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A STAMP Model of the Überlingen Aircraft Collision Accident

出版	Massachusetts Institute of Technology, Department of Aeronautics and Astronautics, 2004
URL	http://books.google.com.hk/books?id=o5iatwAACAAJ&hl=&source=gbs_api

註釋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.