Systems Theoretic Accident Model and Process (STAMP) safety modelling applied to an aircraft rapid decompression event

Allison, Craig K.; Revell, Kirsten M. A.; Sears, Rod; Stanton, Neville A.

doi:10.1016/j.ssci.2017.06.011

Cited by 77 publications

(43 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Other approaches take a still broader view on complex sociotechnical systems, incorporating system constraints [Cognitive Work Analysis (CWA); Vicente 1999], control structures [Systems Theoretic Accident Model and Processes (STAMP); Leveson 2004], task, social, and information networks [Event Analysis of Systemic Teamwork (EAST); Stanton et al 2005Stanton et al , 2008Stanton et al , 2013, or performance variability and resonance [Functional Resonance Analysis Method (FRAM); Hollnagel 2012]. These approaches have been used for risk assessment (e.g., Stanton and Harvey 2017), analysing accidents (Allison et al 2017;Griffin et al 2010), or system design .…”

Section: Introductionmentioning

confidence: 99%

Analysing communication dynamics at the transaction level: the case of Air France Flight 447

David

Schraagen

2018

Cogn Tech Work

View full text Add to dashboard Cite

A system's continuous adaptability is a vital determinant of its safety. It is thus very important for a system to reach graceful extensibility, the ability to adapt in unexpected situations (Woods in Reliab Eng Syst Saf, https ://doi.org/10. 1016/j. ress.2015.03.018, 2015). Current methods to study patterns of adaptation have mostly focused on relatively static network relationships of short time scales. We argue that both adaptive and maladaptive patterns of adaptation are rooted in patterned behaviours that should be studied in light of their previous history of transactions. Those patterns may develop over longer time scales yet exert their effects during unexpected situations on shorter time scales. In this study, we focused on communication patterns that played out during the Air France 447 incident. Butts (2008) relational event model was employed to examine the communication dynamics amongst the pilots in the cockpit of flight AF447, and illustrate how communication patterns may be studied by considering sequences of relational events, thus adopting a dynamic, de-contextualised approach to system analysis, at a 'transaction level'. The analysis of the communication transcript revealed patterned changes in some communication dynamics in the cockpit after the flight entered an unexpected situation, which led to the biased strengthening or weakening of certain links in the network. These changes-even though preliminary due to the limited number of agents analysed-suggest that capturing the structural composition of a system at the transaction level assists in explaining how transactions fail, and can be used for the development of better system structures or training procedures for system interaction.

show abstract

Section: Introductionmentioning

confidence: 99%

Analysing communication dynamics at the transaction level: the case of Air France Flight 447

David

Schraagen

2018

Cogn Tech Work

View full text Add to dashboard Cite

show abstract

“…STAMP represents socio-technical processes as systemic performances in a state of dynamic equilibrium (Leveson, 2004). As such it is particularly suited to the aviation domain that is considered a system of systems (Carlock & Fenton, 2001;Harris & Stanton, 2010) comprised of numerous complex independent agents, distributed across a wide network (Allison et al 2017). STAMP conceptualizes the constraints on multiple levels resulting in a hierarchical control structure.…”

Section: Methodsmentioning

confidence: 99%

“…STAMP-STPA has been applied to multiples domains such as space (Owens et al, 2008;Ishimatsu et al, 2013;Leveson, 2009;Leveson, 2005), nuclear (Thomas et al,2012), rail (Suo, 2012; Song et al 2012), military (Pereira et al, 2006;Abrecht, 2016), automobiles (Placke et al, 2015), and medical domains (Pawlicki et al, 2016;Leveson et al, 2016;Leveson et al, 2012). In the aviation domain STAMP -STPA has been applied to improve safety in ATM (Fleming & Levseon;, for Rotary aircraft (Abrecht et al, 2016), for NextGen avionics (Fleming et al, 2014) and Rapid decompression events (Revell et al, 2016;Allison et al, 2017).…”

Section: Methodsmentioning

confidence: 99%

“…Previous work by the authors demonstrated the utility of the STAMP-STPA method in identifying factors central to the Helios 522 accident when applied to a theoretical rapid decompression scenario in current operations (Allison et al 2017), and for scoping the assumptions for exploring this hazard within a distributed crewing configuration (Revell et al, 2016). This paper progresses this work with a view to advancing the safety case for a distributed crewing configuration by demonstrating the utility of a systems approach to safety by mapping out the extent, influence and interdependence of Unsafe Control Actions (UCAs).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Modelling distributed crewing in commercial aircraft with STAMP for a rapid decompression hazard

et al. 2018

Self Cite

View full text Add to dashboard Cite

Changes to crewing configurations in commercial airlines are likely as a means of reducing operating costs. To consider the safety implications for a distributed crewing configuration, system theoretic accident model and processes (STAMP) was applied to a rapid decompression hazard. High level control structures for current operations and distributed crewing are presented. The CONOPS generated by STAMP-STPA for distributed crewing, and design constraints associated with unsafe control actions (UCAs) are offered to progress in the route to certification for distributed crewing, and improve safety in current operations. Control loops between stakeholders were created using system-theoretic process analysis (STPA). The factors leading to the Helios 255 incident demonstrated the redundancy that a ground station could offer without the risk of hypoxia, during a decompression incident. STPA analysis also highlighted initial UCAs that could occur within the hypothetical distributed crewing configuration, prompting consideration of design constraints and new CONOPS for ground station design. Practitioner Summary: SPO in commercial aircraft is likely as a means to reduce costs. This paper makes a case for distributed crewing using STAMP-STPA. Comparing current operations with a distributed crewing configuration, the redundancy offered by a ground station is demonstrated. Design constraints and new CONOPs for distributed crewing, and current operations are proposed.

show abstract

“…The outstanding point of the model is to account for organizational factors, human errors and adaptations to changes over time. Meanwhile, safety is attained by enforcing safety constraints continuously instead of preventing component failure measures [25,26].…”

Section: Introductionmentioning

confidence: 99%

A Hybrid HFACS-BN Model for Analysis of Mongolian Aviation Professionals’ Awareness of Human Factors Related to Aviation Safety

2018

View full text Add to dashboard Cite

Safety is crucial to ensure the sustainability of aviation growth. To better clarify the influences of human factors on aviation accident risks, this study developed a hybrid HFACS-BN model (HFACS: Human Factors Analysis and Classification System; BN: Bayesian Network). The authors designed and implemented a questionnaire survey based on the four-level HFACS framework and collected valid data from 180 out of 649 aviation professionals working in the Ulaanbaatar International Airport, Mongolian in 2017. The model identified 35 major human factors out of 129 factors. The model validation was performed in terms of content validity and predictive validity. The results showed that even though a majority of respondents perceived that many human factors had a middle-or high-effect on aviation accident risks, the probability of the risks caused by human factors was estimated to be just 1.37%. The Unsafe Acts level is most influential to the risks among the four levels, while the Unsafe Supervision level contributes least. It is revealed that enhancing aviation professionals' awareness of human factors should make full use of causal chaining effects among human factors. Finally, this study contributes to the literature from the perspectives of both methodological development and important empirical analysis.Sustainability 2018, 10, 4522 2 of 20 considered to be more than 80% [4]. Various efforts have been made to improve aviation safety by eliminating human errors, and globally, the International Civil Aviation Organization (ICAO) has always been devoted to improving human factors research achievements and adapting the latest ones into the aviation industry.The history of aviation safety experienced the era of technical factors from the early 1900s to late 1960s, and that of human factors from the early 1970s to mid-1990s, respectively. Recently, organizational factors have become a new concern and safety tends to be viewed from a systemic perspective, including both human and organizational factors as well as other factors [5]. Under this background, an effective tool namely Human Factors Analysis and Classification System (HFACS) was developed and it has been widely applied in aviation operation systems. However, challenges remain since HFACS is a theoretical framework and should be examined based on detailed quantitative data under different contexts. In recent years, research on human factors in aviation has been facing new challenges with the improvement of advanced technologies. In addition, commercial airplanes have adopted three crew members instead of two, and the flight environment has become more and more complicated. Compared with traditional mechanical tools, electronic ones have been widely applied and proven to be more effective.Previous studies have focused on searching for the origin of aviation accidents, but neglected professional opinions from experienced investigators or operators [6,7]. New theories and methodologies for human factors in aviation have been proposed, such as the SHEL (Software, Hardwa...

show abstract

Systems Theoretic Accident Model and Process (STAMP) safety modelling applied to an aircraft rapid decompression event

Cited by 77 publications

References 16 publications

Analysing communication dynamics at the transaction level: the case of Air France Flight 447

Analysing communication dynamics at the transaction level: the case of Air France Flight 447

Modelling distributed crewing in commercial aircraft with STAMP for a rapid decompression hazard

A Hybrid HFACS-BN Model for Analysis of Mongolian Aviation Professionals’ Awareness of Human Factors Related to Aviation Safety

Contact Info

Product

Resources

About