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security systems around campus. Lacking information in the emergency plan, the decision to not notify
staff and students as well as hierarchical issues between the police and the university all influenced the
overall response to the incident. Causes 10 and 11 relate to the inefficient emergency plan. Causes 12 and
13 linked with an OR-gate lead to the decision to not notify people on campus.

3.2.5 Recommendations and generic lessons
Lack of information sharing, misinterpretation and insufficient evaluation of situations, as well as lack of
communication, can be considered the main causes for the shooting. Universities and learning facilities
should promote the sharing of knowledge internally, in particular when it concerns safety and health.
Policies and laws should be carefully reviewed and unclarities identified and addressed. Further, learning
institutions should allocate more resources to their care teams to improve support of students struggling
with mental health issues. Emergency plans should be reviewed and updated regularly. They should
implement a wide range of “what if” scenarios such as shootings. In addition, introducing a wide variety
of communication channels and connecting them via one system can help to effectively warn students and
staff in case of incidents.

3.3 Case study 2: Lion Air 610 Airplane Crash, 2018
3.3.1 Background
On 29 October 2018, a Boing Max 737-8 operated by Lion Air was scheduled to fly from Jakarta to Pangkal
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Pinang, as illustrated in Figure 4 .
The scheduled departure time for flight LNI610 was 05:45. Two pilots, six crew members, and 181
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passengers were on board the airplane . Shortly after its departure, the pilots faced problems with
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indicating the altitude and the airspeed of the plane due to critical sensors registering different readings .
To identify the correct information, they contacted air traffic control. Shortly after, the airplane dropped
over 700 feet as the aircraft’s safety system MCAS, which was triggered by the falsified information of
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altitude, had forced the plane to nose down . The pilots were able to correct and recover from the
drop. However, the MCAS continued to push the plane’s nose down even after pilots proceeded with
counteractions. The plane went up and down more than a dozen times before disappearing from the
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radar .
3.3.2 Logic and technical cause of failure
As the investigation of this disaster is still ongoing and the final report is due to be released in August this
year, the technical causes were based on the Preliminary Aircraft Accident Investigation Report (2018)
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of the Indonesian Transport Committee (KNKT) and news articles related to the subject. The causes
identified can be summarised as follows:
(1) The Angle of Attack (AoA) sensor falsely indicated that the airplane’s nose was too high and that the
airplane was stalling. The information obtained by the AoA sensor triggered the automatic safety system
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Maneuvering Characteristics Augmentation System (MCAS), which forced the airplane’s nose down .
(2) The MCAS overrode the pilots’ response as they were trying to correct the problem by lifting the plane’s
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nose back up .
(3) Pilots were not aware of the existence of MCAS. They seemed to have not received any training for this
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feature and no information was added in the manual .
(4) The airplane did not have the optional warning light that would have indicated the problem’s root.
Issues with previous flights of the airplane and response actions by pilots to overcome those have not been
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carefully evaluated and communicated properly .
(5) The MCAS had a poor system redundancy by being able to be triggered by a single sensor, even though
there are two AoA sensors on every airplane .
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