2026-09-19T11:40:32Zhttps://dspace.mit.edu/server/oai/requestoai:dspace.mit.edu:1721.1/1181312022-01-31T17:01:22Zcom_1721.1_7582com_1721.1_7581col_1721.1_131023
Nancy Leveson.
Mackovjak, John Michael
Technology and Policy Program.
Massachusetts Institute of Technology. Engineering Systems Division
Massachusetts Institute of Technology. Institute for Data, Systems, and Society
Technology and Policy Program
2018-09-18T15:43:32Z
2018-09-18T15:43:32Z
2016
2016
http://hdl.handle.net/1721.1/118131
1051211763
Thesis: S.M. in Technology and Policy, Massachusetts Institute of Technology, School of Engineering, Institute for Data, Systems, and Society, Technology and Policy Program, 2016.
Cataloged from PDF version of thesis.
Includes bibliographical references (page 109).
This thesis uses Dr. Leveson's Systems-Theoretic Accident Model and Process (STAMP) model of accident causation to analyze a collision in late July 2014 between two Offshore Supply Vessels equipped with software-intensive Dynamic Positioning Systems. The Causal Analysis based on STAMP (CAST) is compared with the Root Cause Analysis, a traditional chain of events based model, used by the original investigation team after the collision. Linear chain of event models like the Root Cause Analysis often look for a broken component or incorrect action within the proximal sequence of events leading to the accident. CAST examines a system's entire safety control structure to assess why the system constraints, control loops, and process models were either inadequate or flawed. This thesis aims at identifying how the safety control structure of the Offshore Supply Vessel operations could be improved by identifying the systemic factors and component interactions that contributed to the collision. The primary objective of this thesis is to demonstrate the use of a systems theory-based accident analysis technique in analyzing a complex accident. The secondary objective of this thesis is to compare and contrast the outcomes of the Root Cause Analysis conducted by the Navy Programs organization, with the findings of the CAST analysis. Finally, this thesis examines STAMP's underlying new assumptions regarding the need for new safety analysis in the context of the findings from the CAST analysis of the collision.
by John Michael Mackovjak.
S.M. in Technology and Policy
114 pages
eng
Massachusetts Institute of Technology
MIT theses are protected by copyright. They may be viewed, downloaded, or printed from this source but further reproduction or distribution in any format is prohibited without written permission.
http://dspace.mit.edu/handle/1721.1/7582
Engineering Systems Division.
Institute for Data, Systems, and Society.
Technology and Policy Program.
Systems theoretic accident analysis of an offshore supply vessel collision
Thesis
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Publication
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<Abstract>This thesis uses Dr. Leveson's Systems-Theoretic Accident Model and Process (STAMP) model of accident causation to analyze a collision in late July 2014 between two Offshore Supply Vessels equipped with software-intensive Dynamic Positioning Systems. The Causal Analysis based on STAMP (CAST) is compared with the Root Cause Analysis, a traditional chain of events based model, used by the original investigation team after the collision. Linear chain of event models like the Root Cause Analysis often look for a broken component or incorrect action within the proximal sequence of events leading to the accident. CAST examines a system's entire safety control structure to assess why the system constraints, control loops, and process models were either inadequate or flawed. This thesis aims at identifying how the safety control structure of the Offshore Supply Vessel operations could be improved by identifying the systemic factors and component interactions that contributed to the collision. The primary objective of this thesis is to demonstrate the use of a systems theory-based accident analysis technique in analyzing a complex accident. The secondary objective of this thesis is to compare and contrast the outcomes of the Root Cause Analysis conducted by the Navy Programs organization, with the findings of the CAST analysis. Finally, this thesis examines STAMP's underlying new assumptions regarding the need for new safety analysis in the context of the findings from the CAST analysis of the collision.</Abstract>
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