Accident analysis and hazard analysis for human and organizational factors

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, February 2011.

[1]  Robyn R. Lutz,et al.  Requirements analysis using forward and backward search , 1997, Ann. Softw. Eng..

[2]  Chris W. Johnson Interactions between night vision and brownout accidents: the loss of a UK RAF Puma helicopter on operational duty in Iraq, November 2007 , 2009 .

[3]  Thomas A. Smith What ’ s wrong with behavior-based safety ? , 2012 .

[4]  Frank E. Bird,et al.  Loss control management , 1976 .

[5]  Steffen Bayer,et al.  Business dynamics: Systems thinking and modeling for a complex world , 2004 .

[6]  Chris W. Johnson The Hidden Human Factors in Unmanned Aerial Vehicles , 2008 .

[7]  Jeffrey K. Liker,et al.  The Toyota way : 14 management principles from the world's greatest manufacturer , 2004 .

[8]  Jens Rasmussen,et al.  Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models , 1983, IEEE Transactions on Systems, Man, and Cybernetics.

[9]  D. Vaughan THE DARK SIDE OF ORGANIZATIONS: Mistake, Misconduct, and Disaster , 1999 .

[10]  A. Schaplowsky Handbook of System and Product Safety , 1974 .

[11]  Mark Edward Peterson,et al.  The UAV and the Current and Future Regulatory Construct for Integration into the National Airspace System , 2006 .

[12]  E. Schein Three Cultures of Management: The Key to Organizational Learning , 1996 .

[13]  K. Roberts Some Characteristics of One Type of High Reliability Organization , 1990 .

[14]  H. W. Heinrich,et al.  Industrial Accident Prevention: a Scientific Approach , 1951 .

[15]  Yacov Y. Haimes,et al.  Risk modeling, assessment, and management , 1998 .

[16]  Fred A. Manuele,et al.  On the Practice of Safety , 1993 .

[17]  P. Pronovost,et al.  The checklist--a tool for error management and performance improvement. , 2006, Journal of critical care.

[18]  R L Helmreich,et al.  The evolution of Crew Resource Management training in commercial aviation. , 1999, The International journal of aviation psychology.

[19]  Mary L. Cummings,et al.  Ethical and social issues in the design of weapon control computer interfaces , 2003, Proceedings. International Symposium on Technology and Society, 2003. Crime Prevention, Security and Design. 2003..

[20]  Sidney Dekker,et al.  Ten Questions About Human Error : A New View of Human Factors and System Safety , 2004 .

[21]  Nelson P. Repenning,et al.  Getting quality the old-fashioned way : self confirming attributions in the dynamics of process improvement , 1997 .

[22]  Meghan Dierks,et al.  Healthcare Industry Incentive Structures Pressure System Operators to Operate in a High-risk Risk State , 2009 .

[23]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[24]  David C. Nagel,et al.  Human factors in aviation , 1988 .

[25]  Mary L. Cummings,et al.  Human Factors Analysis of Predator B Crash , 2008 .

[26]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[27]  P. Senge,et al.  The Fifth Discipline Fieldbook , 1994 .

[28]  Nancy G. Leveson,et al.  Safeware: System Safety and Computers , 1995 .

[29]  Scott A. Shappell,et al.  The Human Factors Analysis and Classification System : HFACS : final report. , 2000 .

[30]  Dan Petersen,et al.  Techniques of safety management , 1971 .

[31]  Knut Rygh,et al.  Accident Investigations - Meeting the challenge of new technology - Established methods challenged by uncertain safety concepts and failure behaviour in new technology , 2005, SSS.

[32]  Douglas McKelvie,et al.  Coping but not coping in health and social care: masking the reality of running organisations beyond safe design capacity† , 2007 .

[33]  Mauro Mancini,et al.  Risk analysis in plant commissioning: the Multilevel Hazop , 2002, Reliab. Eng. Syst. Saf..

[34]  James T. Reason,et al.  A systems approach to organizational error , 1995 .

[35]  Chris W. Johnson Insights from the Nogales Predator crash for the integration of UAVs into the National Airspace System under FAA interim operational guidance 08-01 , 2009 .

[36]  Nancy G. Leveson,et al.  Safety-Driven Design for Software-Intensive Aerospace and Automotive Systems , 2010, Proceedings of the IEEE.

[37]  T. Cox,et al.  The structure of employee attitudes to safety: A European example , 1991 .

[38]  Matthieu Couturier,et al.  A case study of Vioxx using STAMP , 2010 .

[39]  Jason S. Carroll,et al.  Incident Reviews in High-Hazard Industries: Sense Making and Learning Under Ambiguity and Accountability , 1995 .

[40]  Andrew Lowe,et al.  EUROCONTROL - Systemic Occurrence Analysis Methodology (SOAM) - A "Reason"-based organisational methodology for analysing incidents and accidents , 2007, Reliab. Eng. Syst. Saf..

[41]  Fawzy Soliman,et al.  The role of SAP software in business process re‐engineering , 1998 .

[42]  David Woods,et al.  Behind human error : cognitive systems, computers, and hindsight : state-of-the-art report , 1994 .

[43]  T. Kletz An Engineer’s View of Human Error , 1991 .

[44]  George Apostolakis,et al.  The work process analysis model (WPAM) , 1994 .

[45]  Fred H. Previc,et al.  Spatial Disorientation in Aviation , 2004 .

[46]  Nancy G. Leveson,et al.  Incorporating Safety Risk in Early System Architecture Trade Studies , 2009 .

[47]  R. Cydulka,et al.  Is handwashing teachable?: failure to improve handwashing behavior in an urban emergency department. , 1996, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[48]  J. Sterman,et al.  Effects of feedback complexity on dynamic decision making , 1995 .

[49]  David O'Hare,et al.  Cognitive failure analysis for aircraft accident investigation , 1994 .

[50]  Ortwin Renn,et al.  A New Approach to Risk Evaluation and Management: Risk‐Based, Precaution‐Based, and Discourse‐Based Strategies 1 , 2002, Risk analysis : an official publication of the Society for Risk Analysis.

[51]  K. Roberts,et al.  Must accidents happen? Lessons from high-reliability organizations , 2001 .

[52]  Sidney Dekker,et al.  Just Culture: Balancing Safety and Accountability , 2012 .

[53]  K. Weick,et al.  Collective mind in organizations: Heedful interrelating on flight decks. , 1993 .

[54]  C. Robson,et al.  Real World Research: A Resource for Social Scientists and Practitioner-Researchers , 1993 .

[55]  Nancy G. Leveson Intent Specifications: An Approach to Building Human-Centered Specifications , 2000, IEEE Trans. Software Eng..

[56]  John M. Flach,et al.  Control Theory for Humans: Quantitative Approaches To Modeling Performance , 2002 .

[57]  D A Wiegmann,et al.  Human error analysis of commercial aviation accidents: application of the Human Factors Analysis and Classification system (HFACS). , 2001, Aviation, space, and environmental medicine.

[58]  Asaf Degani,et al.  Cockpit Checklists: Concepts, Design, and Use , 1993 .

[59]  David John Pumfrey,et al.  The principled design of computer system safety analyses , 1999 .

[60]  J. C. Williams,et al.  Validation of human reliability assessment techniques , 1985 .

[61]  Christopher Nemeth,et al.  Resilience Engineering: Remaining sensitive to the possibility of failure , 2008 .

[62]  Joseph H. Saleh,et al.  Archetypes for organizational safety , 2006 .

[63]  R. John Hansman,et al.  Assuring safety through operational approval : challenges in assessing and approving the safety of systems-level changes in air transportation , 2009 .

[64]  Nadine B. Sarter,et al.  Pilot Interaction With Cockpit Automation II: An Experimental Study of Pilots’ Model and Awareness of the Flight Management System , 1994 .

[65]  K. Weick,et al.  Organizing for high reliability: Processes of collective mindfulness. , 1999 .

[66]  D. Woods,et al.  Behind Human Error , 2010 .

[67]  Nancy G. Leveson,et al.  An analysis of causation in aerospace accidents , 2001, 20th DASC. 20th Digital Avionics Systems Conference (Cat. No.01CH37219).

[68]  Emily S. Patterson,et al.  Shift Changes, Updates, and the On-Call Model in Space Shuttle Mission Control , 1997 .

[69]  S. Dekker,et al.  Balancing "no blame" with accountability in patient safety. , 2010, The New England journal of medicine.

[70]  C.J.H. Mann,et al.  Systems approaches to management , 2002 .

[71]  T. Laporte,et al.  Working in Practice But Not in Theory: Theoretical Challenges of “High-Reliability Organizations” , 1991 .

[72]  Zahra Mohaghegh,et al.  Incorporating organizational factors into Probabilistic Risk Assessment (PRA) of complex socio-technical systems: A hybrid technique formalization , 2009, Reliab. Eng. Syst. Saf..

[73]  A. Lo The Adaptive Markets Hypothesis , 2004 .

[74]  Alan D. Swain,et al.  Human reliability analysis: Need, status, trends and limitations , 1990 .

[75]  J. Carroll,et al.  Moving Beyond Normal Accidents and High Reliability Organizations: A Systems Approach to Safety in Complex Systems , 2009 .

[76]  J. E. Groves,et al.  Made in America: Science, Technology and American Modernist Poets , 1989 .

[77]  A. D. Swain Accident Sequence Evaluation Program: Human reliability analysis procedure , 1987 .

[78]  Nancy G. Leveson,et al.  Beyond Normal Accidents and High Reliability Organizations: The Need for an Alternative Approach to Safety in Complex Systems , 2004 .

[79]  Hiromitsu Kumamoto,et al.  Probabilistic Risk Assessment and Management for Engineers and Scientists , 1996 .

[80]  David R. Krathwohl,et al.  Methods of Educational and Social Science Research: An Integrated Approach , 1992 .

[81]  I. Svedung,et al.  Graphic representation of accident scenarios: mapping system structure and the causation of accidents , 2002 .

[82]  Paulo Gonçalves When Do Minor Shortages Inflate To Great Bubbles ? , 2002 .

[83]  John A. McDermid Software Hazard and Safety Analysis , 2002, FTRTFT.

[84]  Barry Kirwan,et al.  Validation of human reliability assessment techniques: Part 1 -- Validation issues , 1997 .

[85]  Karen Marais,et al.  A new approach to risk analysis with a focus on organizational risk factors , 2005 .

[86]  D M Murphy,et al.  The SAM framework: modeling the effects of management factors on human behavior in risk analysis. , 1996, Risk analysis : an official publication of the Society for Risk Analysis.

[87]  Ilyani Ismail Assessment of safety level in performing building maintenance work in Malaysia , 2006 .

[88]  Chris W. Johnson Military risk assessment in counter insurgency operations: a Case Study in the retrieval of a UAV Nr Sangin, Helmand Province, Afghanistan, 11th June 2006 , 2008 .

[89]  Mark S. Young,et al.  The Field Guide to Understanding Human Error , 2008 .

[90]  Nancy G. Leveson,et al.  Role of Software in Spacecraft Accidents , 2004 .

[91]  J Reason,et al.  The contribution of latent human failures to the breakdown of complex systems. , 1990, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[92]  P. Shrivastava Bhopal: Anatomy of a Crisis , 1987 .

[93]  David G. Fairchild,et al.  Lab Turnaround Time and Delayed Discharges : A Systems-Based Action Research Investigation , 2005 .

[94]  Mark S. Sanders,et al.  Human Factors in Engineering and Design , 1957 .

[95]  J. Katz,et al.  The Human Equation: Building Profits by Putting People First , 1998 .

[96]  Caroline Marie Lamb,et al.  Collaborative systems thinking : an exploration of the mechanisms enabling team systems thinking , 2009 .

[97]  Roland E. Weibel Safety considerations for operation of different classes of unmanned aerial vehicles in the National Airspace System , 2005 .

[98]  Nicolas Dulac,et al.  Incorporating Safety in Early System Architecture Trade Studies , 2005 .

[99]  Mary L. Cummings,et al.  Automated Scheduling Decision Support for Supervisory Control of Multiple UAVs , 2006, J. Aerosp. Comput. Inf. Commun..

[100]  Stacey D. Scott,et al.  Awareness in Unmanned Aerial Vehicle Operations , 2008 .

[101]  Nicolas Dulac,et al.  A framework for dynamic safety and risk management modeling in complex engineering systems , 2007 .

[102]  Sidney Dekker,et al.  Resilience Engineering: Chronicling the Emergence of Confused Consensus , 2017 .

[103]  Erik Hollnagel,et al.  Barriers And Accident Prevention , 2004 .

[104]  Erik Hollnagel,et al.  THE EMPEROR'S NEW CLOTHES Or Whatever Happened To "Human Error"? , 2001 .

[105]  Bernhard Wilpert,et al.  Nuclear Safety: A Human Factors Perspective , 1998 .

[106]  Thomas B. Sheridan Human centered automation: oxymoron or common sense? , 1995, 1995 IEEE International Conference on Systems, Man and Cybernetics. Intelligent Systems for the 21st Century.

[107]  C. M. Holloway,et al.  On the Prevalence of Organizational Factors in Recent U . S . Transportation Accidents , 2005 .

[108]  K. Weick Making Sense of the Organization , 2000 .

[109]  A. D. Swain,et al.  Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report , 1983 .

[110]  Mark S. Sanders,et al.  Human factors in engineering and design, 7th ed. , 1993 .

[111]  N. Pidgeon,et al.  Man-made disasters: Why technology and organizations (sometimes) fail. , 2000 .

[112]  Peter Checkland,et al.  Systems Thinking, Systems Practice , 1981 .

[113]  Michael Ehret,et al.  Self‐protection vs opportunity seeking in business buying behavior: an experimental study , 2006 .

[114]  Edward W Stimpson,et al.  Managing risks in civil aviation , 2008 .

[115]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .