Causal risk models of air transport - NLR-ATSI

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Chapter 6. Risk models in other industries............................................................ 86 6.1. Nuclear power ....................................................................................... 86 6.2. Manned spaceflight ............................................................................... 87 6.3. Offshore industry .................................................................................. 88 6.4. Process industry .................................................................................... 90 6.5. Rail transport......................................................................................... 90 6.6. Health care ............................................................................................ 91 6.7. Conclusions for this section .................................................................. 93 Chapter 7. Modelling............................................................................................. 95 7.1. Model representation............................................................................. 95 7.2. Modelling techniques............................................................................ 97 7.2.1 Boolean Trees ....................................................................................... 97 7.2.2 Bayesian Belief Nets........................................................................... 101 7.2.3 Petri nets.............................................................................................. 105 7.3. Size, depth, complexity and uncertainty ............................................. 106 7.4. Time dependency ................................................................................ 107 7.5. Conclusions for this section ................................................................ 108 Chapter 8. Quantification .................................................................................... 110 8.1. Measurements, quantities, units and values. ....................................... 110 8.2. The need for ratio scales...................................................................... 114 8.3. Uncertainty.......................................................................................... 115 8.4. Model assumptions.............................................................................. 116 8.5. Data sources ........................................................................................ 117 8.5.1 Accident or incident data?................................................................... 117 8.5.2 Accident investigation......................................................................... 118 8.5.3 Incident reporting................................................................................ 119 8.5.4 In-flight recorded data......................................................................... 122 8.5.5 Expert judgement ................................................................................ 124 8.5.6 Empirical studies................................................................................. 124 8.5.7 Safety audits........................................................................................ 126 8.6. Denominator data................................................................................ 128 8.7. Using the data...................................................................................... 129 8.8. Conclusions for this section ................................................................ 132 Chapter 9. Modelling challenges ......................................................................... 134 9.1. Modelling human operators ................................................................ 134 9.2. Modelling safety management ............................................................ 140 9.3. Complexity, completeness and dependencies ..................................... 148 9.4. Conclusions for this section ................................................................ 157 Chapter 10. Model validation .............................................................................. 159 10.1. Introduction......................................................................................... 159 10.2. Validation of the generic accident scenarios....................................... 160 10.2.1. Validation of take-off and landing overrun probability estimates ...... 160 10.2.2. Completeness of the accident scenarios.............................................. 161 10.3. Validation of a model for missed approaches: case validity............... 161 10.3.1. Qualitative description of the model................................................... 161 10.3.2. Quantification of the model variables (the parent nodes) ................... 163 2
10.3.3. Dependencies ...................................................................................... 168 10.3.4. Comparison of model results with observations in practice ............... 169 10.4. Face validity and peer review.............................................................. 171 10.5. Assumption analysis............................................................................ 171 10.6. Conclusions for this section ................................................................ 172 Chapter 11. Summary, discussion and conclusions............................................. 173 References ............................................................................................................ 186 Summary............................................................................................................... 214 Samenvatting ........................................................................................................ 217 Appendix A: The history of third party risk regulation at Schiphol..................... 221 Background....................................................................................................... 221 Stand still for Schiphol risk .............................................................................. 222 New law for Schiphol....................................................................................... 222 Causal model as a solution?.............................................................................. 224 Appendix B: The aviation system......................................................................... 225 A typical flight.................................................................................................. 226 Subsidiary processes......................................................................................... 231 Flight crew training .......................................................................................... 231 Air Traffic Control ........................................................................................... 231 Aircraft design and certification....................................................................... 232 Aircraft maintenance ........................................................................................ 233 Airport processes.............................................................................................. 235 Safety regulation and oversight........................................................................ 237 Appendix C: Causal Model for Air Transport Safety (CATS)............................. 241 Curriculum Vitae .................................................................................................. 243 3
Page 1: Causal risk models of air transport
Page 4 and 5: Dit proefschrift is goedgekeurd doo
Page 6 and 7: Acknowledgements A PhD study has be
Page 10 and 11: List of abbreviations AC Advisory C
Page 12 and 13: STAR Standard Arrival Route STCA Sh
Page 14 and 15: esults of such models are possible
Page 16 and 17: processes? The second dimension is
Page 18 and 19: Chapter 2. Fundamentals of risk Bef
Page 20 and 21: Figure 1: Voluntary exposure to ris
Page 22 and 23: Y (RDC) [km] 495 490 485 480 475 47
Page 24 and 25: achieved (i.e. an aspirational targ
Page 26 and 27: accidents’ because these accident
Page 28 and 29: e restricted to ‘objective’ ris
Page 30 and 31: is irrelevant. The fire-fighter wil
Page 32 and 33: In this example, the drug appears b
Page 34 and 35: ender the model outcome too uncerta
Page 36 and 37: If we adopt Leveson’s [2004a] sys
Page 38 and 39: models. A strategy for avoiding thi
Page 40 and 41: Number of accidents per 100,000 fli
Page 42 and 43: After World War II aviation became
Page 44 and 45: about 100 potential system failure
Page 46 and 47: Airways 25 , although this is excep
Page 48 and 49: Douglas DC-10; an aircraft with a t
Page 50 and 51: of small airlines that went bankrup
Page 52 and 53: Throughout the service life of an a
Page 54 and 55: an inverse relation should exist be
Page 56 and 57: Safety versus the environment: the
Page 58 and 59:
A causal risk model could support t
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adequate levels of safety in the ci
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also because of the large amount of
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met. The explanatory material empha
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Article 8 of the Seveso Directive (
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4.4. Summary of user requirements a
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Grouped by type of requirements, th
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Representation of regulation Regula
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characteristics make test pilots ve
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Table 3: List of fatal flight test
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4.5. User expectations: lessons fro
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helpful tool. This will have to be
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is to have a top-level representati
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Chapter 5. Examples of aviation saf
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therefore the approach cannot be co
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N az ⎡ ⎪⎧ 2λ y& z ⎪⎫ ⎤
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acceptable. The question, scope and
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Chapter 6. Risk models in other ind
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support [Paté-Cornell & Dillon 200
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Techniques that have been used in t
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airline passengers face. A complica
Page 100 and 101:
problems, already well accepted in
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computationally more intensive. A d
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BASIC EVENT - A basic initiating fa
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fault trees best represent the logi
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Bayesian Belief Nets are convenient
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The approach for CATS was with q =
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PDPs can be used to construct model
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analysis is repeated for each secti
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Chapter 8. Quantification The causa
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hole’ is impossible to tell unles
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An example of a complex issue for w
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determined, given the results of th
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Indeed it can be misleading to thin
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determine what preventive action ma
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to provide quantitative data to the
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data the most accurate and detailed
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It takes years to set up and conduc
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Another problem with the use of aud
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Ambiguity in the classification sys
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vulnerable to differences in interp
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Chapter 9. Modelling challenges In
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considerable procedure guidance, do
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Procedures Availability Error proba
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9.2. Modelling safety management IC
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phenomenon 73 . As a matter of fact
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shift changeovers or when an aircra
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will be crossed if no action is tak
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capsule, Grissom realized that he w
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According to this model, ‘fatigue
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Archetype accident example 1: Take-
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Table 8: Runway overrun accidents a
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evolution 78 . An advantage of this
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systems. They then provide a conven
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that the rest contains no ‘new’
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quick handling by the flight crew a
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Cumulative probability 1 0.9 0.8 0.
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speed 86 for the 500 ft altitude ga
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Probability density 0.0008 0.0007 0
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This example concerns an approach f
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10.6. Conclusions for this section
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accident chains in which the ultima
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esults are being used in a certific
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are not ‘calibrated’. These asp
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equirements. The degree to which dy
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this may seem to be an oversimplifi
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Main research question: What does c
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References AAIASB. (2006). Accident
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BEA. (2001). Accident on 25 July 20
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Carpenter, M.S., Cooper, L.G., Glen
Page 198 and 199:
EAI. (2002). Review of Causal Model
Page 200 and 201:
FAA. (1995a). Aviation safety actio
Page 202 and 203:
Hale, A.R. (2000). Railway safety m
Page 204 and 205:
IATA. (2008b). IOSA Standards Manua
Page 206 and 207:
Khatwa, R., Roelen, A.L.C. (1996).
Page 208 and 209:
Lloyd, E. (1980). The development o
Page 210 and 211:
Nijenhuis, W.A.S., Spek, F., Moelek
Page 212 and 213:
Onisko, A., Druzdzel M.J., Wasyluk,
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around airports, Part 1: Main repor
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Simons, M., Valk, P.J.L. (1998). Ea
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Tweede Kamer. (2003b). Toekomst van
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Summary Aviation safety is so well
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existing data bases. Preferably the
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verder verbeteren daarvan, zijn er
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internationale regelgever zoals EAS
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LPG [Tweede Kamer 1983], which set
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of this a situation has been create
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Holding En-route Approach Go-around
Page 234 and 235:
Approximately 5 minutes prior to de
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cockpit announcing flight parameter
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The ground controller then takes ov
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aircraft input will occur. They wil
Page 242 and 243:
Basic principles for the design, co
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egulation became evident and the In
Page 246 and 247:
its functions was to develop and ad
Page 248 and 249:
the delivery systems determines a m
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244
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