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Japan Airlines Flight 123, Unsafe Supervision, Organisational Influences,…
Japan Airlines Flight 123
Unsafe Supervision
Planned Inappropriate Operations
Inadequate risk analysis
The risk of the slight separation in the
material of the wing was overlooked
Inappropriate planning
Not enough checks done on the plane prior to use
Inadequate Supervision
Inexperience
The failed inspection could be
due to inexperience
Supervisory Violation
Not adhering to rules and regulations
The process for inspection
was not properly done
Failed to correct Problem
Failed to provide feedback
The inspection was called 'proper'
Organisational Influences
Organiastional Climate
Accountability for actions
Neither company involved wanted to be accountable
Culture - lack of management care/concern
Inspection found to be proper despite causing the accident
Delegation of authority
Repairs given to workers at Osaka International Airport
Culture - morale
Pilots never gave up trying to correct accident
Resource Management
Training
Pilots were experienced with emergency procedures
Qualifications/Authorisation
All members involved had proper qualifications
Equipment/Facility
Plane was damaged prior to takeoff
Organisational Process
Inadequate control & monitoring
Plane was untested before flight
Risk Management
Plane was repaired after previous damage and inspected after repair
All parties involved were unaware of the incorrect repair
Inadequate procedures
Repair on plane created risk
Preconditions for Unsafe Acts
Substandard Conditions of Operators
Adverse Physiological States
Hypoxia
Pilot did not put on
oxygen masks
Disorientation
Pilots were doing maneuvers
Physical/Mental Limitations
Visual limitation
Cloudy/poor weather
Adverse Mental States
Loss of situational awareness
Environmental Factors
Physical Environment
Weather
Unexpected and unprepared
for weather events
Temperature
Below freezing
Heights
Cruising at 24,000ft
Technological Environment
Hazardous
The plane was improperly fixed after previous damage
Obstructed
Plane crew was working
with inadequate technology
Substandard Practices of Operators
Personal Readiness
Knowledge currency
Pilots and crew were inexperienced in emergency situation
They were also not knowledgeable of these situations
Crew Resource Management
Threat and Error Management
Unsafe Acts
Errors
Perceptual Errors
Spatial disorientation
Hypoxic hypoxia
Knowledge Error
Inadequate information
Crew was not experienced with emergency situations
Inadequate aircraft knowledge (maintenance)
Planes repair was incorrect
Planes internal damage
was not inspected
Decision Errors
Incorrect emergency response
Pilot attempted maneuvers to maintain height
No emergency decent
Misdiagnosed situation
Hypoxic hypoxia
Skilled-Based Errors
Inappropriate technique
Pilot took strange maneuvers
Dutch roll motion
Severe phugiod motion
Omitted step in procedure
Flight crew members did not
put on oxygen masks
Violations
Routine
Did not follow procedures - ground
Plane was damaged prior to takeoff
Exceptional
Not adhering to instructions and/or brief
Pilot took strange maneuver when plane
started having issues