A Systems Perspective


From the reading you should have understood that a systems approach argues that some methods or approaches to understanding accidents are limited, and that this in turn limits additional learning that could prevent future accidents. Taking a broader perspective and considering an entire system, including influences external to a single organization, is a difficult task, but can yield valuable information.


In this assignment you will use your understanding of STAMP to analyze your own observations of the Colgan Air 3407 accident from the previous assignment. Write a brief response, at least 750 words, to the following questions. What things might you have failed to consider? Were you in some way blinded to additional factors because of the perspective presented by NAT or HRT? How can the more holistic system perspective improve your understanding of the factors involved in an accident? Finally, consider how a systems perspective might address benign safety lapses that occur as a result of normalization of deviation or practical drift, and whether or not this is addressed in NAT or HRT.


Your response should be at least 750 words. This assignment is worth 50 points according to the following rubric:

  • 15 Points – Summarize STAMP and how it is different from NAT and HRT. What things would you consider from a systems perspective that you didn’t before?
  • 15 Points – Discuss whether or not a systems perspective allowed you to better understand the events of the accident and how they unfolded. Would you make additional or different recommendations for safety based on this understanding?
  • 15 Points – Describe how a systems perspective might address benign safety lapses and whether the same lapses would be addressed by NAT or HRT.
  • 5 Points – Your response is well written and free of any significant grammatical or spelling errors.