The use of Functional Resonance Analysis Method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience

Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models

“…space shuttle Columbia; Comair flight 5191) have not simply resulted from such trigger events. Instead these accidents emerge as complex phenomena within the normal operational variability of a system (de Carvalho, 2011). Describing accidents in a sequential (cause-effect) fashion is, therefore, arguably inadequate.…”

Systemic accident analysis: Examining the gap between research and practice

“…Many complex system accidents, e.g. space shuttle Columbia and Comair flight 5191, have not simply resulted from catastrophic equipment failure or an unsafe human action, as required according to traditional cause-effect accident models; instead accidents emerge as complex phenomena within the normal operational variability of a system (de Carvalho, 2011). Therefore, describing accidents in a sequential (cause-effect) fashion is arguably inadequate, as it is unable to sufficiently explain the non-linear complexity of modern-day socio-technical system accidents (Hollnagel, 2004;Lindberg et al, 2010).…”

Functional resonance analysis method and its application on Zagreb mid-air collision

“…FRAM je u par navrata korišćen u analizi nezgoda (incidents) i nesreća (accidents) u vazdušnom saobraćaju i pokazao se kao koristan metod [4,7,8] Sistem kontrole letenja je sistem orijentisan ka čoveku (kontrolori letenja i posade vazduhoplova). Kontrolori letenja izdaju instrukcije posadama, koje TEHNIKA -SAOBRAĆAJ 62 (2015) 2 potvrđuju prijem instrukcija i sprovode ih u delo, a kontrolor onda rezultat svega toga vidi ispred sebe na radarskom ekranu [8].…”

“…Kontrolori letenja izdaju instrukcije posadama, koje TEHNIKA -SAOBRAĆAJ 62 (2015) 2 potvrđuju prijem instrukcija i sprovode ih u delo, a kontrolor onda rezultat svega toga vidi ispred sebe na radarskom ekranu [8]. U procesu nadgledanja vazduš-nog saobraćaja, ulazni podaci su predstavljeni manevrima koje posada vrši, a kontrolor prati na ekranu radarskog pokazivača.…”

“…Оdobrenja i instrukcije kontrolora su input za funkciju upravljanja avionom, dok output predstavljaju manevri vazduhoplova. Оstali parametri (vreme, kontrola i preduslovi) su praktično isti za obe funkcije, jedino se resursi razlikuju po tome što kontrolor koristi sisteme obrade radarskih podataka, a pilot sisteme koji mu omogućuju upravljanje vazduhoplovom [8].…”