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Learning Goal: I’m working on a risk management report and need the explanation and answer to help me learn.

Section I Purpose & Background

This Section of the Accident Research Case Study should provide a concise overview regarding the purpose of your study, how you went about conducting your research, and a brief summary of the circumstances leading up to and including the accident.

Section II What Happened?

This Section of the Accident Research Case Study should include whatever information you believe will concisely tell the story of What Happened and the associated consequences. Describe the sequence of events, which includes the date and any applicable timeline(s). You will also need to cover all of the relevant highlights, which includes the individuals involved (company(s) – key individuals), the total number of injuries and fatalities, and a description of damage related to accident (aircraft and applicable infrastructure). Discuss any geographical considerations to include such information as location i.e., country, state, city, and where the accident occurred i.e., on the airport, urban or rural, mountainous terrain, etc. Include aircraft specifics in terms of type, design, series of the aircraft or other equipment involved in the accident. This Section tells the story!

Section III Why It Happened?

This Section of the Accident Research Case Study describes the Why It Happened in terms of the Root Cause(s). The NTSB Report and whatever references you utilized (minimum of three) should provide sufficient context to ascertain those factors identified as causal in the accident. The findings of the accident investigation should have been focused on the three causal factors we discussed in class: Human Factors, Material Factors, or Environment Factors. It is up to you to differentiate and describe these causal factors from your readings and literature review. Include those factors that were present and contributing to the accident, but also include those factors that contributed to the severity of the injuries if applicable.

The contributing events (Causal Factors), which started the accident sequence need to be identified. Causal Factors include unsafe acts (mistakes and errors) and unsafe conditions. A Causal Factor is not necessarily a Root Cause unless it was the fundamental, underlying, system-related reason that the accident occurred. In other words, some Causal Factors if removed improve the outcome; however, if a Root Cause is eliminated, the accident event would not have occurred.

Section IV What Was Done About It?

This Section of the Accident Research Case Study should contain specifics about whatever changes or innovations resulted from the accident. Identify the significant lessons learned and what changed as a result from an aerospace safety standpoint. Determine if the accident resulted in critical changes to regulations, the design and engineering of the aircraft or associated systems, revised maintenance procedures, increased or enhanced training, or new flight technique development. Include any applicable change the came about as a direct result of this accident designed to improve aeronautical safety.

Section V Opinion & Lessons learned

This Section of the Accident Research Case Study should contain your thoughts and opinions such as your perception of the overall accident in terms of whether the findings and recommendations were sufficient and appropriate, or whether the Risk Management Control Measures developed have been effective over time (prevented future and/or similar occurrences). Additionally, include anything you learned through the process of researching and preparing your paper and presentation.

Appendix A Pictures

This Section of the Accident Research Case Study is provided if you wish to insert any pictures you think are relevant and would enhance the overall submission.