REPORT

STUDENT NAME: SARTHAK TELPANDE

STUDENT ID: 25401973

INTRODUCTION
Risk management in engineering is a critical aspect of engineering that involves identifying
and mitigating potential hazards and uncertainties inherent in any engineering project. The
primary goal of risk management is to identify the problem and minimize the impact on
project. Risk management can identify, assessed, mitigate, monitor and manage the problem.
Human error is one of the problem which can be solved by risk management techniques.
Human error can lead to accidents, errors in judgement and suboptimal performance. It
happens due to lack of attention, misunderstanding, stress or fatigue. It has an impact on
industries like healthcare, engineering and aviation. In aviation, human error is dominant
because of the critically in the industry. The aviation industry have two technical teams to
mitigate the risks. The Crew Resource Management [CRM], focuses on improving the
communication, decision-making and teamwork. It is a training program which includes
scenarios and simulations. This provide a crew member a skill to handle various challenges
effectively. The Threat and Error Management [TEM], identify and manage the potential
threats and error throughout the flight. TEM implements strategies to prevent from aviation
accidents. It aims to proactively mitigate error and threat impact on safety. The advancement
of technologies like automation and advanced warning systems are enhancing the safety in
aviation.
AIM
The aim of human error in risk management is to proactively identify, prevent and mitigate
error to increase the safety and organizational performance. The proactive approach not only
reduces financial losses but also enhance the operational efficiency. Identifying is a technique
used to recognize the potential failure. Prevention involves implementing proper training
programs and standardized procedures. Mitigation helps to minimize the impact of error
through the improved training and automation.
IMPORTANCE
Human error holds significant importance in risk management across various industries and
contexts. The frequency and potential impact of human error on accidents and incidents
underscore its critical role in risk management. The layers of unpredictability and challenges
are added by the complexity of human interactions with technology, system and processes to
manage risks effectively. Moreover, factors like fatigue, stress, and individual differences
influence the variability in human behaviour. For developing strategies to mitigate risks,
including automation, training, process redesign, it essential to understand the human error.
For ensuring the safety of employees, customers and the public. It is crucial to address human
factors in risk management for legal and regulatory compliance.
STRUCTURE

IDENTIFICATION

ANALYSIS

ASSESSMENT

PREVENTION

MITIGATION

MONITORING AND REVIEW

CULTURE

CASE STUDY 1- [AIR FRANCE FLIGHT-447]

CASE DESCRIPTION AND SETTING UP BOUNDRIES

Case Description
Air France Flight 447 was a plane that was scheduled to fly from Rio de Janeiro in Brazil to
Paris in France. The aircraft they used was called an Airbus A330 jet. Air France 447 is the
worst plane crash ever in Air France’s history. It’s the worst and deadliest plane crash since
American Airlines Flight 587 crashed on November 12th, 2001. For more than 2 years, Air
France Flight 477 was disappeared in Atlantic Ocean on June 1st, 2009. Everyone wondered
what must have happened to the Air France Flight 447. How could such a super advanced
plane just vanished? Air France 447 flew into storm clouds, its speed sensors became iced
over because of which the speed sensors got icy and frozen, and the autopilot disengaged.
The pilots got confused and lost control because they reacted incorrectly when they lost their
instruments and couldn’t understand the problems they caused. It was not the weather or a
technical problem that caused the crash. It was chain of mistakes made by the crew. A
person’s decisions are influenced by many factors. Pilots don’t make decisions alone, they
are a part of complicated system that can either increase or reduce the chance that they will
make a mistake.
After this incident, people wonder whether we can change pilot training, cockpit procedures
or plane instruments worldwide to prevent this kind of incident to happen again. The men’s
flying Air France 447 were three very skilled pilots working for one of the best airline
company in the world. This means that with all these changes, accidents might still happen
because humans are involved. If the pilots of Air France 447 can make such big mistake, then
any other airlines pilot may do it too.

The boundaries of Air France Flight-447 case includes;

 Timeframe: The event occurred on June 1st, 2009. The flight departs from the Rio de
Janeiro-Galeao International Airport (GIG) and ends up crashing into the Atlantic
Ocean.

 Geographical Boundaries: The

incident happened over the Atlantic
Ocean, the flight was within the
boundaries of flight route from Rio
de Janeiro to Paris. The crash site
was located approximately 600
miles (1,145 kilometers) off the
coast of Brazil.

 Environmental Boundaries: The weather conditions and their impact on the flight
like thunderstorms and turbulence were recorded along the flight path, but an expert
analysis from a meteorological team was lacking.

 Human Factors: The role of human factors, including crew actions, training,
decision-making processes and situational awareness, is a significant aspect of the
boundary. Discussions may involve these factors based on findings from the official
reports.

 Legal Boundaries: Given the tragic nature of the event and the loss of lives, the legal
proceeding is essential to avoid speculative or defamatory actions. The legal matters
boundaries extend from the commencement of the investigation immediately after the
disappearance of flight-447 to the publication of the final investigation reported on
July 2012.
STAKEHOLDER ANAYLSIS

Stakeholder Role/Concerns Impact on Indigenous

Group Communities

Passengers and Waiting for the answers from No indigenous communities were
Families authorities and compensation involved.
for the loss of loved one.
Pilots and Crew Didn’t survive the crash. But No indigenous communities were
tried their best to control the involved.
situation.
Civil Aviation Started investigation, finding No indigenous communities were
Authorities the root cause and making involved.
safety recommendations.
Air France Investigating the matter and No indigenous communities were
ensuring future safety measures involved.
also supporting the victims’
families.

Airbus The manufacturer of the flight- No indigenous communities were

447. Works to prevent similar involved.
incidents in future
Aviation Industry Focused on preventing similar No indigenous communities were
events and improving the safety involved.
standards.
Insurance Dealing the financial impact on No indigenous communities were
Companies Air France and finding out the involved.
compensation payout.
Media and Public Seeking information and No indigenous communities were
understanding the cause. involved.
Investors and Concerned about the financial No indigenous communities were
shareholders impact on stock price due to this involved.
incident.
Government Ensuring proper investigation No indigenous communities were
Authorities and enhancing aviation safety. involved.

 There were no reports indicating direct involvement of indigenous community in Air

France Flight-447. The focus was on incident investigation, malfunctioning of
airspeed sensors and pilot response.
INHERENT RISK
The crash of Air France Flight-447 was influenced by many different inherent risk factors.
Primarily, human error played an important role, with improper responses to critical
situations and inadequate pilot training contributing to the tragedy. The crew relied a lot on
automation to help fly the plane because of the complexity of aviation system. However,
when things went wrong, they didn’t properly understand how to control the plane manually.
In addition, Malfunctioning of airspeed sensor (reading) and confusion in the cockpit was
caused due to a design flaw in the Airbus A330’s pitot tubes. Relying too much on
automation further impeded the crew’s response which highlighted the need for better
preparedness for manual flight control in difficult situations. The pilots didn’t communicate
effectively with each other and didn’t manage the resources in the cockpit well. This hindered
their ability to handle the situation properly. Moreover, the pilots didn’t realize the
malfunctioning of speed sensors and their improper response to autopilot disengagement
resulted into a chain or errors. The investigation further found big problem within the
aviation industry, underscoring that there is a real need to make big changes in how cockpits
are run, how planes are designed, and how pilots are trained. This is important to mitigate the
chances of similar incident in future.

CASUAL CHAIN
The Air France Flight-447 incident involves series of interconnected events that led a flight to
crash. The casual chain begins with the weather conditions, the adverse weather has to be
encountered by the flight. It includes thunderstorms, due to that heavy turbulence can be
observed. Leading to that the pitot tubes, which measure the airspeed got obstructed by ice
crystal due to the weather conditions. This resulted into faulty readings of airspeed and also
the disconnection of autopilot mode. The loss of situational awareness can be seen easily and
this resulted into inappropriate response of pilot, that includes pulling the aircraft’s nose up,
which exacerbated the aerodynamics stall. This led to deactivation of high-altitude stall
protection system.
The pilot’s loss the control, this take the aircraft into deep stall condition from which
recovery was not possible. The aircraft started losing the altitude rapidly and impacted on the
ocean surface. That resulted into loss of 216 passengers and 12 crew members. Lastly the
investigation highlighted the incident, which shows the lack of training and procedures leads
to this incident and also the design limitation of airspeed sensors. Overall, a combination of
weather conditions, technical error, human error and system failures contributed to this tragic
incident.
CASE STUDY 2- [KOREAN AIR FLIGHT-801]

CASE DESCRIPTION AND SETTING UP BOUNDARIES

Case Description
Korean Air Flight-801 was a scheduled International passenger flight that was supposed to go
from Seoul, South Korea to Guam. But on 6th August, 1997, the plane crashed while trying to
land in Guam. Sadly, out of the 254 people on board, 228 lost their lives. The National
Transportation Safety Board said that the main reason for this crash was the poor
communication between the flight crew. They also said that the captain made a bad decision
when trying to land the plane. It remains the worst and deadliest aviation disaster in the
United States and its territories where some people survived. Usually, Korean Air used a
smaller Airbus A300 for this route. But on that day, they had to take Chamorro athletes to a
sports event in American Samoa. So, they used a bigger Boeing 747-300 plane instead.
On August 5th, Flight 801 left Seoul-Kimpo International Airport at 8:53 pm local time. There
were 254 people on board, including the flight attendants, passengers from four countries and
the flight crew. Among the passengers, there were three babies younger than 24 months, and
three children between 2 and 12 years old. Six of the passengers were Korean Air Flight
attendants who were not working on that flight.
During the flight, everything seemed normal until around 1:00 am on August 6th, when the
plane was getting ready to land. It was hard to see as there was heavy rain in Guam.
Therefore crew attempted an instrument landing. However, the glidescope instrument landing
system for runway 6L wasn’t working. The captain thought it was working and followed a
signal he picked up at 1:35 am, but it turned out to be from an irrelevant electronic device on
the ground.
The co-pilot and flight engineer noticed that the plane was descending very steeply, and they
kept saying that they couldn’t see the airport. The flight engineer, Nam, even said that the
signal they detected wasn’t from the right landing equipment. But Captain Park didn’t listen
and continued the landing. At 1:42 am, the plane crashed into Bijia Peak, just before reaching
the runway. The crash happened at an altitude of 660 feet. Even though the crash site was
near the Nimitz VOR navigation beacon, it is important to note that it’s not on Nimitz Hill,
but rather separated by the Fonte River Valley. Out of the 254 people on the plane, sadly 228
lost their lives in the crash. There was one survivor named Hyun Seong Hong, who was 36
years old and from the United States. He was sitting in first class, seat 3B. he mentioned that
the crash happened very fast, and the passengers didn’t even have time to scream. This is
what exactly happened in the incident of Korean Air Flight-801.
The boundaries of Korean Air Flight 801 case includes;
 Time Frame and Flight Details: The flight departs from the Seoul-Kimpo
International Airport (now Gimpo International Airport), South Korea and the
destination was Antonio B. Won Pat International Airport, Guam. The Korean Air
Flight-801 was a Boeing 747 type of aircraft. The incident occurred on August 6,
1997.

 Geographical boundaries: The geographic focus of Korean Air Flight-801 is the

crash site at Nimitz Hill, situated around 3 miles (5 kilometers) southwest of Antonio
B. Won Pat International Airport in Guam. This location is central to understanding
the incident’s spatial context and its proximity to the intended destination.

 Casualties and Impact: The incident claimed 228 lives from 254 passengers and
crew. Survivors faced diverse injuries, while families coped with immense sorrow.
Communities, notably in Guam, felt profound impacts. Swift actions involved rescue
missions and inquiries. Long-lasting effects included enduring emotional anguish,
advancements in aviation safety, and increased recognition of flight hazards.

 Investigation findings: The National Transportation Safety Board (NTSB) found that
the Korean Air Flight-801 crash resulted from the captain’s mishandling of the
approach. Crew tiredness and insufficient training were also factors.
Recommendations emphasized better crew training, rest management, and teamwork
in the cockpit. Korean Air and regulators then made changes to boost safety measures
and avoid future accidents.

 Causes and Factors: The crash stemmed from pilot mistakes, crew exhaustion,
insufficient training, adverse weather and internal problems within the airline. These,
coupled with communication and cockpit management shortcomings, highlighted the
imperative for substantial enhancements in aviation safety procedures and regulatory
supervision.

STAKEHOLDER ANALYSIS
REFERANCE:
 Crash site image: https://www.google.com/url?sa=i&url=https%3A%2F
%2Fwww.earthmagazine.org%2Farticle%2Fbenchmarks-april-4-2011-air-france-
flight-447-wreckage-found-using-modern-oceanography-
tools&psig=AOvVaw1KBRSSV0FdFVa0JuJe3Nv3&ust=1710660093650000&sourc
e=images&cd=vfe&opi=89978449&ved=0CBMQjRxqFwoTCNiEssyf-
IQDFQAAAAAdAAAAABAE