Case Study: The Crash of Asiana Flight 214 (PLG1)

View the following YouTube videos:
Air Disasters – Terror in San Francisco (Asiana Airlines Flight 214) (6:32) (Links to an external
site.)

NTSB “Animation of Asiana Flight 214 accident sequence” (3:55) (Links to an external site.)

ABC news update: “Aircraft Accidents Investigation: Asiana Airlanes Flight 214 Crash” (3:15)
(Links to an external site.)

Asiana 214: Full Crash And Rescue Footage – Airport Camera Video C225 (47:42) (Links to an
external site.)

Tower camera video of crash, evacuation, and emergency response
Read the following:
Board Meeting: Crash of Asiana Flight 214 Accident Report summary (NTSB) (Links to an
external site.)
https://www.ntsb.gov/news/events/Pages/2014_Asiana_BMG-Abstract.aspx
Asiana airlines crash caused by pilot error and confusion, investigators say (The Guardian)
(Links to an external site.)
https://www.theguardian.com/world/2014/jun/24/asiana-crash-san-francsico-controlsinvestigation-pilot
The crash of Asiana Flight 214 on July 6, 2013 was one of the most widely publicized crashes up to that point that dealt primarily with automation. Of the 307 people on board the B-777 aircraft, 3
were killed and 187 injured, of which 49 were serious injuries. The weather was clear and perfect
for the visual approach the pilots elected to fly that day. But what should have been a routine
approach and landing for these highly experienced pilots took a dramatic turn. So, what went
wrong? Let’s see what can we learn using systems safety techniques about this crash? Based
on the videos and anything else you researched, use one of the techniques you learned about in
this module to conduct an analysis of one of the system malfunctions that happened and led to
this crash. Take this analysis and draft a one to two-page report to show your boss the findings
and how to correct this problem before it happens again.
As with every case study, don’t feel limited to just the video and reading posted here. Feel free to
use any credible sources you wish to complete this assignment but be sure to cite them
accordingly.
This assignment has two requirements that must be completed. The first is a chart presenting the
data you selected to analyze in your chosen technique (examples are found in the Ericson text).
The second is 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.
Discussion forum responses should reflect a Master’s level of understanding of the topic and
should demonstrate the ability to put this understanding into a well thought out discussion of the
topic with supporting references, where needed. References are not required in your discussions
but if you use something from an outside source, be sure to cite and reference it appropriately.
Bottom line here is put what you are saying into your own words and attempt to teach all of us in
the class something new. If you go into it with that approach, you should be fine.
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
System Safety and Risk Management: A Guide for Engineering Educators (PDF)
Note: Available through the CDC