Masters Theses

Date of Award

8-2004

Degree Type

Thesis

Degree Name

Master of Science

Major

Aviation Systems

Major Professor

Ralph D. Kimberlin

Committee Members

Richard J. Ranaudo, Charles T. N. Raludan

Abstract

Aviation safety has improved dramatically in the last 50 years as evidenced by declining mishap rates. Improvements in aviation safety have come about primarily through work on two fronts; mechanical improvements (aircraft and its support systems) and human improvements (human interface, training and process interaction). Safety improvements on the hardware side of aviation have come relatively quickly and continuously, paralleling advances in engineering and science. Today’s aircraft have become extremely reliable machines with redundancy built into every system.

Unfortunately, while the overall aviation mishap rate has declined, the percentage of accidents attributed to “human error” has steadily increased. Strides in the human or software side of aviation safety have not kept pace with the mechanical or hardware advances. Most think of “human error” in terms of the individual, be it pilot, controller, or mechanic. A less obvious aspect is the organizational responsibility to aviation safety. Why is one airline or squadron able to maintain a perfect safety record with the same machines and personnel available to other less successful organizations?

This thesis will examine a Judge Advocate General (JAG) Investigation (written and conducted by the author) of a Landing Mishap involving a Navy FA-18 Hornet. The mishap is significant because a key causal factor was poor organizational climate. The analysis of real-world mistakes and lessons learned in a “high risk” organization will aid in identifying the warning signs of a failing organization and assist in producing some practical solutions towards improving the safety of any aviation organization.

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