Root Cause Analysis

Answer all questions. (Total 100 marks)

Singapore Airlines Flight SQ006 Crash at Taipei airport on 31 October 2000

On 31 October 2000 at close to midnight, Singapore Airlines (SIA) Flight SQ006 carrying 159 passengers and 20 crew members crashed at Chiang Kai-shek International Airport in Taipei, Taiwan during take-off. Flight SQ006 was on stop-over at Taipei while on its way to Los Angeles from Singapore.

Of the 179 occupants on-board the Boeing 747-400 airliner, 83 died in the accident, including 2 passengers who died later in a hospital as a result of their injuries. This was SIA’s first major and fatal aviation accident.

The aircraft had crashed into concrete barriers and construction equipment when it attempted to take-off on a runway that was partially closed for maintenance. The aircraft was destroyed as a result of the collision and post-impact fire.

Flight SQ006 was cleared by the Air Traffic Control (ATC) to depart from runway designated 05L but the aircraft taxied into the closed runway designated 05R when it took a turn too early.

The weather at the time of incident was heavy rainstorm with strong winds which resulted in poor visibility. The ATC controllers could not confirm the location of SQ006 when it entered the closed runway 05R. SQ006 flight crew did not see the construction equipment parked on the closed runway about a kilometre away from the point where the aircraft began to roll on its take-off. When the pilot saw the equipment, it was too late to turn the plane away from the obstruction as the plane was in the midst of rolling off the ground. The plane hit the construction equipment and broke into two which caused the fuel tank to explode. The huge fire destroyed the forward section of the plane and its wings. Many of the casualties were from the middle section of the plane. The fire was extinguished eventually at midnight.

96 people survived from the accident of which 71 suffered injuries such as severe burns.

You are tasked to conduct an Accident Investigation on what caused these losses using evidence that has already been established. You are not expected to uncover new evidence, but should use sources already in existence and discoverable to the public.

Question1 – Evidenceand Timeline

(a) Examine the collected evidence for this accident and present this using the structure of the Quadrant Model.

(b) You should preseneachQuadrant independentlyand highlight your reasons for placing each item within the Quadrant. You should also state where there are shortcomings in the evidence, the reasons why these shortcomingsare so, and how they might be overcome (if possible).

(c) For all evidence that you use, you should present actual and/or potential scientific verification, and you shouldformally cite the source(s).

(d) From this evidence, create a timeline of events that led up to the crash and the subsequent loss of the plane andthe lives. Each element of the timeline should identify contributory factors and from which sector of the Quadrant Model these come from.

(e) You are free to use other additional tools to support your analysis, but state your reason(s) for doing so.

(40 marks)

Question2 – RootCauseAnalysis

(a) From the evidence gathered and your timeline, construct a Root Cause Analysis using the Quadrant Modelcreated in Question 1.

(b) Identify the Root Cause(s) of the accident using a Causal Tree.

(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations toensure this incident does not happen again.

(d) Analyse the likelihood of success for each recommendation, presenting reasoning for this.

(e) You are free to choose the format of the recommendations; however the format chosen should support the earlierassessment methodologies that you employed.

(40 marks)

Question3 – IncidentReport

Write a detailed report of this accident using the structure studied in this course i.e.

• What happened?

• What caused it to happen?

• What do you recommend should happen next?

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