Malaysia Airlines MH17 disaster A systems accident
On 13 October 2015 the Dutch Safety Board published its Final Report into the Malaysia Airlines MH17 disaster, where a Boeing 777, carrying 298 passengers and crew, was downed by a missile over eastern Ukraine.
The day after the Board published its report, Dr Simon Bennett, Director of the University of Leicester's Civil Safety and Security Unit, published a systems-thinking-informed analysis of the shoot-down. Dr Bennett argued that while immediate responsibility for the disaster lay with the soldiers or separatists who fired the missile, contributory factors included airspace management decisions and airlines' risk assessments.
According to Dr Bennett, the destruction of Flight MH17 was a 'systems accident' (see Professor Jim Reason's work for a definition of 'systems accident') whose origins lay both in discrete military decisions, and in the interplay between the elements that compose the international aviation system.
The peer-reviewed journal paper, published by the International Journal of Aviation, Aeronautics and Aerospace (IJAAA), is available for download here. (When the IJAAA page comes up, it will give you the paper's Abstract. Please click on the Download button for the full paper.)