Write a short summary of the incident showing you understand what happened, the causes of the incident, and conclusion.

Part 1:  Write a short summary of the incident  showing you understand what happened, the causes of the incident, and conclusion.

Part 2: 

Identify and describe the primary system in the case.  

Identify 2 different decisions that were made at different times during the course of events

• For each decision you identified, describe what were two factors (name and describe the terms) from those discussed in lecture that impacted that decision.  Make sure to show how that concept from lecture relates here.
• Part 3:  Briefly describe and list at least two ways to redesign the system that could have helped avoid the accident.  (remember “system” refers to the whole situation and so a redesign could refer to the equipment, people, environment, training, etc.)