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Commercial Aviation Safety                                                                          August 15, 2021


Term Paper


The term paper will consist of an accident case study from one covered in the course, or you may choose another case study from the NTSB database.  The scenario is this: you are a member of the ‘go team’ and have been dispatched to an accident. Use the “Hammerton’s Accident Report – Field Worksheet: Form 101” as an evidence gathering tool. Please attach this to the last page of your report.



Format your report with head notes as follows:


Title of the report: “Commercial Aviation Safety -Term Paper”


Name the Airline in question and the date of accident.


By – Print and Sign your name as the Investigator In Charge.


Factual Findings

State the relevant facts of the accident that include the following areas where applicable.  

  • Weather
  • The Crew
  • The Aircraft
  • Maintenance
  • Organizational / Management
  • ATC’s roll      


Causation – The Actual Cause: use the relevant facts to create a chain of causation.


Causation – The Root Cause: ask the ‘why’ of the actual cause. Consider the following:

  1. Weather
    • Analyze whether the weather was a factor
    • If the weather was different; what result
    • Time of day – if it happened at a different time of day – what’s the probable result.
  2. The Crew
    • Was the act intentional
    • Analyze crew performance
    • Were they following company procedures
    • Any intentional violations or deviations
    • Any miscommunications, vagueness, not sharing a mental model
    • Human Factors
  3. The Aircraft
    • Analyze the manufactured aircraft 
    • Design flaw?
    • Safety equipment on the plane
    • Was it functioning properly or
    • Was it intentionally disabled
  4. Maintenance
    • What work was recently performed on the aircraft
    • Where those procedures being followed
    • Human Factors
  5. Organizational / Management
    • Resource Management
    • Organizational Process
    • Unsafe Supervision
    • Failure to correct problem
    • Preconditioned for an Unsafe Act
    • Human Factors
  6. ATC’s roll
    • Was there a confusing clearance or miscommunication; if so, was there any attempt to correct the miscommunication.
    • Was ATC silent when they could have spoken and prevented the accident
    • Human Factors



You must have a recommendation in order to prevent a repeat of the accident. 

Consider making changes in each of the factual findings above. Asking the ‘what if this where different” may help in your recommendation.



Consider the Impact to the industry on those changes

What will it cost $

Do a quick cost/benefit/probability analysis.

NOTE: This is not the investigators concern. However, to round out your education, please consider it here.


The term paper can be turned in at any time; but before the last two weeks of the semester. It is suggested to be turned in toward the end of the semester so that concepts learned in the course can be applied to the specific accident that the report is based on.






Your report might look something like this:


Commercial Aviation Safety -Term Paper


ABC Airline - August 15, 2021


By – Ivan Investigator; Ivan Investigator


Factual Findings


The Actual Cause:


The Root Cause: