Learning from rare events: an analysis of ValuJet Flight 592 and Swissair Flight SR 111 crashes

Konstantinos Grigoriou, Ashraf Labib, Sara Hadleigh-Dunn

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Abstract

Why do organisations need to learn from prior failures in this uncertain and complex environment? How can they learn from prior failures? This paper aims to answer the above questions using the relevant literature and by analysing two cases from the aviation industry. To achieve this, Fault Tree Analyses and Reliability Block Diagram will be applied to ValuJet Flight 592 and Swissair Flight SR111 crashes to identify their root causes and discuss the lessons learned or not learned. Thus, learning from failures using advanced techniques do not only indicates the root causes of the disaster but increase the knowledge of the organisation as they can identify the gaps in their system and learn from them.
Original languageEnglish
JournalEngineering Failure Analysis
Early online date18 Oct 2018
DOIs
Publication statusEarly online - 18 Oct 2018

Keywords

  • Learning from rare events
  • Fault Tree Analysis
  • Reliability Block Diagrams
  • ValuJet Flight 592
  • Swissair Flight SR 111

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