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STAMP is a method for evaluating accidents that is based on systems theory. It departs from traditional event chain models that tend to focus on human errors instead of the goals and motives that triggered the errors. The thesis presents a STAMP model of the mid-air collision that occurred on July 1, 2002 near Uberlingen, Germany. This model focuses on the air traffic controller in charge of the aircraft that collided and the surrounding central environment at ACC Zurich, which was the ATC center controlling the aircraft at the time. First the components in the system are analyzed to determine their roles in the system and to identify the safety-related issues. Next, the interactions of the components and the resulting communications failure are studied. Conclusions as to the causes of the accident are presented. A system dynamics model of the control room environment is constructed and studied to determine how the issues relating to the accident developed over time. Finally, the findings from the STAMP model are summarized and recommendations are made based on the analysis. The recommendations based on the model agree with those of the official accident investigation report; in addition, several new recommendations are made.
This book constitutes the refereed proceedings of the Second International Conference on Information Systems for Crisis Response and Management in Mediterranean Countries, ISCRAM‐med 2015, held in Tunis, Tunisia, in October 2015. The objectives of the ISCRAM‐med conference are to provide an outstanding opportunity and an international forum for local and international researchers, practitioners, and policy makers to address and discuss new trends and challenges with respect to information systems for crisis response and disaster management. The 14 full papers and 4 short papers presented in this volume were carefully reviewed and selected from 41 submissions. They are organized in topical sections on social computing, modeling and simulation, information and knowledge management, engineering of emergency management systems, and decision support systems and collaboration.
A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a simpler, analog world, have changed very little over the years. In this groundbreaking book, Nancy Leveson proposes a new approach to safety—more suited to today's complex, sociotechnical, software-intensive world—based on modern systems thinking and systems theory. Revisiting and updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate, Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP), then shows how the new model can be used to create techniques for system safety engineering, including accident analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems. She applies the new techniques to real-world events including the friendly-fire loss of a U.S. Blackhawk helicopter in the first Gulf War; the Vioxx recall; the U.S. Navy SUBSAFE program; and the bacterial contamination of a public water supply in a Canadian town. Leveson's approach is relevant even beyond safety engineering, offering techniques for “reengineering” any large sociotechnical system to improve safety and manage risk.
Merriam Press Military History. Detailed history of each of 33 aircraft wreck sites visited and investigated by the authors, with photos of the aircraft before the accident, and numerous photos of the crash site and evidence found at the site. Includes Washington, Oregon and Idaho state crash locator lists. 354 color photos, 42 B&W photos.
Taking an integrated, systems approach to dealing exclusively with the human performance issues encountered on the flight deck of the modern airliner, this book describes the inter-relationships between the various application areas of human factors, recognising that the human contribution to the operation of an airliner does not fall into neat pigeonholes. The relationship between areas such as pilot selection, training, flight deck design and safety management is continually emphasised within the book. It also affirms the upside of human factors in aviation - the positive contribution that it can make to the industry - and avoids placing undue emphasis on when the human component fails. The book is divided into four main parts. Part one describes the underpinning science base, with chapters on human information processing, workload, situation awareness, decision making, error and individual differences. Part two of the book looks at the human in the system, containing chapters on pilot selection, simulation and training, stress, fatigue and alcohol, and environmental stressors. Part three takes a closer look at the machine (the aircraft), beginning with an examination of flight deck display design, followed by chapters on aircraft control, flight deck automation, and HCI on the flight deck. Part four completes the volume with a consideration of safety management issues, both on the flight deck and across the airline; the final chapter in this section looks at human factors for incident and accident investigation. The book is written for professionals within the aviation industry, both on the flight deck and elsewhere, for post-graduate students and for researchers working in the area.
Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.
A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a simpler, analog world, have changed very little over the years. In this groundbreaking book, Nancy Leveson proposes a new approach to safety—more suited to today's complex, sociotechnical, software-intensive world—based on modern systems thinking and systems theory. Revisiting and updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate, Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP), then shows how the new model can be used to create techniques for system safety engineering, including accident analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems. She applies the new techniques to real-world events including the friendly-fire loss of a U.S. Blackhawk helicopter in the first Gulf War; the Vioxx recall; the U.S. Navy SUBSAFE program; and the bacterial contamination of a public water supply in a Canadian town. Leveson's approach is relevant even beyond safety engineering, offering techniques for “reengineering” any large sociotechnical system to improve safety and manage risk.
This study of aircraft crashes on hills and mountains of the UK and Ireland covers the period 1928 to 1992, the majority relating to World War II. Drawing upon Air Force records, civil accident reports and news reports, the author has included the accounts of survivors, eye-witnesses and rescuers.