Case Study Analysis: Accident Research

The de Haviland DH-106 Comet 1 Tragedies

This case study explores three separate accidents involving the de Haviland DH-106 Comet 1 aircraft, G-ALYV at Calcutta, G-ALYP at Elba, G-ALYY at Naples, and fatigue testing accomplished on G-ALYR. All three accidents encountered inflight breakups with no warnings. Everyone perished in this series of accidents. What caused these new aircraft to structurally fail catastrophically?

For this case study analysis, do not create a separate report for each accident, but rather compare commonalities and combine this series of accidents into a single report.
Review the FAA Lessons Learned from the de Havilland DH-106 Comet 1 (Links to an external site.) link and its contents related to a series of accidents related to inflight breakups of de Haviland DH-106 Comet 1 aircraft.
https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=28&LLTypeID=0

Your case study analysis must include the following sections, sequentially:

  1. Title or Cover Page – Include title, activity number, course number, and your name at a minimum.
  2. Introduction or executive summary – include a brief paragraph to introduce your reader to your approach to this analysis and what to expect.
  3. Primary Causal Factor(s) of the Accident – Include one to two paragraphs identifying the probable cause(s) of the accident. Usually, it is hard to narrow an accident event down to a single cause, especially if two related or intertwined systems or system components are involved simultaneously, referred to as ‘coupling’ in the context of safety analysis. This content must be evidence-based and factual in nature.
  4. Contributing Factors to the Accident – Include two to four paragraphs identifying what the contributing factors were causal to the accident. These factors contributed to the accident, even though they weren’t primary. These factors could be links in the ‘accident chain’ of events leading up to the mishap. These factors may reduce or exacerbate the accident conditions and resulting severity. A thorough analysis in this section should aid you in formulating potential risk mitigation or reduction strategies in a subsequent section. This content must be evidence-based and factual in nature.
  5. Structural and Mechanical Factors Related to the Accident – Include two to four paragraphs identifying the structural and mechanical factors involved in this accident. This portion should entail the bulk of your analysis. Use this section to detail any strengths and weaknesses of the applicable aviation system(s), whether aircraft design, construction, maintenance, component reliability, etc. This content must be evidence-based and factual in nature.
  6. Relevant Human Factors and/or Organizational Factors Related to the Accident – Include two to four paragraphs identifying what the relevant human/organizational factors were involved in this accident. Be sure to include how these deficiencies led to or exacerbated the situation. This content must be evidence-based and factual in nature.
  7. Outcomes of the Accident – Include two to four paragraphs stating what happened subsequent to the accident (this may be months or years later). Although a bulleted list of outcome items may be provided, there should be sufficient explanations to describe any disparities between the investigation board’s proposed solutions (i.e., recommendations) versus ‘real-world’ eventual actions by the various governmental and industry groups. Examples may include possible airworthiness directives (ADs) issued, new regulations or rules adopted or amended, redesign standards, etc. Consider which recommendations were suggested by the investigation board. Were these recommendations followed or complied with? What recommendations were left unheeded? If so, why? This content must be evidence-based and factual in nature.
  8. Risk Mitigation or Reduction Strategies – Include two to four paragraphs explaining, from your analysis, any risk mitigation or reduction strategies or methods that you believe may have either prevented this accident or lessened its severity. This is your opportunity to demonstrate and integrate your knowledge learned up to this point of the course and apply learned facets in analyzing this accident. This is where you can interject your opinions, suggestions, any differences you may have regarding investigation board results, and any differences toward eventual outcomes related to this accident. This section should prepare you for your Discussion – Case Study Reflection
  9. Conclusion or Summary – Include one or two paragraphs to explain your main take-aways from this case study. This is your opportunity to demonstrate and integrate your knowledge learned up to this point of the course and apply learned facets in analyzing this accident. This is also where you can interject your opinions, suggestions, or differences regarding investigation board results related to this accident. This section should prepare you for your Discussion – Case Study Reflection
  10. Reference Page – Include all references cited in the paper of information sources, in current APA edition format.

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