices of the Faculty of Economics and Information Technology Systems: (A Case Study of Walter Sisulu University: Komani campus)
- Authors: Klishi, Konwaba Bomikazi
- Date: 2022-10-14
- Subjects: Sustainable development Study and teaching (Higher) South Africa Mthatha , System theory , Curriculum evaluation South Africa Mthatha , Community engagement , Walter Sisulu University for Technology and Science
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/405281 , vital:70157
- Description: Sustainable development is a global concern that intertwines several factors, including poverty, biodiversity, inequality, water, and energy. This interconnection does not only affect the current generation but may have long term implications for future generations as we see the rapid spread of environmental risk in our local communities. In this study, systems theory was adapted for analysing the sustainability focus of the Faculty of Economics and Information Technology Systems (FEITS) at Walter Sisulu University. A qualitative research method was used during this research, and data collected from a purposive sample of staff, activities and documentation. In this study, Von Bertalanffy’s systems theory is applied to analyse the sustainability foci and practices of the FEITS. The study describes sustainability practices and concerns that emerge from research activities, community engagement activities and work-integrated learning. The theory is also used to analyse the connection between various subsystems of the faculty when addressing emerging local sustainability concerns. Education for sustainable development is an important aspect of this study as it considers the sustainability concerns in the curriculum from the perspective of current and future alternatives for the economy and socio-ecological aspects of communities. The following findings have emerged from the study: Contextual realities related to inequality were foci of discussion and concern in various qualifications. Socioecological issues and risks were found to be related to water and sanitation, food security and climate change. Sustainability discourse is related to health and wellbeing, peace, and security. There is an alignment of green skills to the curriculum of the faculty and pedagogical practices which relate to sustainability. The faculty participates in stakeholder platforms to respond local sustainability challenges and is developing courses in response to local development needs. This study has implications for the faculty’s curriculum in terms of the content of various qualifications, future research, and community engagement activities of the university. , Thesis (MEd) -- Faculty of Education, Education, 2022
- Full Text:
- Date Issued: 2022-10-14
- Authors: Klishi, Konwaba Bomikazi
- Date: 2022-10-14
- Subjects: Sustainable development Study and teaching (Higher) South Africa Mthatha , System theory , Curriculum evaluation South Africa Mthatha , Community engagement , Walter Sisulu University for Technology and Science
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/405281 , vital:70157
- Description: Sustainable development is a global concern that intertwines several factors, including poverty, biodiversity, inequality, water, and energy. This interconnection does not only affect the current generation but may have long term implications for future generations as we see the rapid spread of environmental risk in our local communities. In this study, systems theory was adapted for analysing the sustainability focus of the Faculty of Economics and Information Technology Systems (FEITS) at Walter Sisulu University. A qualitative research method was used during this research, and data collected from a purposive sample of staff, activities and documentation. In this study, Von Bertalanffy’s systems theory is applied to analyse the sustainability foci and practices of the FEITS. The study describes sustainability practices and concerns that emerge from research activities, community engagement activities and work-integrated learning. The theory is also used to analyse the connection between various subsystems of the faculty when addressing emerging local sustainability concerns. Education for sustainable development is an important aspect of this study as it considers the sustainability concerns in the curriculum from the perspective of current and future alternatives for the economy and socio-ecological aspects of communities. The following findings have emerged from the study: Contextual realities related to inequality were foci of discussion and concern in various qualifications. Socioecological issues and risks were found to be related to water and sanitation, food security and climate change. Sustainability discourse is related to health and wellbeing, peace, and security. There is an alignment of green skills to the curriculum of the faculty and pedagogical practices which relate to sustainability. The faculty participates in stakeholder platforms to respond local sustainability challenges and is developing courses in response to local development needs. This study has implications for the faculty’s curriculum in terms of the content of various qualifications, future research, and community engagement activities of the university. , Thesis (MEd) -- Faculty of Education, Education, 2022
- Full Text:
- Date Issued: 2022-10-14
- «
- ‹
- 1
- ›
- »