HFS353 Incident and Accident Investigation End-of-Course Assessment 2026, Singapore

HFS353 End-of-Course Assessment

ECA Submission Deadline: Thursday, 8 October 2026, 12:00 pm

(Full marks: 100)

Question 1

This end-of-course project aims to gauge your ability to (1) analyse the potential that exists for incident and injury investigation; (2) examine the necessary preparations to deal with an incident and injury investigation; (3) illustrate the purpose of incident and injury investigations and assess its suitability; (4) indicate resources and expertise that may need to be involved to conduct an investigation; (5) compose and prioritise recommendations; and (6) create a structured incident report.

Read the case study below before you attempt the questions.

Tenerife Airport Accident, 27 March 1977

The Tenerife Airport Disaster occurred on 27 March 1977 at Los Rodeos Airport (now

Tenerife North Airport) in Spain’s Canary Islands. The accident involved two Boeing 747 aircraft operated by KLM Royal Dutch Airlines and Pan American World Airways (Pan Am), which collided on the runway during departure operations.

The collision claimed the lives of 583 passengers and crew members, making it the deadliest aviation accident in history.

Earlier that day, a terrorist bombing at a nearby airport forced numerous flights to divert to Tenerife, creating severe congestion and delays at Los Rodeos Airport. As traffic levels increased, airport operations became more complex and demanding and that eventually led to the accident.

You are to conduct an accident investigation to determine the causes of the above accident based on evidence that has already been established. You are NOT expected to uncover new evidence. Instead, your analysis should rely solely on publicly available and accessible sources.

Using the concepts and methodologies taught in this course, you are to collect and examine the relevant data, identify the root cause(s) of the incident, and develop recommendations to prevent similar occurrences in the future. Your incident report should be in a form ready for submission to the company’s management. You are to apply the format in your report and answer the questions as shown below:

Detailed Format

1. Investigation Report Cover Page

2. Table of Contents

3. Abbreviations

4. List of Figures

5. List of Tables

6. Synopsis

7. Factual Information. This can include information from documentation, records, checklists, Standard Operating Procedures, policies, acts, standards, and interviews. The factual information should be presented in the following format:

a. Include a timeline of events that led to the accident and the loss of lives.

b. Injuries to people.

c. Damages to equipment/structure/facilities/others.

d. Personnel information (License / Certification / Qualifications / Experiences/ Duty-time / Rest Period / Others)

e. Equipment operation

f. Meteorological information

g. Communication
i. Emergency responses
ii. Fire and fire-fighting
iii. Evacuation

h. Barricade

i. Tests and research

8. Analysis

a. Examine the factual information for this incident and identify the HFACS factors.

b. Present the factors with reference to the layers of Organisational Influence, Unsafe Supervision, Preconditions, and Unsafe Acts.

c. Indicate where there are limitations in the evidence, the reasons for the limitations, and how they might be addressed (if possible).

d. For all evidence. show actual and/or potential scientific verification. Cite all the sources using the American Psychological Association (APA) 7th edition format. Please refer to this website https://libguides.suss.edu.sg/apa.

e. Unknowns, Uncertainties, and Controversy.

9. Conclusions of Analysis

10. Safety Actions

• From the factual information and HFACS analysis, compose the safety actions taken to ensure this incident does not happen again.

11. Safety Recommendations

• From the factual information and HFACS analysis, use the Hierarchy of Controls to propose recommendations to ensure that this incident does not happen again.
• Evaluate all recommendations and prioritize based on the likelihood of success for each recommendation. Present your evaluations clearly.

12. Expansion. From the Safety Actions and Safety Recommendations, illustrate how these actions and recommendations may apply to:

a. Other Countries
b. Other Jobs
c. Other Companies
d. Other Industries

13. Appendices. You can include the following information if it is relevant:

a. Photos
b. Records
c. People involved

14. References

The following assessment rubric will be used:

(100 marks)

—– End of  ECA Paper  —–