Tenerife Accident Analysis: a comparison of Fault Tree Analysis, Failure Mode and Effects Analysis and Causal Analysis based on System Theory

Abstract

Air transport is considered to be the safest means of transport. However, if an accident occurs, it often ends in catastrophe. Thus, significant efforts have been paid to sustain successful operations in aviation. Several studies have been carried out to understand the underlying reasons for accidents. This study used Fault Tree Analysis (FTA), Failure Mode and Effects Analysis (FMEA) and Causal Analysis based on Systems Theory (CAST) methods to analyse Tenerife aircraft accident and to compare the findings of different methods. The findings showed that while all three methods provided some overlapping findings, the CAST method led to the identification of all causes that were identified by other methods. Considering the nature of the causal factors, FMEA provided more causal factors that are related to organisation and technology than FTA. This study indicates that CAST has a significant value to identify all causes that can be identified by the use of traditional methods.

Keywords

• Accident investigation
• CAST
• FMEA
• FTA
• Risk management

References

1. [1] Insua, D. R., Alfaro, C., Gomez, J., Hernandez-Coronado, P., Bernal, F., “Forecasting and assessing consequences of aviation safety occurrences”, Safety Science, 111: 243–252, (2019).
2. [2] Juniac, A. D., "Annual review 2017", At-Automatisierungstechnik, 74(12): (2018).
3. [3] Civil Aviation Authority (CAA), “CAP 1036: Global fatal accident review 2002 to 2011”, 1036, 1–134, (2013).
4. [4] Arnaldo Valdés, R. M., Gómez Comendador, F., “Learning from accidents: Updates of the European regulation on the investigation and prevention of accidents and incidents in civil aviation”, Transport Policy, 18(6): 786–799, (2011).
5. [5] Sujata, M., Madan, M., Raghavendra, K., Jagannathan, N., Bhaumik, S. K., “Unraveling the cause of an aircraft accident”, Engineering Failure Analysis, 97: 740–758, (2019).
6. [6] Leveson, N. G. “System safety engineering: Back to the future”, Sunnyday Mit Edu, (2002).
7. [7] Hudson, P., “Accident causation models, management and the law. Journal of Risk Research”, 17(6): 749–764, (2014).
8. [8] Leveson, N. G., “A systems approach to risk management through leading safety indicators”, Reliability Engineering and System Safety, 136: 17–34, (2015).

9. [9] Rasmussen, J., “Risk management in a dynamic society: a modelling problem”, Safety Science, 27: 183–213, (1997).
10. [10] Patriarca, R., Di Gravio, G., Costantino, F., “A Monte Carlo evolution of the Functional Resonance Analysis Method (FRAM) to assess performance variability in complex systems”, Safety Science, 91: 49–60, (2017).
11. [11] Hollnagel, E., “The Functional Resonance Analysis Method”, (2018).
12. [12] Kaya, G. K., Canbaz, H. T., “The problem with traditional accident models to investigate patient safety incidents in healthcare", In C. A. H. Calisir F., Cevikcan E. (Ed.), Industrial Engineering in the Big Data Era. Lecture Notes in Management and Industrial Engineering, Springer, 481–488, (2019).
13. [13] Reason, J., “Managing the risks of organisational accidents”, Ashgate, (1997).
14. [14] Leveson, N. G., “A new accident model for engineering safer systems”, Safety Science, 42(4): 237–270, (2004).
15. [15] Hollnagel, E., “Barriers and accident prevention”, Ashgate, (2004).
16. [16] Hollnagel, E., “FRAM: the Functional Resonance Analysis Method modelling complex socio-technical systems”, Ashgate Publishing, 1st editio, (2012).
17. [17] Leveson, N. G., “Cast handbook: How to learn more from ıncidents and accidents”, (2019).
18. [18] Hasan, R., Chatwin, C., Sayed, M., “Examining alternatives to traditional accident causation models in the offshore oil and gas industry”, Journal of Risk Research, 23(9): 1242-1257, (2020).
19. [19] Waterson, P., Jenkins, D. P., Salmon, P. M., Underwood, P., “‘Remixing Rasmussen’: The evolution of Accimaps within systemic accident analysis”, Applied Ergonomics, 59: 483–503, (2017).
20. [20] Kaya, G. K., Ovali, H. F., Ozturk, F., “Using the functional resonance analysis method on the drug administration process to assess performance variability”, Safety Science, 118: 835–840, (2019).
21. [21] Stanton, N. A., Salmon, P. M., Walker, G. H., Stanton, M., “Models and methods for collision analysis: a comparison study based on the Uber collision with a pedestrian”, Safety Science, 120: 117–128, (2019).
22. [22] Hulme, A., Stanton, N. A., Walker, G. H., Waterson, P., Salmon, P. M., “What do applications of systems thinking accident analysis methods tell us about accident causation? A systematic review of applications between 1990 and 2018”, Safety Science, 117: 164–183, (2019).
23. [23] Yamaguchi, S., Thomas, J., “A system safety approach for tomographic treatment”, Safety Science, 118: 772–782, (2019).
24. [24] Salehi, V., Veitch, B., Smith, D., “Modeling complex socio-technical systems using the FRAM: A literature review”, Human Factors and Ergonomics in Manufacturing, October, 1–25, (2020).
25. [25] Mogles, N., Padget, J., Bosse, T. “Systemic approaches to incident analysis in aviation: Comparison of STAMP, agent-based modelling and institutions”, Safety Science, 108: 59–71, (2018).
26. [26] Oriola, A. O., Adekunle, A. K., “Assessment of runway accident hazards in Nigeria aviation sector”, International Journal for Traffic and Transport Engineering, 5(2): 82-92, (2015).
27. [27] Kornecki, A. J., Liu, M., “Fault tree analysis for safety/security verification in aviation software”, Electronics, 2(1): 41-56, (2013).
28. [28] Yao, Q., Wang, J., Zhang, G., “A fault diagnosis expert system based on aircraft parameters”, In 2015 12th, Web Information System and Application Conference (WISA), IEEE, 314-317, (2015).
29. [29] Lee, W. K., “Risk assessment modeling in aviation safety management”, Journal of Air Transport Management, 12(5): 267-273, (2006).
30. [30] Laracy, J. R., Leveson, N. G., “Apply STAMP to critical infrastructure protection”, In IEEE Conference on Technologies for Homeland Security, 215-220, (2007).
31. [31] Passenier, D., Sharpanskykh, A., De Boer, R. J., “When to STAMP? A Case Study in Aircraft Ground Handling Services”, Procedia Engineering, 128: 35–43, (2015).
32. [32] Fleming, C. H., Spencer, M., Thomas, J., Leveson, N. G., Wilkinson, C., “Safety assurance in NextGen and complex transportation systems”, Safety Science, 55: 173–187, (2013).
33. [33] KLM, Pan Am, “Final Report - Collision between B747 KLM and B747 PAN AM”, Tenerife - KLM & PanAm joint report, (1978).
34. [34] Weick, K. E., “The Vulnerable System: An Analysis of the Tenerife Air Disaster”, Journal of Management, (1990).
35. [35] Ziomek, J., “Disaster on Tenerife: history’s worst airline accident”, HistoryNet, (2020).
36. [36] Antoine, B., “Systems Theoretic Hazard Analysis (STPA) applied to the risk review”, MIT, (2013).
37. [37] Zhong, L. Z., “Fault tree analysis of train crash accident and discussion on safety of complex s ystems”, Industrial Engineering and Management, 16(4): 1–8, (2011).
38. [38] Hyun, K. C., Min, S., Choi, H., Park, J., Lee, I. M., “Risk analysis using fault-tree analysis (FTA) and analytic hierarchy process (AHP) applicable to shield TBM tunnels”, Tunnelling and Underground Space Technology, (2015).
39. [39] Song, T., Zhong, D., Zhong, H., “A STAMP analysis on the China-Yongwen railway accident”, Lecture Notes in Computer Science (Including Subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics), (2012).
40. [40] Zhang, Z., Liu, X., “Safety risk analysis of restricted-speed train accidents in the United States”, Journal of Risk Research, 1–19, (2019).
41. [41] Liu, Y., Fan, Z. P., Yuan, Y., Li, H., “A FTA-based method for risk decision-making in emergency response”, Computers and Operations Research, (2014).
42. [42] Kim, C. E., Ju, Y. J., Gen, M., “Multilevel fault tree analysis using fuzzy numbers”, Computers and Operations Research, (1996).
43. [43] Lee, W. S., Grosh, D. L., Tillman, F. A., Lie, C. H., “Fault Tree Analysis, Methods, and Applications - A Review”, IEEE Transactions on Reliability, (1985).
44. [44] BS EN IEC 31010. "ISO/IEC 31010", Standards Publication Risk management – Risk assessment, (2019).
45. [45] Hollenback, J. J., “Failure mode and effect analysis”, SAE Technical Papers, 117–127, (1977).
46. [46] Simsekler, M. C. E., Kaya, G. K., Ward, J. R., Clarkson, P. J., “Evaluating inputs of failure modes and effects analysis in identifying patient safety risks”, International Journal of Health Care Quality Assurance, 32(1): 197–207, (2019).
47. [47] Liu, C. T., Hwang, S. L., Lin, I. K., “Safety analysis of combined FMEA and FTA with computer software assistance - Take photovoltaic plant for example”, IFAC Proceedings Volumes (IFAC-PapersOnline), 46(9): 2151–2155, (2013).
48. [48] Spath, P. L., “Using failure mode and effects analysis to improve patient safety”, AORN Journal, 78(1): 16–37, (2003).
49. [49] McNally, K. M., Maxwell, A. P., Sunderland, V. B., “Failure-mode and effects analysis in improving a drug distribution system”, American Journal of Health-System Pharmacy, 54(2): 171–177, (1997).
50. [50] Thornton, E., Brook, O. R., Mendiratta-Lala, M., Hallett, D. T., Kruskal, J. B., “Quality initiatives: Application of failure mode and effect analysis in a radiology department”, Radiographics, 31(1), (2011).
51. [51] British Standards Institution (BSI), “BS EN-60812: Analysis techniques for system reliability: procedure for failure mode and effects analysis (FMEA)”, (2006).
52. [52] Kim, T. E., Nazir, S., Øvergård, K. I., “A STAMP-based causal analysis of the Korean Sewol ferry accident”, Safety Science, 83, 93-101, (2016).
53. [53] Leveson, N. G., “Engineering a safer world: systems thinking applied to safety”, The MIT Press, (2011).
54. [54] Düzgün, H. S., Leveson, N. G., “Analysis of soma mine disaster using causal analysis based on systems theory (CAST)”, Safety Science, 110: 37–57, (2018).
55. [55] Mattos, T. D. C., Santoro, F. M., Revoredo, K., Nunes, V. T., “A formal representation for context-aware business processes”, Computers in Industry, 65(8): 1193–1214, (2014).
56. [56] Helferich, J., Dunn, C., “"Causal Analysis using System Theory STAMP approach to accident analysis”, STAMP Workshop, (2013).
57. [57] Armed Forces, “Aircraft accident report: accident reconstruction by evaluation of injury patterns”, (1978).
58. [58] Bennett, S. A., “Aviation crew resource management–a critical appraisal, in the tradition of reflective practice, informed by flight and cabin crew feedback”, Journal of Risk Research, 22(11): 1357–1373, (2019).
59. [59] Mearns, K., Flin, R., O’Connor, P. “Sharing ‘worlds of risk’; improving communication with crew resource management”, Journal of Risk Research, 4(4): 377–392, (2001).
60. [60] Woltjer, R., Pinska-Chauvin, E., Laursen, T., Josefsson, B., “Towards understanding work-as-done in air traffic management safety assessment and design”, Reliability Engineering and System Safety, 141: 115–130, (2015).
61. [61] Kaya, G. K., Hocaoglu, M. F., “Semi-quantitative application to the Functional Resonance Analysis Method for supporting safety management in a complex health-care process”, Reliability Engineering and System Safety, 202, 106970, (2020).
62. [62] British Standards Institution (BSI), “BS EN 31010: Risk management: risk assessment techniques”, (2010).
63. [63] Rao, S., “Safety culture and accident analysis—a socio-management approach based on organizational safety social capital”, Journal of hazardous materials, 142(3): 730-740, (2007).
64. [64] Cowlagi, R. V., Saleh, J. H. “Coordinability and consistency in accident causation and prevention: formal system theoretic concepts for safety in multilevel systems”, Risk Analysis, 33(3): 420-433, (2013).
65. [65] McCreary, J., Pollard, M., Stevenson, K., Wilson, M. B. “Human factors: Tenerife revisited”, (1998).
66. [66] Card, A., “The problem with ‘5 whys”, BMJ Quality and Safety, 26: 671–677, (2017).