Case Study

Use information given in CAP 718 concerning this accident and in Slides 2-7 of this presentation.
Analyze the human errors of this A/C accident using the SHELL and REASON model:

1- Identify all mismatches between Liveware and the other components of the SHELL model, i.e. L-S, L-H, L-E and L-L resulting in human errors

2- Identify all mismatches of the L-L category that could have been prevented if there was better information exchange and communication.

3- Identify all latent failures from the different levels of the Reason model resulting in the aircraft accident
The Instructor want to describe every mismatches between liveware and every other components of SHELL model one by one and every reason model.


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