TECHNICAL UNIVERSITY OF CRETE - .Engineering and Management, Technical University of Crete ... The

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  • TECHNICALUNIVERSITYOFCRETE

    DEPARTMENTOFPRODUCTIONENGINEERINGANDMANAGEMENT

    DIPLOMATHESIS

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    3 APPLYINGACCIDENTANALYSISTECHNIQUES(AcciMapSTAMP)TOTHEHELIOSAIRWAYS

    CRASHATGRAMMATIKO.

    ExaminingBoard:

    AssociateProfessorTomKontogiannis(Supervisor)

    AssistantProfessorEliasKosmatopoulos

    AssistantProfessorVangelisGrigoroudis

    PAPETTAS ANDREAS I.

    JUNE 2009

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    Acknowledgements

    I thankMr. Tom Kontogiannis for introducing and guidingme to the social sensitiveworldofsafetyengineering.

    The crossdisciplinary undergraduate curriculum at Department of ProductionEngineering and Management, Technical University of Crete provided a greatbackground incouplingtogetherthedisciplinesfromdifferentlevels;fromtechnicaltomanagerial.

    My gratitude to my parents Ioannis and Despo for supporting me (mentally and byfunds)inmyfirstacademicquestwhicheventuallyendsbythiswork.AndofcoursemyyoungerbrothersMichaelandMarioforkeepingmefit.

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    To Lambidona and Michael.

    Although gone; they are still around.

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    4 ABBREVIATIONS

    AAIASB AirAccidentInvestigationandAviationSafetyBoard(Greece)AMM AirplaneMaintenanceManualAOC AirOperatorsCertificateATC AirTrafficControlATPL AirlineTransportPilotLicenseCAA CivilAviationAuthorityofUnited Kingdom (UK)CRM CrewResourceManagementCVR CockpitVoiceRecorderDCA DepartmentofCivilAviation(Cyprus)EASA EuropeanAviationSafetyAgencyFCOM FlightCrewOperationsManualFDR FlightDataRecorderFMS FlightManagementSystemICAO InternationalCivilAviationOrganizationJAA JoinAviationAuthoritiesNVM NonVolatileMemoryQRH QuickReferenceHandbookSOP StandardOperationalProceduresTUC TimeofUsefulConsciousness

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    TableofContentsABBREVIATIONS...............................................................................................................................7

    Prologue........................................................................................................................................11

    1 Chapter1IntroductiontoAnalysisTechniques...................................................................13

    1.1 Thecauseconsequencechart[28]...............................................................................14

    1.2 Criteriafortheevaluationofaccidentanalysistechniques[11]...................................15

    1.2.1 Sequentialandtemporalaspectsofaccidentscenarios.......................................16

    1.2.2 Aspectsoftheaccidentanalysisprocess...............................................................16

    1.2.3 Aspectsofaccidentprevention.............................................................................17

    2 Chapter2AccidentAnalysisTechniques..............................................................................19

    2.1 TheRasmussensframework.........................................................................................19

    2.1.1 TheAcciMaprepresentation.................................................................................19

    2.1.2 ThegenericAcciMap.............................................................................................22

    2.1.3 TheActorMapandInfoMap..................................................................................22

    2.2 SystemsTheoreticAccidentModelandProcesses.......................................................25

    2.2.1 TheCentralRoleofConstraintsinSystemSafety.................................................26

    2.2.2 ControlLoopsandProcessModels.......................................................................29

    2.2.3 SocioTechnicalLevelsofControl..........................................................................31

    2.2.4 AClassificationofAccidentFactors.......................................................................34

    2.2.5 InadequateEnforcementofSafetyConstraints....................................................35

    2.2.6 InadequateExecutionoftheControlAction.........................................................40

    2.2.7 InadequateorMissingFeedback...........................................................................40

    3 Chapter3AnalysisusingAcciMap.........................................................................................41

    3.1 Level1theGovernmentPolicyandLegislation............................................................42

    3.2 Level2theRegulatoryBodiesandAssociations...........................................................42

    3.2.1 TheCyprusDepartmentofCivilAviation..............................................................42

    3.2.2 TheUKCAA............................................................................................................43

    3.3 Level3LocalareaGovernment,CompanyManagementPlanningandBudgeting......44

    3.4 Level4TechnicalandOperationalManagement..........................................................45

    3.5 Level5PhysicalprocessesandActoractivitiesandLevel6EquipmentandSurroundings.............................................................................................................................46

    4 Chapter4AnalysisusingSTAMP...........................................................................................49

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    4.1 ThePhysicalProcessundercontrol:..............................................................................49

    4.2 HazardSource:...............................................................................................................50

    4.3 TheOperationalLinecontrollers/operators(Figure42)..............................................50

    4.3.1 TheManufacturer:Boeing....................................................................................50

    4.3.2 ThePilots:CaptainandFirstOfficer......................................................................53

    4.3.3 CabinCrew.............................................................................................................55

    4.3.4 Dispatcher/GroundEngineer.................................................................................56

    4.4 TheManagerialControlStructure(Figure43).............................................................56

    4.4.1 TheOperatorsStaff..............................................................................................57

    4.4.2 TheMaintenanceContractor................................................................................58

    4.4.3 TheOperator.........................................................................................................59

    4.5 TheRegulatoryAuthorityOversightControlStructure(Figure44).............................60

    4.5.1 TheCyprusDepartmentofCivilAviation/MinistryofCommunicationsandWorks(Government)........................................................................................................................60

    4.5.2 TheUKCAA............................................................................................................61

    4.5.3 TheInternationalOversightOrganizations(JAA,ICAO,EASA)................................62

    4.6 ModelingSystem(Behavioral)Dynamics......................................................................63

    5 Chapter5ConclusionAnalysis...............................................................................................65

    5.1 Causes............................................................................................................................65

    5.2 ActionstakenafterrecommendationsbyAAIASB........................................................66

    5.3 Resultsofmethodsusedinanalysis..............................................................................69

    5.3.1 Humanfactorperformance...................................................................................69

    5.3.2 CrewResourceManagement(CRM).....................................................................70

    5.3.3 Workclimateandbehavior...................................................................................72

    5.3.4 InstitutionalOutsourcing.......................................................................................73

    5.4 Assessmentoftheaccidentanalysistechniques..........................................................73

    5.4.1 TheRasmussensframework.................................................................................73

    5.4.2 TheSTAMP.............................................................................................................74

    5.5 EventVsControldomain.(AlmeidaandJohnson2004,p.3)........................................75

    5.6 Furthersuggestionsforstudyanddevelopment..........................................................76

    6 Bibliography...........................................................................................................................77

    7 APPENDICES...........................................................................................................................81

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    Prologue

    TheHeliosAirwayscrashatGrammatikoswasoneshockingairdisasterwith121fatalitieswhichimplicatedseveralsafetyissues.TheofficialreportbyAAIASB[1]resultedinsafetyamendmentsby Boeing, the aircraftmanufacturer and caused the undergoing CyprusDepartment of CivilAviationfullscalereorganization.

    For the analysis of the above accident two novel techniques are chosen. The first one , theRasmussens framework[28], which will be also referred as AcciMap, provides a series ofgraphicalrepresentationinrepresentinganaccident.ApplicationsofthistechniqueinliteratureareprovidebyHopkins(2000)ontheESSOAustralianGasE

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