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    Systems-Theoretic Accident Model and

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    This document discusses various accident prevention theories and models that can be applied to designing a safety-driven air navigation service provider (ANSP). It introduces Normal Accident Theory (NAT) which views some accidents as inevitable due to system complexity and coupling. High Reliability Organizations (HRO) focus on failure prevention through practices like preoccupation with failure. STAMP (Systems-Theoretic Accident Modeling and Processes) detects hazards earlier and is expected to allow ANSP managers to more effectively ensure safety. STAMP/STPA (Systems-Theoretic Process Analysis) identifies potential hazards and accidents resulting from inadequate control or enforcement of safety constraints. The document provides an example of applying STAMP/STPA to

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    Systems-Theoretic Accident Model and

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    atcosupport
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    This document discusses various accident prevention theories and models that can be applied to designing a safety-driven air navigation service provider (ANSP). It introduces Normal Accident Theory (NAT) which views some accidents as inevitable due to system complexity and coupling. High Reliability Organizations (HRO) focus on failure prevention through practices like preoccupation with failure. STAMP (Systems-Theoretic Accident Modeling and Processes) detects hazards earlier and is expected to allow ANSP managers to more effectively ensure safety. STAMP/STPA (Systems-Theoretic Process Analysis) identifies potential hazards and accidents resulting from inadequate control or enforcement of safety constraints. The document provides an example of applying STAMP/STPA to

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    Bemildo Presentation Final

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    This document discusses various accident prevention theories and models that can be applied to designing a safety-driven air navigation service provider (ANSP). It introduces Normal Accident Theory (NAT) which views some accidents as inevitable due to system complexity and coupling. High Reliability Organizations (HRO) focus on failure prevention through practices like preoccupation with failure. STAMP (Systems-Theoretic Accident Modeling and Processes) detects hazards earlier and is expected to allow ANSP managers to more effectively ensure safety. STAMP/STPA (Systems-Theoretic Process Analysis) identifies potential hazards and accidents resulting from inadequate control or enforcement of safety constraints. The document provides an example of applying STAMP/STPA to

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views42 pages

    Systems-Theoretic Accident Model and

    Uploaded by

    atcosupport
    This document discusses various accident prevention theories and models that can be applied to designing a safety-driven air navigation service provider (ANSP). It introduces Normal Accident Theory (NAT) which views some accidents as inevitable due to system complexity and coupling. High Reliability Organizations (HRO) focus on failure prevention through practices like preoccupation with failure. STAMP (Systems-Theoretic Accident Modeling and Processes) detects hazards earlier and is expected to allow ANSP managers to more effectively ensure safety. STAMP/STPA (Systems-Theoretic Process Analysis) identifies potential hazards and accidents resulting from inadequate control or enforcement of safety constraints. The document provides an example of applying STAMP/STPA to

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    SYSTEMS-THEORETIC ACCIDENT MODEL AND

    PROCESSES (STAMP) APPLIED TO DESIGN A SAFETYDRIVEN CONCEPT OF AN AIR NAVIGATION SERVICE


    PROVIDER (ANSP)

    A bit of the History of


    Accident Prevention in Complex Systems

    NAT Normal Accident Theory


    HRO High Reliable Organizations
    NAT+HRO - Mixed

    NAT

    Interactive complexity and tight coupling in some


    technological systems, such as nuclear power
    plants, leads to unpredictability of interactions and
    hence system accidents that are inevitable or
    normal [Perrow 1999]

    HRO

    Preoccupation with failure, Reluctance to


    Simplify interpretations, Sensitivity to
    operations, Commitment to resilience, and
    Deference to experience. [Weick, 1999]

    Does a plane crash mean that NAT is right or


    does the reduction in plane crashes over
    time mean that HRO is right? [Leveson 2008]

    NAT + HRO

    Complexity and Tight Coupling


    +
    Redundancy and Descentralized Decisions

    Both groups assume


    accidents are caused by
    component failures. This
    confusion of component
    reliability with system safety
    leads to a focus on
    redundancy as a way to
    enhance reliability, without
    considering other ways to
    enhance safety.
    [Leveson, 2008]

    Common assumptions (myths) about safety


    That if each person and component in the
    system operates reliably, there will be no
    accidents
    Increasing protection will increase safety
    Human error is the largest single cause of
    accidents and incidents
    System will be safe if people comply with the
    procedures they have been given
    Accident analysis can identify root causes
    (the truth) of why the accident happened
    Accident investigation is the logical and rational
    identification of causes based on facts
    Retrospective analysis of adverse events is
    required and perhaps the best way to improve
    safety

    Detected procedures in accident investigation

    Contemporary theories concerning


    Accident Prevention in Complex Systems

    http://skybrary.aero/index.php/Toolkit:Systems_Thinking_for_Safety/Systems_Thinking_Methods

    Resilience Engineering (RE)

    Focus on what goes right: Dedalus

    SAFETY II
    (e.g.: RE)

    SAFETY I
    (e.g.: SMS)

    Focus on what went wrong: Icarus

    SAFETY I

    SAFETY II

    ETTO FRAM
    Accident Analysis

    STAMP
    Systems-Theoretic Accident
    Model And Processes

    STAMP (Systems-Theoretic Accident


    Modeling and Processes) is expected
    to allow managers to more effectively
    detect hazards within the organization
    from the early design stage.

    STAMP

    STAMP

    STAMP

    STAMP

    STAMP

    STAMP/CAST

    Causal Analysis based on STAMP

    STAMP/STPA
    Systems-Theoretic Process Analysis

    STPA

    STPA

    STPA

    Example of a
    Safety
    Control
    Structure

    Example of a
    Safety
    Control
    Structure

    ANSP

    ANSP
    Safety
    Control
    Structure

    ANSP
    Safety
    Control
    Structure
    (CBO analysis)

    ANSP
    Safety
    Control
    Structure
    (CBO and TBO analysis)

    Successful
    cases of using
    STAMP/STPA
    in industry
    http://psas.scripts.mit.edu/home/2013-workshop-presentations/

    FAA

    Thank You!!!
    Bemildo Ferreira
    FVPSudeste@gmail.com

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