{"id":62764,"date":"2025-02-01T19:20:45","date_gmt":"2025-02-01T19:20:45","guid":{"rendered":"https:\/\/peraltafinancing.com\/airline\/increasing-learning-from-accidents-a-systems-approach-illustrated-by-the-ups-flight-1354-cfit-accident\/"},"modified":"2025-02-01T19:20:45","modified_gmt":"2025-02-01T19:20:45","slug":"increasing-learning-from-accidents-a-systems-approach-illustrated-by-the-ups-flight-1354-cfit-accident","status":"publish","type":"post","link":"https:\/\/fivemor.com\/?p=62764","title":{"rendered":"Increasing Learning from Accidents A Systems Approach illustrated by the UPS Flight 1354 CFIT Accident"},"content":{"rendered":"<p> <br \/>\n<\/p>\n<div id=\"post-891\">\n<p>\t\t\t\t\t<!-- .entry-meta --><\/p>\n<div class=\"entry-content\">\n<p><a href=\"http:\/\/sunnyday.mit.edu\/UPS-CAST-Final.pdf\">Please click the link here for the full paper.\u00a0<\/a><\/p>\n<p>Most accident analyses are based on ad hoc approaches. Many formal analysis techniques have been\u00a0proposed, but few are widely used. This case study shows how a structured process called CAST (Causal\u00a0Analysis based on Systems Theory), based on a more powerful model of accident causation, can improve\u00a0the results of accident investigation. The case study used is a CFIT (controlled flight into terrain) accident<br \/>involving a UPS A300-600 aircraft while landing at the Birmingham-Shuttlesworth International Airport\u00a0on August 14, 2013. The results are compared with the official NTSB accident report. The NTSB process\u00a0is usually considered the \u201cgold standard\u201d in accident investigations, and indeed, they do an excellent\u00a0job. Therefore, a comparison of the results is informative about how accident investigation and analysis\u00a0might be improved beyond the standard approach used by the NTSB and most others.<\/p>\n<p>The structured analysis method used, called CAST\u00a0(Causal Analysis based on System Theory), is\u00a0based on an expanded accident model called STAMP (Systems-Theoretic Accident Model and Processes)\u00a0[Leveson, 2012]. Traditionally, accidents have been thought of as resulting from a chain of failure events,\u00a0each event directly related to the event that precedes it in the chain. For example, the baggage door is\u00a0not completely closed, the aircraft climbs to a level where unequal pressure between the cargo<br \/>compartment and the passenger cabin causes the cabin floor to collapse, the cables to the control\u00a0surfaces (which run through the floor) are severed, the pilots cannot control the aircraft, and the plane\u00a0crashes. The biggest problem with such a chain-of-events model is what it omits. For example, why did\u00a0the design of the baggage door closure mechanism made it difficult to determine whether it was\u00a0effectively sealed? Why did the pilots not detect that the door was not shut correctly? Why did the\u00a0engineers create a design with a single point failure mode by running all the cables through the cabin\u00a0floor? Why did the FAA certification process allow such designs to be used? And so on. While these<br \/>additional factors can be included in accident investigation and analysis, there is no structured process\u00a0for making sure that \u201csystemic\u201d causal factors are not missed.<\/p>\n<p>STAMP extends the traditional model of accident causation to include the chain-of-events model as\u00a0one subcase but includes the causes of accidents that do not fit within this model, particularly those that\u00a0occur in the complex sociotechnical systems common today. These causes (in addition to component\u00a0failure) include system design errors, unintended and unplanned interactions among system\u00a0components (none of which may have failed), flawed safety culture and human decision making,\u00a0inadequate controls and oversight, and flawed organizational design. In STAMP, accidents are treated as\u00a0more complex processes than simple chains of failure events. The focus is not simply on the events that\u00a0led to the accident, but why those events occurred.<\/p>\n<p><span id=\"wordads-inline-marker\" style=\"display: none;\"\/>\t\t\t<\/p><\/div>\n<p><!-- .entry-content --><\/p>\n<div id=\"entry-author-info\">\n<div id=\"author-avatar\">\n\t\t\t\t\t\t\t<img alt=\"\" src=\"https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=60&amp;d=identicon&amp;r=G\" srcset=\"https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=60&amp;d=identicon&amp;r=G 1x, https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=90&amp;d=identicon&amp;r=G 1.5x, https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=120&amp;d=identicon&amp;r=G 2x, https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=180&amp;d=identicon&amp;r=G 3x, https:\/\/1.gravatar.com\/avatar\/71222e839936336880e5ead5cc76aa2fcca467386a8082d8acec7a434b719bca?s=240&amp;d=identicon&amp;r=G 4x\" class=\"avatar avatar-60\" height=\"60\" width=\"60\" loading=\"lazy\" decoding=\"async\"\/>\t\t\t\t\t\t<\/div>\n<p><!-- #author-avatar --><\/p>\n<div id=\"author-description\">\n<h2>\n\t\t\t\t\t\t\tAbout Shem Malmquist FRAeS\t\t\t\t\t\t\t<\/h2>\n<p>\t\t\t\t\t\t\tB-777 Captain.  Air Safety and Accident Investigator.  Previous experience includes Flight Operations management, Assistant Chief Pilot. Line Check Airman, ALPA Aircraft Technical and Engineering Chairman, Aircraft Performance and Designs Committee MEC Chair, Charting and Instrument Procedures Committee, Group Leader-Commercial Aviation Safety Team-Joint Safety Implementation Team (CAST)-Loss of Control-Human Factors and Automation, CAST-JSIT- Aircraft State Awareness. Fellow of the Royal Aeronautical Society, full Member of ISASI, AIAA, IEEE, HFES, FSF, AFA and the Resilience Engineering Association.  I am available for consulting, speaking or providing training seminars to your organization.  Please contact me at https:\/\/malmquistsafety.com\/for inquiries.\t\t\t\t\t\t\t<!-- #author-link\t-->\n\t\t\t\t\t\t<\/div>\n<p><!-- #author-description -->\n\t\t\t\t\t<\/div>\n<p><!-- #entry-author-info --><\/p>\n<div class=\"entry-utility\">\n\t\t\t\t\t\t\tThis entry was posted in <a href=\"https:\/\/airlinesafety.blog\/category\/safety\/\" rel=\"category tag\">Safety<\/a>. Bookmark the <a href=\"https:\/\/airlinesafety.blog\/2019\/05\/28\/increasing-learning-from-accidents-a-systems-approach-illustrated-by-the-ups-flight-1354-cfit-accident\/\" title=\"Permalink to Increasing Learning from Accidents A Systems Approach illustrated by the UPS Flight 1354 CFIT\u00a0Accident\" rel=\"bookmark\">permalink<\/a>.\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<p><!-- .entry-utility -->\n\t\t\t\t\t<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Please click the link here for the full paper.\u00a0 Most accident analyses are based on ad hoc approaches. Many formal analysis techniques have been\u00a0proposed, but few are widely used. This case study shows how a structured process called CAST (Causal\u00a0Analysis based on Systems Theory), based on a more powerful model of accident causation, can improve\u00a0the [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":62765,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[12028],"tags":[16487,17183,11240,34432,2364,4217,13639,1554,11355,6919],"dealstore":[],"offerexpiration":[],"class_list":["post-62764","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-airline","tag-accident","tag-accidents","tag-approach","tag-cfit","tag-flight","tag-illustrated","tag-increasing","tag-learning","tag-systems","tag-ups"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Increasing Learning from Accidents A Systems Approach illustrated by the UPS Flight 1354 CFIT Accident - Som2ny Network<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/fivemor.com\/?p=62764\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Increasing Learning from Accidents A Systems Approach illustrated by the UPS Flight 1354 CFIT Accident - Som2ny Network\" \/>\n<meta property=\"og:description\" content=\"Please click the link here for the full paper.\u00a0 Most accident analyses are based on ad hoc approaches. 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