Safety in U.S. Navy Navigation Applying STAMP Processes to Surface Ship Collisions
Name
canady-canadyam-sm-sdm-2023-thesis.pdf
Description
Thesis PDF
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10.86 MB
Format
Adobe PDF
Checksum (MD5)
cc35bc6e2fa86145fea741e9911e69e4
Author(s)
Canady, Andrew Michael
Advisor(s)
Leveson, Nancy G.
Date Issued
February 2023
Publisher
Massachusetts Institute of Technology
Abstract
The collisions and accidents occurring throughout the U.S. Navy surface fleet warranted the appointment of a 34-personnel review team to analyze the three ship collisions and one grounding in 2017. These accidents resulted in 17 U.S. Navy sailors' deaths and damage to the operational ships. There were 12 incidents between 2007 and 2017; this increase in frequency drove the need to conduct the review. The concern is that the fundamental causal factors were not adequately addressed and that a future collision is imminent without further corrective action.
This thesis uses Dr. Nancy Leveson’s Systems-Theoretic Accident Model and Process (STAMP) model of accident causation to analyze two U.S. Navy ship collisions in 2017. The Causal Analysis based on STAMP (CAST) is conducted on both collisions, and an analysis of the results is compared with the traditional U.S. Navy findings. CAST examines the system’s safety control structure to assess why the designed controls were inadequate to prevent the accident. The goal of this thesis is to determine whether a STAMP approach to accident analysis would add value to the U.S. Navy. If so, it seeks to determine what new factors the CAST analysis provides and how it may be used to prevent future mishaps.
MIT Department
System Design and Management Program.
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