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CONTRIBUTING FACTORS

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Protective barriers to control flowafter release of hazard. Acceptabledowntime of individual barriersselected according to predictedoverall risk of major accidents.

Critical event:Hazard releasecause

Root Causalchain flow of effects

Accidental Targetvictim

PublicbarriersFlowLoss of control of

major energy balance

Government

of evaluation philosophy

Staffing and managementperformance as assumed for riskanalysis. Explicit priority rankingwith reference to risk analysis.

Safety reviews, accident analyses,comparisons across branches,international state of the art.

Regulators, Branch Associations

Industry standards, operational Incident reports, review of companypractices, organizational structureand internal audit practice and results

Acceptance criteria, industrystandards and regulations

Documentation of system designbasis, analysis of accident scenarios,prediction of overall risk to society.

System OperationSystem Design

and Analysis

CompanyOperational reviews with emphasison compliance with preconditionsfor safe operation.staffing, and work resources

management performance, plantCompany policy with respect to

Management

Workload and plan evaluations.and unusual occurrences. maintenance of defenses, incidents, Logs and work reports emphasizing

according to safety preconditions.specifications. Work plans work resources according toStaffing, competence, and

maintenance.operational practice, in particular forrespect to staffing, competency, andPreconditions of safe operation with

Staff

and repairtest, calibration, equipment faults, of protective systems; records ofObservations on operational state

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Work and Hazardous ProcessChain of Events

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evolution and

DESIGNERS OPERATORS

MODELMODEL

originaldesignspec

operationalexperience

operationalprocedures

training

changes over timeand constructionvariances

continually test

constructed system

Designer dealswith ideals oraverages, not

Operators

their modelsagainst reality

ACTUAL

SYSTEM

manufacturing

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_\ 2 sD 2 O \ 2 J2 D Y1e 2x2 \ DD 2 Y"g ]u? ?uY=cY2 2 Y2 D2 J TBT 2Y TP b D TB62 ? = - 2 2 ?2 YC2 u &zJ u? 2 T 2Y Y Tg 2Y T] 2 2 O 2 JQ 2 T g J2 u \ P D2 J 2Y\Y=x 2huD YuY1 2Y?uY1n ( ? 2 D Q YT 2\u 2Yc > s2 ^ 1B2 u u D J x 2>O c\ 2Y 2 ]T \\D x2 s O 2 2h = ? 6 2 e\ D 2 T : T.i JIj B2\?Q T B 2\ Y \\ K 2 ( ? T( Y ? Y 2 ( ?2 \ D \ 1lYR (D 2K2 22? 2 du D 2 z u \ J Y ?2Yd ( ? \2 Y \2e Ae 2 2 2 2 n\ D " 2s T2Y Td D 2dY D T2 Mh ( 2 c ?> ? 2\?e 82 c ] 2 ( \" s Y2P S2YT u2 :hzu ?2Y>K2 J \ x2 2 T2 ? hJB ~ 52\hR82 n Rd \ AD fO ?2Y?( 62 T \ D ] 2 2? ~2 Rd2 =

Direct PerceptionProcess

Controls

Displays

Operator

2g L ? \J 2 (D 2Ys \ D 6 \u T

] T \\ 2Y \\ T "Y* ( ? B u D 2 ? ~ 2 D b2 Td2 D O2\ 2Yu cY2 z2 \\ d g Y 2B Ag]\? 2 D (* > d2\?e ( ? dYenYQ Qb ?2?( 2 l\ D 2 Y 2 \ D =2? 2 2Y 2 T d q R b D \Y u J 8 D h\O ?2Y?( 2 x\ D 2 22? 2 T d2 S Q] 2Y c\ 2 l\ ? 2 B\ D 2? g2 ( ? fdx 2T~ D 2Y 2 ~hJ8T \\D 2 b 2 2 O \ c\?]\O ?2Y2 ( ? h 2Y[? Y T z2 ]\ D ~F(2 c 2 \ -T2 ? 2 Y ?2Y u b YB2 \} \ 2Y|2 YTB2 ? 2 2

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Synthesized PerceptionOperator

Displays

Controls

Sensors

Actuators

Process

Y 2g L ( ? \J] 2 6\O ?2Y?( \ D 2? 2

2Y n\ \ u 2 2Yne2 ( ? qTb 2 2\?g\ \22 P] x * ? cY2 e2 x 2K 2 \ D > 2 ? gYTge*?( gYB TI2 \\ 22 u QD \i T/ \ \B] e r2 -u 2 ? ( 2D u 2\?c2 \ \c 2 1Y\ g52\ J 2 2 P e Q 2 u z 2u? * \ \ 2 P"2\?B2 \ Y "\Y 2 Y2 z ?( \D e / \2 6 T | 2c 2 x2 Sz ]2 2 h 2 = 6b 2 \\ 2 2 T]2 d2 2Y*c" 2 ? 2YY=l Y 2e Ahh2 2 2 D2 ? 2YzY2 ~b 6 2Y ( ? 6 2\?e\ \ D 2 \ l cY s \\ T SQ] ? T ?\\ 2 u YY2 T P K u Y2Y\- T2? " x x 2 Q2 B T 2d 2Y T \\D 2 2uY=b c2 - 1 \\ P S \ = D K u x2\?h K\2 \?u Y 2n T2 u u S _ 2 gYK\ n\ 2 2 Y2 62d =]2\? ? l c Rd

Synthesized Perception

Indirect Control

Controls

Operator

Displays Sensors

Computer

Actuators

Process

Y 2 L ( ? \J z & ? n | P T 2 \ D ~2 " z

FQc2 2 T]2\?e? d2 P 2Y \ Sm ^ Y T2 b D D Y12d 2Y> A\ 2Yf x ?2Y>n] x 2 T282\ ( \ 2YB2\? T2Y Y ?u " T2 T \ D b ?2Y ( ? \ 2 \2 \ D

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2? 1 T b D 2 \ 2Y K( 2 b D 2 ]\ \ D d u x 2" ^ Ycb D b \Y& Sd2\l2 P Jg u\ u Jg2 D Y 2A( 2 "2 2 A2 Y>b gD 2 dJ ?2\c2 h =8]kN6(Vi8/:aQkN\R $a$a52d =K2 L 2 Ad2 S6 2d J6\ A \ u 2 c Q ~"2 2 Y=Bz2 ?2"Y 2\?8 T~ P T?cuY >YR Q |YR 1 \ Y T \ D | ( ? = f 2 hu D 8?8YR ~P2 \ T] \ D b D 2 2? 1 2 Tcb cu 2 \ D Q 2Yu Tx \ c 2 \ D \ \ \ ? T ] 2 ? = 2 T 2 Y? s2 \ Y ~2 Y* 1 T

\ D Yun \ g =eKs\ A T T ~uJ 2 u \I\S 2?2Y ] D T s2 2 " \ 2Y~

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uJ2Y 2 2YuY1b 2? =A\ ? 2? = 2\?h D 22 2Yn?h"Y* : \ ? Y \ ? h\ D u n?( T b D T 6D ( ?2Y\? u e 2? K 2 \ 2Y Q\ D\2 n2 ( ? u 2 \? \ 2 \ 2Y2u? b D2 2? = c ]2 ( ? d 2 2 c ( ?2Y]\? RQ\ 2 u \\ 2?z2 2\? 2? 2 \ 2Y] 2P\ 2\?e\ 2? = ? \ 2 2 ] \PbY* Y l 2*s1 Y Y \u e\ \ m2? 1 T I A\ 2 x2 ? 2? 1T D Y2 - u 2 uY 2? \ J 2?2Y> f g \ YI ( ? 2 2" \J1huJ2 u \ T A\ 2 b \ Y Tlbq2 bA" O ( ?2Yb2 YTA cY2T 2YB 1 2 Q AD ?O" / 2 8b BD YTB\\ d2 Y T \ Ye ? " :> Y2? 1 e(2 \ Y T ( ?2Y\ 62 D ?O~ Y2 2 \D l?2Y L" ? 1\ ( ?2Y ( 2Y2 Y\ 2Y Y " 2Y K 2 T u ?2Y \ ?2Y u\ Kx \ 1 2 1h \ q D u D ?bc b \2 c \ ? n2 c c2 J 2Yc? ]2 ( ?2Y\ \ cu 2 ? =\Y2eJuJ |Jg JO ?2Y?( 2? ( ?2 \ D\ 8] ( ?2Y\ \ T WYu2 \ A > \ K z "2 / 2 ?( h2 e O D |2 2d YhY 2

h 1 P2 \ u > [? = : u 2 K 2 h \ ?2Y \u 2 I2 RQ =r(= Gs- 5R \ h2 b ?2 D 2 dQ 2? 1 2 R h [ ]Pt ^us- vR" \ u ?( *K( 2 Y2 Tc 2 S2?2 Y 2 xwA \ u l D Y2 >Ts A \ \ 2 :] l n 2 u n \2 6x 2 \ Y6 \ T z \ 2 2 c 2d 2 2 1h" 8 n(2 h T X A\ 2

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(Feedback)

ConstraintsControl Commands

MeasuringChannel

LEVEL N+1

LEVEL N

Channel

OperationalExperience

Reference

Goals, Policies,

Y \2g xw L u ?2Y \u h 1 F

\ S2? ( ?2P \ lJc2 T \2 2?2Y \ h ? = / \] 2d c 2 2 ? 2 1 2 u u \J2 ? \ 2 2 g D b 2? 1l l\? TB] P 2 TQ ? ?g2\d ~ \ B 2n Y2 O 2 ?2 D 2 ?2Y2? = ? 2 Tx ( ?2Y] b \ xR Y6 uY 6 2 u \ \? T2? 2 2 2 ?2> 2 T eYe \ Y 2? 2 T8 ( B 22 eb 2 u \ ? = /Yc 2 2 d2 ? h Y2hJc JQx 2P 2 2 T z n 2 b 2? 2 2J 2 \ 2 52 Y T \ LRc2 bg Y P A T e 2 2 Yx2Y s \ T u 6 h2 g2 l 2 \ ] \Y 1 T u D R \ \ \Y Qs n 2 YR n2 \ T 2x ?2Y\ 2 c TB 2 ? 2Y Y BD |cu \ T *2 A 2 \ A \Y2 ( O c2 d2 2Y T e/ \ g2 e 2\g2 ( ?2Y\ \ D\ - Y2 A\ P T | 2 |\ A \Y2 \ D T2YO ( ? = Q2 \ 2Y ( ?22 c 2 \ D\2 g u\ T2 >?( ] 2Y T2 J D [ \ 2 J 2 T J ]2 \ d2 PYlcY2Z22 B 2 2 2 \D | 2 g u \ Te 2 * Y \ 2Y\?\ \Y |2 2 -\ Y T \ D *2 82 Y2 \ \Y J8 J T2?2Yx2 2? 1T 2 ? n 2Y" ? 2 - x 2Y ?2Y\ 2 J 2 T \ D g s2 2Y 2\ \ D x2 K\ D 6 P 6 T >hb n2 ( ?2Y T u 2 5 \ 2Y-2 2 c b ? J "T 2Y 1 q2 1h, \ D 2 2? 1 2 T x\ Y T2\ O 2 uJ~O ?2

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M_? Y= ]c g u K u Y2 J 2 h 2u\D 2 d P D 2 Y(? Y1x * \ ? L \ J]\2 ?2Y \ D\2 ORdA

] e T2 \ D 6 \ T 2u E \ \2 L2RQ?]2 e YT62 2 2 2 ? K2 T2 Y z u n 22 8 u z 2 2"2 T 2 \ 2 2n \( > g \\ \ ? "2 2YzY= 2\ Y1f T2?u1 ] J2 QcY2 2 c2 Y ]2 T \ ~D ?2 h2 Yu1cu2 \ \ T8 2?z2\?2c 6u u Y2S x Y8 ( ?2\ K 2 ] 6\ \ T 2?u2 2 ? ( B \ \n2 2 D "2 2 ? ( u 2YT u T 2 2u?2 l2 ? 2 2 \ ? c \2 2u? ? ] BJ 2 u\ "K( 2 ] 2\? T f D > u u d 21 ( ?2] ] \ n ? B 6 \ u u J 2 uY 2 2 \ | 2? 2 PY D 6u 2\?2YO _\ uY 2 2 \ B 2 x z ?( 2u T2\?2-x 2 ? u s \ \ nuYOB? 2 h h2? ]Y /Y\J6P 2 ? 2 ?TA 2\ 2 ] ]s2 2? = u 2 f2 u z ? \ ? 1 m2 \ 2 sR l DL Q 2 q D T ?2\ n2 \ \2 R n 2 \ ?2l? 2 T 5D \\ K(2 n\ \ e2 u 2 R 2 n 2 \2 26 2 2 2 2 ? J2 z P 2 \ Txe2 P \ ~c \Y D Y2 ]2\?62 \ A 6 T2 ?]2 2d 2 g\ D ] 62 u D Rcl ](" \ T2Yb2 ? = Tb 2 6|2 T E u 2 ] ( ?2YE \\ P2? 1 u 2 h?hu h/ B2 h u u J Y \ uY 22 2 &?1 u2 \ u u u 2 ? B 2 Yu1b 2? 1] nu2 O \ D\ - K 2 2u? 2 2? 1 T 2 h 2

*-,

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: 6RA F T 5 MgI FI6 M 6 m6tG=6 D P

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Control

Process Behavior

Inadequate Enforcement

HazardousProcess

Hierarchical Safety Control Structure

Hazardous System State

Inadequate

of Safety Constraints on

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Controller 2

process changes,(Flaws in creation,

or adaptation)

Sensor

Component failures

Incorrect or no

Feedback Delays

missing feedbackInadequate or

control actionineffective or missing

Inappropriate,

Delayedoperation

Controller

Actuator

Controlled Process

extermal informationControl input or

wrong or missing

Changes over time

Measurement

Feedback delays

information provided

inaccuracies

InadequateOperation

operationInadequate

1

4

4 3

Algorithm

Inadequate Control2

Process Modelinconsistent,

incomplete, orincorrect

3

Unidentified oroutofrange

Process outputcontributes to

disturbance

system hazard

Process inputmissing or wrong

Conflicting control actions

incorrect modification

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Airspace Control Order (Guidance for all local air operations in OPC)ACO

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Air Force BaseAirborne Intercept:(a type of radar on fighter aircraft)Aircraft Read Files (supplement to the ACO including the ROE)Air Surveillance Officer (one of the positions in the AWACS)Air Tasking Order (specific mission guidance for the day)

CTF

Air to Air Interrogation (used with IFF)Airborne Command Element: (the commanders representative in the AWACS)

Airborne Warning and Control System (a military air traffic control system in the sky)Black HawkBattle Staff Directive (