Case Study Worksheet

Aircraft Type:Souls on Board:
Aircraft ID/Flight Number:Injuries:
Date and Location:Fatalities:

Instructions

This worksheet guides you through a comprehensive analysis of an aviation accident or incident report. Read the report carefully and consider the following sections to deepen your understanding of the events.

1. NTSB Reporting Requirements

  • Review the NTSB's accident and incident reporting requirements under 49 CFR Part 830.
  • Determine if and when the operator is required to notify the NTSB or to submit an accident or incident report.

2. Broad Analysis

  • Determine the type of flight plan (IFR or VFR), type of operation (e.g., commercial, private, instructional), time of day, route, and any other general aspects of the flight.

3. Probable Cause and Contributing Factors

  • Using the PAVE checklist, analyze the causal and contributing factors to the accident or incident.

Pilot

  • Evaluate the pilot's background, experience, and decision-making process.
  • Look for human factors, including signs of arrogance, ignorance, complacency, distractions, and personal biases.
  • Determine if and how the pilot contributed to the accident or incident.

Aircraft

  • Investigate the aircraft's design, maintenance history, and any technical issues reported.
  • Determine if and how the aircraft's condition and maintenance contributed to the accident or incident.

Environment

  • Analyze the environmental conditions at the time of the accident, including weather, terrain, and airspace.
  • Determine if and how the environmental conditions contributed to the accident or incident.

External Pressures

  • Consider operational demands, regulatory compliance issues, and passenger influences.
  • Determine if and how external pressures contributed to the accident or incident.

4. Poor Judgment Chain

  • Trace the sequence of events leading to the accident or incident.
  • Identify the points at which intervention could have "broken" the chain.

5. Safety Recommendation

  • Evaluate key issues in the accident or incident that pose a risk to future flights.
  • Propose safety measures to mitigate the risks.