A STAMP model of the Überlingen aircraft collision accident
Name
60406009-MIT.pdf
Description
Full printable version
Size
4.8 MB
Format
Adobe PDF
Checksum (MD5)
c743cc217b8d200654a79e793a952cfe
Author(s)
Wong, Brian, 1982 Nov 11-
Advisor(s)
Nancy Leveson.
Alternative Title
Systems Theoretic Accident Model and Processes model of the Überlingen aircraft collision accident
Date Issued
2004
Publisher
Massachusetts Institute of Technology
Abstract
STAMP is a method for evaluating accidents that is based on systems theory. It departs from traditional event chain models that tend to focus on human errors instead of the goals and motives that triggered the errors. The thesis presents a STAMP model of the mid-air collision that occurred on July 1, 2002 near Uberlingen, Germany. This model focuses on the air traffic controller in charge of the aircraft that collided and the surrounding central environment at ACC Zurich, which was the ATC center controlling the aircraft at the time. First the components in the system are analyzed to determine their roles in the system and to identify the safety-related issues. Next, the interactions of the components and the resulting communications failure are studied. Conclusions as to the causes of the accident are presented. A system dynamics model of the control room environment is constructed and studied to determine how the issues relating to the accident developed over time. Finally, the findings from the STAMP model are summarized and recommendations are made based on the analysis. The recommendations based on the model agree with those of the official accident investigation report; in addition, several new recommendations are made.
Description
Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, 2004.
Includes bibliographical references (p. 69).
Subjects
Aeronautics and Astronautics.
MIT Department
Massachusetts Institute of Technology. Department of Aeronautics and Astronautics
Terms of Use
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