Development of a Multi-Factorial Instrument for Accident Analysis Based on Systemic Methods
The present research is built on three major pillars, commencing by making some considerations on accident investigation methods and pointing out both defining aspects and differences between linear and non-linear analysis. The traditional linear focus on accident analysis describes accidents as a sequence of events, while the latest systemic models outline interdependencies between different factors and define the processes evolution related to a specific (normal) situation. Linear and non-linear accident analysis methods have specific limitations, so the second point of interest is mirrored by the aim to discover the drawbacks of systemic models which becomes a starting point for developing new directions to identify risks or data closer to the cause of incidents/accidents. Since communication represents a critical issue in the interaction of human factor and has been proved to be the answer of the problems made by possible breakdowns in different communication procedures, from this focus point, on the third pylon a new error-modeling instrument suitable for risk assessment/accident analysis will be elaborated.
Digital Object Identifier (DOI): doi.org/10.5281/zenodo.1315697Procedia APA BibTeX Chicago EndNote Harvard JSON MLA RIS XML ISO 690 PDF Downloads 939
 C. V Bălan (Pietreanu)., Contribuţii la dezvoltarea metodelor de analiză a accidentelor de zbor, PhD Thesis, Bucharest 2016.
 J. Reason, The human contribution: Unsafe acts, accidents and heroic recoveries, Farnham: Ashgate, 2008.
 J. Leplat, Occupational accident research and system approach, Journal of occupational accidents, 1984.
 S. Sklet, Methods for accident investigation, Reliability, safety and security studies at NTNU, Norwegian University of Science and Technology, 2002.
 J. Rassmusen, Human error and the problem of causality in analysis of accidents, Phil. Trans. Royal Soc., London, 1990.
 E. Hollnagel, Understanding accidents-from root causes to performance variability, Proceedings of the 2002 IEEE 7th Conference on Human factors and power plants, 2002.
 E. Hollnagel, Barriers and accident prevention, Aldershot, UK: Ashgate, 2004.
 E. Hollnagel, J. Speziali, Study on developments in accident investigation methods: A survey of the'state-of-the-art. SKI Report, Sophia Antipolis, France: Ecole des Mines de Paris, 2008.
 E. Hollnagel, O. Goteman, The Functional Resonance Accident Model. In Cognitive Systems Engineering in Process Control, 2004.
 N. G. Leveson, A new accident model for engineering safer systems, Safety Science, April, 2004.
 N. G. Leveson, System safety engineering: back to the future, Massachusetts Institute of Technology, Aeronautics and Astronautics, USA, 2002.
 P. Underwood, P. Waterson, A Critical Review of the STAMP, FRAM and Accimap Systemic Accident Analysis Models, Loughborough University, UK, 2012.
 V. M. Iordache, C. V. Bălan (Pietreanu), Safety Culture in Modern Aviation Systems – Civil and Military, INCAS BULLETIN, Volume 8, Issue 2/ 2016, pp. 135 – 142, Bucharest 2016.
 A. Mosleh, PRA: A perspective on strengths, current limitations and possible improvement, Nuclear Engineering and technology, 2014.
 https://www.iata.org/IATA/Controlled/Flight/Into/Terrain/Accident/Analysis/Report2016 (Accessed 7 March 2017).
 http://www.iata.org/services/statistics/gadm2017 (Accessed 19 March 2017).
 ICAO Doc 9806, Human Factors Guidelines for Safety Audits Manual
 ICAO Doc 9859, Safety Management Manual
 Boeing Aeromagazine, The role of human factors in improving aviation safety.
 I. A. Herrera, R. Woltjer, Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis, Reliability Eng. System Safety, 2010.
 E. Hollnagel, Modelling transport systems with FRAM: Flows or functions?,University of Southern Denmark, 2015.
 P. D. Krivonos, Communication in aviation safety: lessons learned and lessons required, Regional Seminar of the Australia and New Zealand Societies of Air Safety Investigators, June 2007.
 R. Baron, Barriers to Effective Communication: Implications for the Cockpit, A Viationsafety, 2005.
 M. Nevile, Communication in context: a conversational analysis tool for examining recorded data in investigations of aviation occurrences, ATSB Research and 33 Analysis Report, 2006.
 M. Krifka, S. Martens, F. Schwarz, Group interaction in the cockpit: some linguistic factors, Communication in High Risk Environments, Hamburg, Germany, 2003.
 Federal Aviation Administration, Communication and coordination between flight crew members and flight attendants, Advisory Circular 120-48. Washington, D.C.
 C. V. Pietreanu, S. E. Zaharia, Perspectives on accident modeling in aviation, Proceedings of the 6th International Conference on Air Transport “INAIR”, 14-16 October 2017, Prague, Czech Republic, pp 36-44, ISBN 978-80-554-1387-7.