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- Ternov, Sven, et al.
(författare)
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A method, DEB analysis, for proactive risk analysis applied to air traffic control
- 2004
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535. ; 42:7, s. 657-673
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Complex production systems as, for instance, those used in health care, in off shore industry, in nuclear power industry or in aviation suffer now and then from severe system breakdowns. Lessons learnt from these often lead to changes in the "system". A more rational approach would be to identify these "system weaknesses" before accidents happen. A new proactive method, DEB analysis, for identifying hazards in a complex system was applied to an air traffic control unit in Malmoe, Sweden. The system weaknesses (i.e. latent system failures and insufficient safety barriers), which could cause these hazards, were identified. The effectiveness of the method was assessed by comparing these "prospective" identified system weaknesses with "retrospective" identified system weaknesses in a consecutive series of loss of separation cases (n = 15), investigated by the central aviation administration. Main findings: The system weaknesses in 14 out of the 15 cases were found with the proactive method. One sub-task was missed. Discussion: The method is an effective tool in disclosing system weaknesses that can give rise to hazards. The method should be modified with increased engagement of operators. It might be applied to other complex systems as well.
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- Ternov, Sven, et al.
(författare)
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Operator-centred local error management in air traffic control
- 2004
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535. ; 42:10, s. 907-920
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: A large number of air traffic control occurrences take place without resulting in loss of separation between aircraft. Unfortunately such occurrences are seldom reported and therefore not used for disclosing system weaknesses, Such as inappropriate methods and procedures. The ATCC (Air Traffic Control Centre) Malmoe made a trial with local reporting of "learning occurrences". The trial was ATCO-(Air Traffic Controller) centred. The study objectives were to evaluate if ATCOs would start to report after a defined training and marketing effort, if they could identify system weaknesses, if concrete actions for safety improvement would be taken as a result of the trial and to what extent expert support was necessary. Method and material: The trial period was eight months. The ATCO report would be made on a simple form, available on site. These reports would then be analysed in groups and the marketing and feedback efforts would be co-ordinated by the local flight safety group. Results: 43 reports were filed and analysed during the trial period. The initial motivational training and marketing was considered adequate. During the group discussions, the ATCOs identified system weaknesses within 40 of the reports. The resulting safety improvement actions included: the ATCC unit becoming more active in contacting the pilots and airline companies, the renaming of some waypoints (due to name similarities), the implementation of safer procedures when relieving ATCOs, the training of ATCOs in cockpit flight management systems, and the initiation of a research project primarily concerned with ATCO mental overload. Expert support was required in the beginning to help ATCOs focus on the system rather than on the individual.
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