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Master's Dissertation
DOI
10.11606/D.6.2009.tde-14012010-095713
Document
Author
Full name
Marcia Fajer
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2009
Supervisor
Committee
Fischer, Frida Marina (President)
Almeida, Ildeberto Muniz de
Colacioppo, Sergio
Title in Portuguese
Sistemas de investigação dos acidentes aeronáuticos da aviação geral: uma análise comparativa
Keywords in Portuguese
Acidente Aeronáutico
Acidente de Trabalho
Fator Humano
Fator Organizacional
Incidente Aeronáutico
Abstract in Portuguese
Descreve o panorama do surgimento da aviação e das teorias de investigação de acidentes aeronáuticos. Objetivo - Analisar a investigação dos acidentes e incidentes aeronáuticos ocorridos na Aviação Geral no Estado de São Paulo no período de 2000 a 2005 e verificar sua associação a fatores organizacionais. Método - Foram comparadas as atuações das agências de investigação de acidentes aeronáuticos dos Estados Unidos, União Européia e Brasil, identificado os métodos de investigação de acidentes empregados. Foi realizado o levantamento das ocorrências com as aeronaves classificadas na categoria de aviação geral no estado de São Paulo no período 2000 a 2005 e feita a análise comparativa de 36 relatórios finais de acidentes utilizados pelo Centro de Investigação e Prevenção de Acidentes (CENIPA) com o Human Factors Analysis and Classification System (HFACS). Resultados Identificou-se que as agências de investigação dos Estados Unidos e União Européia atuam de forma sistêmica e a brasileira atua isoladamente. Foi constatado que houve 636 ocorrências com aeronaves da aviação geral, sendo que 92 por cento foram incidentes, que não foram investigados. Dos acidentes, 5,5 por cento possuíam relatórios finais concluídos. A análise dos relatórios finais, segundo o CENIPA, apontou 163 fatores contribuintes, sendo que o principal fator foi o deficiente julgamento presente em 80,5 por cento dos acidentes. A utilização do modelo HFACS identificou a presença de 370 fatores contribuintes e os erros de habilidade, de decisão e planejamento inadequado foram os principais fatores contribuintes com 86,1 por cento . Considerações Finais O estudo possibilitou a identificação da falta de integração de diversos órgãos governamentais na investigação dos acidentes aeronáuticos. A ausência de investigação de incidentes aeronáuticos dificultando a prevenção. A análise do CENIPA não contempla de forma adequada os fatores organizacionais. O HFACS não deve ser uma ferramenta apenas quantificadora das causas de acidentes aeronáuticos
Title in English
Accident investigation systems for the general aviation: a comparative analysis
Keywords in English
Air Accident
Air Incident
Human Factors
Organizational Factors
Work Accident
Abstract in English
Introduction Describes the birth of aviation and aeronautical accidents factors. investigation theories. Objective Analyze the investigation of aeronautical accidents and incidents occurring in the General Aviation in the State of São Paulo during the period of 2000 through 2005 and verify their association with organizational factors. Method The air accident agencies of the United States, European Union and Brazil were studied, identifying and comparing the accident investigation methods used. It was registered the number of events with aircrafts in the State of Sao Paulo from 2000 to 2005, and performed the comparative analysis of 36 accident final reports used by the Centro de Investigação e Prevenção de Acidentes (CENIPA; Accident Prevention and Investigation Center) using the Human Factors Analysis and Classification System (HFACS). Results It was observed that the investigation agencies of the United States and the European Union work in a systemic way, and that the Brazilian one works alone. It was observed that there were 636 events with aircrafts of the general aviation, of which 92 per cent were not-investigated incidents. Of the accidents, 5.5 per cent had their final reports finished. The analysis of the final reports according to CENIPA pointed out 163 contributing factors, being the main factor "inadequate evaluation", present in 80.5 per cent of the accidents. The HFACS model identified 370 contributing factors, and the "skill errors", "decision" and "inadequate planning" were the main contributing factors, being present in 86.1 per cent of the cases. Final Considerations The study allowed identifying the lack of integration of several administration agencies when investigating air accidents. The non investigation of air incidents hinders the prevention. The CENIPA analysis does not study properly the organizational factors. HFACS must not be just a quantifying tool of the air accidents causes.
 
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Publishing Date
2010-01-21
 
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