MIT16_842F09_sw10

MIT16_842F09_sw10 - A New Accident Model for Engineering...

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A New Accident Model for Engineering Safer Systems 16.842 – 13 November, 2009 Student 10, T. Ishimatsu, and Student 11
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Introduction Traditional accident models view accidents as resulting from a chain or sequence of events. But today, the types of systems and the context in which they are built have been changing: Fast pace of technological change Changing nature of accidents New types of hazards Decreasing tolerance for single accidents Increasing complexity and coupling More complex relationships between humans and automation Changing regulatory and public views of safety These changes are facing the limits of current accident models and new approaches are needed.
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Includes FTA, FMECA, Event Trees, etc. Explains accidents in terms of multiple events sequenced as a chain over time. – Ignores non-linear causality relationships including feedback. Is subjective in the choice of events to include. – There is no well-defined “start” of the causal chain involved in accidents. May provide too superficial an explanation of why the accident occurred. Shift from “cause” to “reasons” Event Chain Model Example of a fault tree A Top event Leak not detected Intermediate failure event Controller fails Pressure transducer 1 fails Basic failure event B G H I C F T E 1 E 2 E 3 E 4 E 5 Image by MIT OpenCourseWare.
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AA965 Cali Accident Crew Procedure Error Pilot Error Approach Chart and FMS Inconsistencies FMS Design Deficiency American Airlines Training Deficiency Manufacturer’s Deficiencies International Standards Deficiency
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Limitations of Event Chain Models Event-based models do NOT account for: – Social and organizational factors Structural deficiencies in the organization Management deficiencies Flaws in the safety culture of the company or industry – System accidents and software errors Reducing the ability to detect all potential undesired interactions Increasing the incidence of system accidents – Human error May appear safe and rational locally. May be unsafe in the larger socio-technical system as a whole. – Adaptation over time Under pressure toward cost-effectiveness and increased productivity in an aggressive, competitive environment – Component interaction accidents Violate the safety constraints
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STAMP: Systems-Theoretic Accident Model and Processes Safety is viewed as a control problem.
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This note was uploaded on 11/08/2011 for the course AERO 16.810 taught by Professor Olivierdeweck during the Winter '07 term at MIT.

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MIT16_842F09_sw10 - A New Accident Model for Engineering...

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