Error Chains and SMS Critical Analysis

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Review the module material, and respond to the following question using the written format included in the instructions and support pages.

Writing Prompt 

Read the two NTSB accident reports. 

Write a paper discussing the possible similarities of error chains and how the dynamics of SMS may have prevented these accidents.

NTSB: Accident Report - New Mexico AAR-11/04 (PDF)

NTSB: Accident Report - Alaska AAR-14/03 (PDF)

 Please read through all sections before proceeding to the next page, and refer back whenever necessary.View the NTSB Slide presentation, by the Honorable Robert L. Sumwalt, see the NTSB process of accident investigation. SMS: What the heck is it, anyway? (PDF)The ICAO files are handout presentation slides and part of ICAO Safety Management Online course material. You may want to enlarge the webpage ( pdf) for better viewing.Directory of Workshop Modules:ICAO website: ICAO Safety: Source - SMS Workshop ModulesView the ICAO Slide Module 8 presentation on SMS "Planning."ICAO SMS Module N° 8 – SMS planning 2008-11 (E) (PDF)Important Tip: ICAO slidesYou do not need to complete any exercises within any ICAO slide modules. Notice procedures and organization that is required for an SMS driven operation. Remember, however, that SMS can be scaled to fit any type of operation.Proceed to the NTSB Webpage section.

 Safety Advocacy MenuExplore all the sub-topics; Most Wanted List, Safety Alerts, Safety Studies, and Safety RecommendationsRead, preview, and explore the NTSB main page and especially these headings to see the importance in developing safety programs.Investigations MenuExplore all the sub-topics; The Investigative Process, Accident Dockets, Data & Stats, Accident Reports, Aviation Database, and General Aviation Safety.

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Explanation & Answer

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Critical Analysis- Error Chains and SMS
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Critical Analysis- Error Chains and SMS
The two aviation accidents that occurred in New Mexico and Alaska present notable
similarities. The helicopters were conducting search and rescue missions when the unfortunate
accidents occurred. A significant cause of the accidents was poor weather conditions that had the
crews of both helicopters notified of the imminent danger. The accidents were preventable had
the pilots adhered to the warnings and the weather alerts issued, rendering the flights a risk. The
pilots could have accommodated safety program measures by identifying the hazard and
correcting it to prevent an accident (Sumwalt, 2013). While the purpose of the flights did not
necessarily entail many passengers or crew members, it was undoubtedly a risky event and an
unsafe act that the pilots needed to exercise caution to avoid. Weather is the major cause of the
two accidents as it seems to be a notable factor that significantly contributed to the crash.
However, some underlying factors existed that had weather conditions eventually causing the
crashes. The crashes comprise an error chain, which in the aviation safety context and SMS, is a
sequence of errors, either mechanical or managerial, that are overlooked and eventually become
hazardous, causing an accident (International Civil Aviation Organization, 2013). A link in the
error chain could have been removed to prevent the crashes, especially pilot error and issues
regarding organizational influence and unsafe acts.
The 2009 New Mexico aviation accident was due to an error chain that could have been a
warning signal to the organization to terminate the mission immediately. The report links the
accident to a terrain impact due to visual flight rules, resulting in a fatal injury (Nat...

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