Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX

Detalhes bibliográficos
Autor(a) principal: Moreira, Leandro Silva
Data de Publicação: 2020
Tipo de documento: Trabalho de conclusão de curso
Idioma: por
Título da fonte: Repositório Universitário da Ânima (RUNA)
Texto Completo: https://repositorio.animaeducacao.com.br/handle/ANIMA/8087
Resumo: This monograph is a study that aims to analyze, within the field of operational safety, the accidents that occurred on Flights JT610 and ET302 involving the aircraft model Boeing 737-8 MAX. It is characterized by being an exploratory and qualitative study. There are several regulatory, inspection and advisory bodies that operate in the sector, as well as various prevention, improvement and updating practices and methodologies that aim to ensure the maintenance of aviation operational safety are disseminated. The human factor has a significant influence in this context. The survey's conclusion showed that the final investigation report involving Flight JT610 exposed that the aircraft's automatic system (MCAS) received incorrect sensor readings, resulting in the AOA DISAGREE failure, which may have triggered other problems. Given the situation, the team was subjected to severe stress, which may have resulted in human errors that corroborated the accident. On the other hand, it has not yet been possible to reach precise conclusions about the tragedy of Flight ET302, since the competent investigative bodies have not published the final report of the case. However, during the analysis of the box that records the flight data, clear similarities were observed between Ethiopian Airlines flight 302 and Lion Air flight 610, which suggests that there is some common fault in these two tragedies. The manufacturer of the model has been promoting maintenance and new updates in order to correct possible failures in the anti-stall sensor.
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spelling Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAXSegurança operacionalBoeing 737-8 MAXFalha AOA DISAGREESensor antiestolThis monograph is a study that aims to analyze, within the field of operational safety, the accidents that occurred on Flights JT610 and ET302 involving the aircraft model Boeing 737-8 MAX. It is characterized by being an exploratory and qualitative study. There are several regulatory, inspection and advisory bodies that operate in the sector, as well as various prevention, improvement and updating practices and methodologies that aim to ensure the maintenance of aviation operational safety are disseminated. The human factor has a significant influence in this context. The survey's conclusion showed that the final investigation report involving Flight JT610 exposed that the aircraft's automatic system (MCAS) received incorrect sensor readings, resulting in the AOA DISAGREE failure, which may have triggered other problems. Given the situation, the team was subjected to severe stress, which may have resulted in human errors that corroborated the accident. On the other hand, it has not yet been possible to reach precise conclusions about the tragedy of Flight ET302, since the competent investigative bodies have not published the final report of the case. However, during the analysis of the box that records the flight data, clear similarities were observed between Ethiopian Airlines flight 302 and Lion Air flight 610, which suggests that there is some common fault in these two tragedies. The manufacturer of the model has been promoting maintenance and new updates in order to correct possible failures in the anti-stall sensor.A presente monografia é um estudo que tem por objetivo geral analisar, dentro do campo da segurança operacional, os acidentes ocorridos nos Voos JT610 e ET302 envolvendo a aeronave modelo Boeing 737-8 MAX. Caracteriza-se por ser um estudo exploratório e qualitativo. Existem diversos órgãos regulamentadores, fiscalizadores e orientadores que atuam no setor, bem como são disseminadas várias práticas e metodologias de prevenção, de aperfeiçoamento e de atualização que almejam garantir a manutenção da segurança operacional da aviação. O fator humano exerce significativa influência nesse contexto. A conclusão da pesquisa mostrou que o relatório final da investigação envolvendo o Voo JT610 expôs que o sistema automático da aeronave (MCAS) recebeu leituras incorretas de sensores, resultando na falha AOA DISAGREE, a qual pode ter desencadeado outros problemas. Diante da situação, a equipe foi submetida à grave quadro de estresse, o que pode ter resultado em erros humanos que corroboraram para a ocorrência do acidente. Por outro lado, ainda não foi possível chegar a conclusões precisas sobre a tragédia do Voo ET302, uma vez que os órgãos competentes de investigação não publicaram o relatório final do caso. Entretanto, durante a análise da caixa que registra os dados do voo, foram observadas semelhanças claras entre o voo 302 da Ethiopian Airlines e o voo 610 da Lion Air, o que leva a crer que existe alguma falha em comum nessas duas tragédias. A empresa fabricante do modelo vem promovendo manutenções e novas atualizações, a fim de corrigir possíveis falhas no sensor antiestol.Lohn, Joel IrineuMoreira, Leandro Silva2020-08-31T21:37:59Z2020-11-28T23:14:23Z2020-08-31T21:37:59Z2020-11-28T23:14:23Z2020info:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/bachelorThesis47 f.application/pdfhttps://repositorio.animaeducacao.com.br/handle/ANIMA/8087Ciências Aeronáuticas - Unisul VirtualPolo Ribeirão PretoAttribution-NoDerivs 3.0 Brazilhttp://creativecommons.org/licenses/by-nd/3.0/br/info:eu-repo/semantics/openAccessporreponame:Repositório Universitário da Ânima (RUNA)instname:Ânima Educaçãoinstacron:Ânima2020-12-01T23:57:50Zoai:repositorio.animaeducacao.com.br:ANIMA/8087Repositório InstitucionalPRIhttps://repositorio.animaeducacao.com.br/oai/requestcontato@animaeducacao.com.bropendoar:2020-12-01T23:57:50Repositório Universitário da Ânima (RUNA) - Ânima Educaçãofalse
dc.title.none.fl_str_mv Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
title Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
spellingShingle Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
Moreira, Leandro Silva
Segurança operacional
Boeing 737-8 MAX
Falha AOA DISAGREE
Sensor antiestol
title_short Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
title_full Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
title_fullStr Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
title_full_unstemmed Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
title_sort Gerenciamento de segurança operacional: um estudo envolvendo os acidentes com as aeronaves Boeing 737-800 MAX
author Moreira, Leandro Silva
author_facet Moreira, Leandro Silva
author_role author
dc.contributor.none.fl_str_mv Lohn, Joel Irineu
dc.contributor.author.fl_str_mv Moreira, Leandro Silva
dc.subject.por.fl_str_mv Segurança operacional
Boeing 737-8 MAX
Falha AOA DISAGREE
Sensor antiestol
topic Segurança operacional
Boeing 737-8 MAX
Falha AOA DISAGREE
Sensor antiestol
description This monograph is a study that aims to analyze, within the field of operational safety, the accidents that occurred on Flights JT610 and ET302 involving the aircraft model Boeing 737-8 MAX. It is characterized by being an exploratory and qualitative study. There are several regulatory, inspection and advisory bodies that operate in the sector, as well as various prevention, improvement and updating practices and methodologies that aim to ensure the maintenance of aviation operational safety are disseminated. The human factor has a significant influence in this context. The survey's conclusion showed that the final investigation report involving Flight JT610 exposed that the aircraft's automatic system (MCAS) received incorrect sensor readings, resulting in the AOA DISAGREE failure, which may have triggered other problems. Given the situation, the team was subjected to severe stress, which may have resulted in human errors that corroborated the accident. On the other hand, it has not yet been possible to reach precise conclusions about the tragedy of Flight ET302, since the competent investigative bodies have not published the final report of the case. However, during the analysis of the box that records the flight data, clear similarities were observed between Ethiopian Airlines flight 302 and Lion Air flight 610, which suggests that there is some common fault in these two tragedies. The manufacturer of the model has been promoting maintenance and new updates in order to correct possible failures in the anti-stall sensor.
publishDate 2020
dc.date.none.fl_str_mv 2020-08-31T21:37:59Z
2020-11-28T23:14:23Z
2020-08-31T21:37:59Z
2020-11-28T23:14:23Z
2020
dc.type.status.fl_str_mv info:eu-repo/semantics/publishedVersion
dc.type.driver.fl_str_mv info:eu-repo/semantics/bachelorThesis
format bachelorThesis
status_str publishedVersion
dc.identifier.uri.fl_str_mv https://repositorio.animaeducacao.com.br/handle/ANIMA/8087
url https://repositorio.animaeducacao.com.br/handle/ANIMA/8087
dc.language.iso.fl_str_mv por
language por
dc.relation.none.fl_str_mv Ciências Aeronáuticas - Unisul Virtual
dc.rights.driver.fl_str_mv Attribution-NoDerivs 3.0 Brazil
http://creativecommons.org/licenses/by-nd/3.0/br/
info:eu-repo/semantics/openAccess
rights_invalid_str_mv Attribution-NoDerivs 3.0 Brazil
http://creativecommons.org/licenses/by-nd/3.0/br/
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv 47 f.
application/pdf
dc.coverage.none.fl_str_mv Polo Ribeirão Preto
dc.source.none.fl_str_mv reponame:Repositório Universitário da Ânima (RUNA)
instname:Ânima Educação
instacron:Ânima
instname_str Ânima Educação
instacron_str Ânima
institution Ânima
reponame_str Repositório Universitário da Ânima (RUNA)
collection Repositório Universitário da Ânima (RUNA)
repository.name.fl_str_mv Repositório Universitário da Ânima (RUNA) - Ânima Educação
repository.mail.fl_str_mv contato@animaeducacao.com.br
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