Sample Aviation Term Paper on Organizational Lapses Accident Report

Organizational Lapses Accident Report

Fine Airlines Services Flight 101 was a cargo flight which pitched up sharply after taking off reaching a very high altitude. The aircraft stalled and then crashed resulting to the death of three flight crew members, one security guard on board, and a motorist who was on the ground. The aircraft was damaged by a post crash fire and this was as a result of failure by the firm to adhere to some principles of safety management system. Safety management system principles greatly contribute to reductions in aircraft accidents because of the procedures and regulations that have been set (Flouris & Yilmaz, 2009).  This essay identifies two Safety Management System principles that were missing from the organization that contributed to the accident.

The principles of safety management are used as a yardstick in formulating regulations that ensure safety of all those who are concerned. The goal of Safety Management System is to improve safety by helping ensure that the outcomes of any management or system activity incorporate informed, risk based decision making (Dillingham, 2013). The NTSB found out that the cause of the crash was an incorrect loading of cargo and a correspondingly incorrect stabilizer trim setting, precipitating an extreme pitch-up at rotation.

Firstly, the safety policy of fine air was not effective enough and thus led to ineffective loading which contributed to the accident. The firm was unable to exercise control over some of its operations and processes which led lapses in the loading process which contributed to the accident. Fine air failed to provide a framework that could be used to identify and address the deficiencies in equipments, operations, and procedures in the loading department. The lapses that existed in the safety policy of fine air resulted to the failure of the Cargo loader to load the plane as it was specified by the regulations of the company. This indicates that the procedures and rules that were laid down by the company on how to load the cargo were not adhered to the loader. The rules and regulations were not backed up with strict enforcement mechanisms that could ensure that all procedures were followed.  The organizations did not have a strong internal environment to ensure compliance to the standards that were set in the process and procedures of loading cargo. A strong control environment mandates that reliability be woven into the fabric of every business transaction; it’s the fiber of operational execution (Maitre, 2015).

Secondly, the safety promotion strategy of the firm failed because of the failure by the management of fine air to exercise operational control in the loading procedures. The firm failed to provide those concerned with the loading process of the basic skills that are needed in cargo loading and to ensure that the deficiencies that existed in the cargo loading procedures were corrected. Fine air failed to develop instruction for loaders that could guide them towards the successfully performance of their duties. Fine air also failed to adhere to the safety compliance principle which requires that a firm providing such services should comply with certain standards.

Safety Management System is a formal, proactive approach to manag­ing safety which emphasizes on proactive and predictive safety processes to identify hazards before reactive safe­ty techniques are necessary (Ostrowski, Valha& Ostrowski, 2014). Failure of the company to act in accordance with some of the safety management principles contributed to the accident that led to the loss of lives. The firm did not have effective monitoring structures to ensure that the cargo was packed according to the laid down procedures and ensure that deficiencies were corrected before the plane took off.


Dillingham, G. L. (2013). Is the Federal Aviation Administration Making Sufficient Progress on Safety Initiatives? Congressional Digest, 92(6), 13-19.

Flouris, T., & Yilmaz, A. K. (2009). Change Management as A Road Map for Safety Management System Implementation in Aviation Operations: Focusing on Risk Management and Operational Effectiveness. International Journal of Civil Aviation (IJCA), 1(1), 1-19.

Maitre, S. (2015). Risk Management, Internal Controls and Aviation Safety. Armed Forces Comptroller, 60(1), 24-27.

Ostrowski, K. A., Valha, D., & Ostrowski, K. E. (2014). Gap Analysis Using ICAO Safety Management Guidance. (cover story). Professional Safety, 59(7), 26-32.