Safety Analysis of Systemic Accidents Triggered by Performance Deviation

Sawaragi, Tetsuo; Horiguchi, Yuji; Hina, Akihiro

doi:10.1109/sice.2006.315635

Cited by 28 publications

(14 citation statements)

References 2 publications

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“…System failure can occur due to the interactions, even if all the components on their own are functional. As there is degree of autonomy in most aircraft, the pilot's ability to interact effectively with the system without losing too much control or situational awareness is extremely important so that in an emergency event the pilot is still able to effectively take manual control of the aircraft [11,15,49] or transition from one level of control (autopilot) to another (manual) [37], with incomplete information [46], or mode confusion [50] (dissonance between the mental model of the operator and the actual state of the technical system). The sociotechnical interactions on the flight desk are still not fully understood, particularly with respect to how they are affected by cultural influences [15], the representations of the hardware state to the pilot [46], and how the pilot builds mental awareness of the environment [51].…”

Section: Cognitive Processes and Sociotechnical Interactionsmentioning

confidence: 99%

Aviation Human Error Modelled as a Production Process

Pons¹,

Dey

2015

TOERGJ

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As technology systems have become more complex, so it is increasingly difficult for human operators to comprehend how the system is behaving. There is a need to better understand the causes of human-error in the context of the situational variables. The specific case under examination is the process of landing an aircraft. This paper applies a production engineering perspective. By production-process, we refer to the set of actions that are necessary to move a system from one state to a desired new state. Such processes involve mechanisms for taking inputs and converting them to the desired outputs, under certain controls and constraints. Human error is thus treated as a constraint on the processes. A novel process methodology is developed to represent how technical systems, situational variables, external factors, and human error evolve over time in a process. The applicability is demonstrated with a dataset of case studies. In parallel, a new categorization of human errors is derived for this situation. The method permits cases to be examined individually, and also collectively for patterns. The results show that the initial landing approach is often the point of error initiation. For the specific case of landing accidents the methodology identifies that the failure causality was the lack of attention to establish procedure at the very start of descent, followed by persistent disregard of disconfirmatory evidence at the initial landing approach, especially under conditions of poor visibility. The paper makes a methodological contribution as well as suggesting new insights for how human error occurs at landing.

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Section: Cognitive Processes and Sociotechnical Interactionsmentioning

confidence: 99%

Aviation Human Error Modelled as a Production Process

Pons¹,

Dey

2015

TOERGJ

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“…Since its introduction, FRAM's usefulness was demonstrated through many applications in many fields as in construction [31], manufacturing [32], healthcare [33], railway systems [34], and mostly in aviation [35] [36] [37] [38], etc. The early applications of FRAM mostly were conducted in a retroactive manner as an accident investigation method, which was indicated in the original naming of FRAM as the "Functional Resonance Accident Model" [39].…”

Section: Fram's Applications and Evolutionmentioning

confidence: 99%

A Proposal for a Predictive Performance Assessment Model in Complex Sociotechnical Systems Combining Fuzzy Logic and the Functional Resonance Analysis Method (FRAM)

Slim¹,

Nadeau²

2019

AJIBM

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Modern sociotechnical systems exhibit dynamic and complex behavior, which can be difficult to anticipate, model and evaluate. The perpetually evolving nature and the emergent properties of such systems require a continuous re-evaluation of adopted safety and risk analysis methods to comply with arising challenges and ensure successful performance. One of the interesting methods proposed in recent years is the Functional Resonance Analysis Method (FRAM). FRAM adopts a systemic perspective to model sociotechnical systems characterizing non-linear relationships and quality of outcome arising from performance variability and functional resonance. This paper aims to further improve the framework and expand the spectrum of features provided by FRAM through the integration of fuzzy logic. Fuzzy logic offers adequate mathematical tools capable of quantifying qualitative concepts and uncertain information applying comprehensible inference systems based on human judgement. An example of a possible application scenario is included through a simulation of aircraft on-ground deicing operations. The preliminary results of this project present an approach to generate numerical indicators for the quality of outputs, which can allow for a more comprehensible representation of potential performance variability. The presented model, however, requires further validation and optimization work to provide more representative and reliable results.

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“…Sybert et al [12] pointed out that FRAM lacked system assessment on interactions between functions and variability in performance during hazard identification in Air Traffic Control (ATC), by analyzing the elastic characteristics of ATC system and confirming the variability existing in the system behaviors [13]. Besides, FRAM was applied to analyzing air accidents, and its effectiveness was verified by Hollnagel et al [14] and Sawaragi et al [15]. FRAM has also been adopted in train control, nuclear power, and electric systems; for example, Belmonte et al [16] analyzed the safety of Automatic Train Monitoring System (ATS) through FRAM, and Macchi et al [17] applied FRAM on the maintenance in nuclear power plant to explain the principle of the local maintenance activities and the possible influences on system safety.…”

Section: Literature Reviewmentioning

confidence: 99%

Extended FRAM by Integrating with Model Checking to Effectively Explore Hazard Evolution

Duan

Tian

2015

Mathematical Problems in Engineering

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Functional Resonance Analysis Method (FRAM), which defines a systemic framework to model complex systems from the perspective of function and views accidents as emergent phenomenon of function's variability, is playing an increasingly significant role in the development of systemic accident theory. However, as FRAM is typically taken as a theoretic method, there is a lack of specific approaches or supportive tools to bridge the theory and practice. To fill the gap and contribute to the development of FRAM, (1) function's variability was described further, with the rules of interaction among variability of different functions being determined and (2) the technology of model checking (MC) was used for the analysis of function's variability to automatically search the potential paths that could lead to hazards. By means of MC, system's behaviors (normal or abnormal) are simulated and the counter example(s) that violates the safety constraints and requirements can be provided, if there is any, to improve the system design. The extended FRAM approach was applied to a typical air accident analysis, with more details drawn than the conclusions in the accident report issued officially by Agenzia Nazionale per la Sicurezza del Volo (ANSV).

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Safety Analysis of Systemic Accidents Triggered by Performance Deviation

Cited by 28 publications

References 2 publications

Aviation Human Error Modelled as a Production Process

Aviation Human Error Modelled as a Production Process

A Proposal for a Predictive Performance Assessment Model in Complex Sociotechnical Systems Combining Fuzzy Logic and the Functional Resonance Analysis Method (FRAM)

Extended FRAM by Integrating with Model Checking to Effectively Explore Hazard Evolution

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