Applying System Thinking to Learn from Accident of Modern Automatic Control Systems

Modern societies increasingly rely on auto- matic control systems. These systems are hardly pure tech- nical systems; instead they are complex socio-technical sys- tems, which consist of technical elements and social com- ponents. It is necessary to have a systematic approach to analyze these systems because it is growing evidence that accidents from these systems usually have complex causal factors which form an interconnected network of events, rather than a simple cause-effect chain. We take railway Train control systems (TCS) as an example to demonstrate the importance of the socio-technical approach to analyze the system. The paper presents an investigation of recent high-speed railway accident by applying STAMP - one of the most notable socio-technical system analysis tech- niques, outlines improvements to the system which could avoid similar accidents in the future. We also provide our valuable feedback for the use of STAMP.