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Page 12 Schmidt et al. J Surveill Secur Saf 2020;1:1-15 I http://dx.doi.org/10.20517/jsss.2019.02

Figure 6. Reliability Block Diagram of Lion Air 610 airplane crash

similarities between the two cases in relation to failures associated with the disasters. These include failures
in information sharing, communication and lack of knowledge. Further, both cases presented unlearning
from near misses before the disasters occurred. However, the cases differ in their level of learning from
the disasters. In the case of the Virginia Tech Shooting, the failures have been detected, analysed and
lessons learned implemented nationwide through updated regulations, laws and policies. However, in the
case of the Lion Air 610 crash, the failures have only been partly detected as investigations have not been
concluded yet. Hence, the organisations involved have the just begun with learning from the failure. This is
also reflected in the crash of the Ethiopian Airlines last month (March, 2019), which was identified to have
similar causes of failure seemingly not having been completely addressed yet.

Regarding the case of the Virginia Tech Shooting, the RBD identified gaps in the emergency response.
Referring to the Swiss Cheese Model, it can be indicated that a lack of barriers resulted in the emergency
response to be the most vulnerable part of the system. In comparison, the RBD for the Lion Air 610 crash
identified gaps in the design of the MCAS and internal communication among airline entities.

As the case study of the Lion Air 610 crash mainly addresses systematic failures, the FTA proved to be
easily applicable. However, the FTA of the Virginia Tech Shooting showed limitations due to the complexity
of the case. The authors are aware that Cho’s personality might be seen more as a symptom rather than
a cause. However, in this case, it was interpreted as a cause since this particular incident would not
have happened without Cho and the root causes were related to issues in communication and missing
supporting features.