The process of aircraft accident and serious incident investigation is the basis for understanding the underlying causes ofthese events. The sole objective of the investigation is making safety recommendations intended to prevent recurrences. Followingthe international standards and recommended practices as described in ICAO Annex 13 - Aircraft accident and incident investigation,it is possible to obtain and understand factual information about the accident/incident and to develop measures which could mitigateand/or reduce future risks. This paper deals with the results of an investigation of the accident of Flight 1153 from Bari (Italy) toDjerba (Tunisia) that was simulated in order to get insight into the possible errors and their potential avoidance. Obtained resultscould serve as an important factor in identifying hazards that led to the accident, one of the primary purposes of the aviation safetymanagement system.
LEARNING FROM ERRORS – CASE STUDY OF AN AIRCRAFT ACCIDENT
ABBONDATI, FRANCESCO;
2014-01-01
Abstract
The process of aircraft accident and serious incident investigation is the basis for understanding the underlying causes ofthese events. The sole objective of the investigation is making safety recommendations intended to prevent recurrences. Followingthe international standards and recommended practices as described in ICAO Annex 13 - Aircraft accident and incident investigation,it is possible to obtain and understand factual information about the accident/incident and to develop measures which could mitigateand/or reduce future risks. This paper deals with the results of an investigation of the accident of Flight 1153 from Bari (Italy) toDjerba (Tunisia) that was simulated in order to get insight into the possible errors and their potential avoidance. Obtained resultscould serve as an important factor in identifying hazards that led to the accident, one of the primary purposes of the aviation safetymanagement system.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
