The Lessons of ValuJet 592 1. Identify one or two risks your project is encountering and strategies that might mitigate them •Risk 1: Due to time constraints and meeting deadlines, our group may be forced into a position that does not allow us to fully research the most effective means of developing a functional lighting system to prevent future runway incursions. •Mitigation: The deadline cannot be pushed back, so we need to collectively get together to ensure we are up-to-date on the current research in this area •Risk 2: Another risk we may encounter is “reinventing the wheel. With all the research and designs that are presently being tested, it will be difficult to create a system unique to those that are currently being investigated. •Mitigation: Since we determined our population (airports with ATC towers), we need to focus on research for lighting systems in same/similar airports. Gathering data from a defined sample population should make research more condensed. 2. Coordination and process breakdowns are described in the ValuJet article. How might these system vulnerabilities have been discovered and addressed prior to serious incident or failure?
What risk management approach might you take if you were responsible for the system? *Paper attached The catastrophic ValuJet 592 plane crash shocked the world. With over 100 people killed, the impact on the airline industry and its customers were far reaching. The investigation unveiled breakdowns in the coordination and the processes involved prior to its final departure. If these system vulnerabilities were discovered and addressed prior to their ultimate epic failure, this incident may have been avoided altogether.
Plan risk management, analyzing the potential risks, and ensuring proper documentation are some examples of items that could have implemented prior to this devastating disaster. Theoretically, one can assume the airline industry’s top priority it safety, but that is sadly a false assumption. Cutting costs and providing a cheap means of air transportation seems to be the main concern of airline executives. The adage “you get what you pay for” seems fittingly appropriate for the ValuJet crash. To reduce expenses, temporary outside orkers did seventy-five percent of the aircraft maintenance, mainly from the company SabreTech. Wageworkers feared losing their jobs, so they performed maintenance on ValuJet 592 on day and night shifts, and sometimes even on the weekends to meet deadlines (Langewiesche, 1998). This led to documentation that inaccurately reflected the work completed on aircraft 592. Due to these time constraints, the work cards were not followed and jobs were certified as being properly performed and completed by mechanics that were unaware of the actual procedures followed.
Personally, I worked in aircraft maintenance and witnessed this myself. When performing routine procedures, work cards are not followed exactly, and many times are not even out for reference. The majority of instances this occurs there is no adverse impact on the system or mission. I am confident the mechanics who performed the maintenance on this aircraft felt the same way. Another pitfall was the packaging, labeling, and placement of the cardboard boxes (that were packed full of oxygen generators), which was later discovered to be the fatal flaw that caused the explosive fire on board the flight.
Trying to rid of these boxes for an inspection seemed like a decision that would have a positive impact on SabreTech’s reputation, but instead showed the miscommunication and complacency of its workers. In hindsight, it seems simple to prevent mishaps similar to this from happening. Unfortunately, defining procedures and assuming risks are sometimes not as easy to predict. Until events actually occur, it is difficult to determine specific and unique risks associated with any tasks.
Although guidelines were in place to define and enforce proper procedures, it ultimately comes down to the person executing the task. However, in this case there are certainly things that could have been done differently. First, during process activities developing a plan for risk management, which defines and documents a strategy, should have been done. Once this was completed, the next step would be to manage the risk profile to determine thresholds and identify both the acceptable and unacceptable risks involved (Haskins et al. , 2010, p 216).
The workers should have been trained to understand the risks involved with handling, dismantling, and packaging the oxygen generators. If this was done correctly, the lanyards would not have been removed and the caps that cover the firing pins would have been in place. Mechanics would have understood that surrounding these canisters with consumables, such as the cardboard boxes and tires, is unthinkable and highly hazardous. Another risk management strategy that is important in the ValuJet case study is documentation. The downfall to this is ensuring the documentation is not falsified.
Documenting everything is crucial and something that was accomplished, but did not reflect the job performance accurately. By avoiding costs and schedule risks, SabreTech employees increased the technical risks associated with maintenance of the jet and hangar. Similarly, the paperwork insisting ValuJet get “re-certified” was completed and submitted for evaluation, but no one evaluated it! Documentation is important, but not if it is not accurate and assessed. The crash and burn (or vice-versa) of ValuJet 592 changed the standards and procedures of the airline industry.
Sadly, it took the lives of over a hundred people to show the discrepancies in how ValuJet did business. Prior to its final departure, numerous failures in the organization, management, and various systems that were looked over, and in some cases, went completely unnoticed. This incident could have been avoided if proper risk management techniques were followed. A lack of a plan for risk management, the need for an analysis of the possible risks, and falsified documentation played a crucial role in the demise of ValuJet flight 592.
In the future, using these techniques can prevent tragic events like this from reoccurring. ?
References Haskins, C, Forsberg, K. , Krueger, M. , Walden, D. , & Hamelin, R. D. (2010). INCOSE Systems Engineering Handbook, version 3. 2 (Report No. INCOSE-TP-2003-002-03. 2). Retrieved from INCOSE website: SE Handbook 2010-0201 v3. 2 Updated Final 8. 5×11. pdf Langewiesche, W. (March 1998). The lessons of ValuJet 592. The Atlantic Monthly Online. Retrieved 17 Oct 2010 from http://www. theatlantic. com.