A Case Study of Fishbone Sequential Diagram Application and ADREP Taxonomy Codification in Conventional ATM Incident Investigation

Cheng, Schon Z.Y. Liang; Valdés, Rosa María Arnaldo; Comendador, Fernando Gómez; Nieto, Francisco Javier Sáez

doi:10.3390/sym11040491

Cited by 7 publications

(4 citation statements)

References 19 publications

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“…Data collected from these incident reports are identified as factors and events, which are also denominated as precursors to future accidents. These factors and events can be extracted and codified by standardized methodologies [ 20 , 21 , 22 ] and taxonomies [ 23 ], which have been applied in this process. Factors based on taxonomy can be divided into two groups: descriptive factor (DF) and explanatory factor (EF).…”

Section: Methodsmentioning

confidence: 99%

Detection of Common Causes between Air Traffic Serious and Major Incidents in Applying the Convolution Operator to Heinrich Pyramid Theory

Cheng

Valdés

Comendador

et al. 2019

Entropy

Self Cite

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Heinrich’s pyramid theory is one of the most influential theories in accident and incident prevention, especially for industries with high safety requirements. Originally, this theory established a quantitative correlation between major injury accidents, minor injury accidents and no-injury accidents. Nowadays, researchers from different fields of engineering also apply this theory in establishing quantitatively the correlation between accidents and incidents. In this work, on the one hand, we have detected the applicability of this theory by studying incident reports of different severities occurred in air traffic management. On the other hand, we have deepened the analysis of this theory from a qualitative perspective. For this purpose, we have applied the convolution operator in identifying correlations between contributing causes to different incident severities, also known as precursors to accidents, and system failures. The results suggested that system failures are mechanisms by which the causes are manifested. In particular, the same underlying cause can be manifested through different failures which contribute to incidents with different severities. Finally, deriving from this result, an artificial neuronal network model is proposed to recognize future causes and their possible associated incident severities.

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Section: Methodsmentioning

confidence: 99%

Detection of Common Causes between Air Traffic Serious and Major Incidents in Applying the Convolution Operator to Heinrich Pyramid Theory

Cheng

Valdés

Comendador

et al. 2019

Entropy

Self Cite

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“…Fishbone (Ishikawa) Analysis. The Fishbone (Ishikawa) Analysis is an effective tool for identifying and categorizing the various contributing factors that combined to result in the accident (Liang et al, 2019). This is referred to as a root cause analysis, which is a structured process for identifying the various underlying causes or factors that result in an accident.…”

Section: Atlantic Southeast Airlines Flight 529 Embraer Emb-120 Brasi...mentioning

confidence: 99%

An Inductive Approach to Identify Aviation Maintenance Human Errors and Risk Controls

Jiang¹,

Lu²,

Fu³

et al. 2022

cari

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Human errors can be present in any maintenance task and cause latent but dangerous situations to commercial aviation. By looking into past accidents and incidents caused by aviation maintenance errors, the importance of safety measures would be highlighted -including continuous education on maintenance human factors. Currently, the FAA Part 147 airframe and powerplant (A&P) training curriculum includes general, airframe, and powerplant modules. However, the curriculum does not mandate human factors education or aviation safety pedagogical content. The objectives of this study are to: 1. Find and analyze emerging themes of aviation maintenance-related accidents from existing documentation; 2. Apply risk assessment tools to conduct a risk assessment and identify causal and latent variables; 3. Use detailed qualitative case analysis on major accidents to identify contributing variables of human factors; and 4. Provide recommendations to advocate the importance of human factors education. This study uses a qualitative approach, employing meta-narrative analysis and the VOSviewer visualization tool to demonstrate inter-connected themes related to aviation maintenance problems. Detailed Fishbone (Ishikawa) diagrams showcasing the effectiveness of the selected tools for pedagogical purposes are followed by several case studies, together shedding light on the criticality of continuous education of maintenance human factors. The recommendations based on research findings are beneficial to maintenance training institutions for them to be more aware of potential shortcomings.

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“…The Ishikawa fishbone diagram shown in Figure 2 consists of the head and backbone of a fish. In creating the fishbone model, the 5 M's + E principle was used [97] Names of the individual components of the Ishikawa diagram, i.e., 5 M's + E principle were adjusted to the specifics of the analyzed markets, similarly to studies by other authors [98][99][100]. The fishbone head presents the problem to be solved, which is the difficulty of maintaining a sustainable food supply chain during COVID-19 pandemic and the backbone fish describes the main causes.…”

Section: Implications Of the Difficulties In Marinating The Resilience On The Analyzed Meat Marketsmentioning

confidence: 99%

Qualitative Research on Solving Difficulties in Maintaining Continuity of Food Supply Chain on the Meat Market during the COVID-19 Pandemic

Zielińska-Chmielewska

Mruk-Tomczak

Wielicka-Regulska

2021

Energies

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Although the pandemic phenomenon is not the first of its kind in human history, the common feature of COVID-19 is its rapid impact on the global economy. The challenge for the national economy on the world stage is to maintain a continuous food supply. The scientific purpose of the study is to report, analyze and evaluate backgrounds, causes of instabilities and their effects of the COVID-19 pandemic on supply and demand side of the meat market in the United States of America, China and Russia. The practical purpose of the study is to present implemented measures and recommendations on how to return to meat market equilibrium. In the theoretical part of the study, the revised public source of information coming from well-known organizations such as: EC, FAO, OECD, and WB, are used. In the practical part of the manuscript, qualitative research on the People’s Republic of China, Russian Federation, and the United States of America, along with semi-structured in-depth interviews with experts and Ishikawa diagram are presented. The primary data come from authors’ own research and collection of multiple sources. The article indicates the use of qualitative systematic review, supported by a creation of a prototype of the issues of maintaining continuity of the food supply chain during the COVID-19 pandemic in the secondary sources, intensified by a keyword search. The results of the research are diverse and oriented toward the needs of the analyzed meat markets. In the case of the People’s Republic of China, the solution is to develop a system of subsidies and preferential rates for the use of rail transport in exports. In the case of Russia, the solution is to provide support to the meat and poultry farmers for cold storage of slaughtered animals. In the case of the USA, the solution is to develop technical and technological facilities in order to speed up the supply chain between local livestock with meat and poultry farmers. Moreover, the outcomes indicate that sustainability of the food supply chain needs well-thought-out support on agri-food supply production.

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A Case Study of Fishbone Sequential Diagram Application and ADREP Taxonomy Codification in Conventional ATM Incident Investigation

Cited by 7 publications

References 19 publications

Detection of Common Causes between Air Traffic Serious and Major Incidents in Applying the Convolution Operator to Heinrich Pyramid Theory

Detection of Common Causes between Air Traffic Serious and Major Incidents in Applying the Convolution Operator to Heinrich Pyramid Theory

An Inductive Approach to Identify Aviation Maintenance Human Errors and Risk Controls

Qualitative Research on Solving Difficulties in Maintaining Continuity of Food Supply Chain on the Meat Market during the COVID-19 Pandemic

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