Systems Theoretic Process Analysis (STPA)

Transcription

1 Systems Theoretic Process Analysis (STPA) 1

2 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 2

3 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 3

4 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 4

5 ITP Exercise a new in-trail procedure for trans-oceanic flights 5

6 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 6

7 Example System: Aviation Image removed due to copyright restrictions. System-level Accident (Loss):? 7

8 Example System: Aviation Image removed due to copyright restrictions. System-level Accident (Loss): Two aircraft collide 8

9 Image removed due to copyright restrictions. System-level Accident (Loss): Two aircraft collide System-level Hazard:? 9

10 Hazard Definition: A system state or set of conditions that, together with a particular set of worst-case environmental conditions, will lead to an accident (loss). Something we can control Examples: Accident Satellite becomes lost or unrecoverable People die from exposure to toxic chemicals People die from radiation sickness People die from food poisoning 10 Hazard Satellite maneuvers out of orbit Toxic chemicals are released into the atmosphere Nuclear power plant releases radioactive materials Food products containing pathogens are sold

11 Image removed due to copyright restrictions. System-level Accident (Loss): Two aircraft collide System-level Hazard: Two aircraft violate minimum separation 11

12 Aviation Examples System-level Accident (loss) Two aircraft collide Aircraft crashes into terrain / ocean System-level Hazards Two aircraft violate minimum separation Aircraft enters unsafe atmospheric region Aircraft enters uncontrolled state Aircraft enters unsafe attitude Aircraft enters prohibited area 12

13 Aviation Examples System-level Accident (loss) A-1: Two aircraft collide A-2: Aircraft crashes into terrain / ocean System-level Hazards H-1: Two aircraft violate minimum separation H-2: Aircraft enters unsafe atmospheric region H-3: Aircraft enters uncontrolled state H-4: Aircraft enters unsafe attitude H-5: Aircraft enters prohibited area 13

14 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 14

15 North Atlantic Tracks source unknown. All rights reserved. This content is excluded from our Creative Commons license. For more information, see 15

16 STPA application: NextGen In-Trail Procedure (ITP) Current State Pilots will have separation information Pilots decide when to request a passing maneuver Air Traffic Control approves/denies request Proposed Change 16

17 STPA Analysis High-level (simple) Control Structure Main components and controllers???? 17

18 STPA Analysis High-level (simple) Control Structure Who controls who? Flight Crew? Aircraft? Air Traffic Controller? 18

19 STPA Analysis High-level (simple) Control Structure What commands are sent?? Air Traffic Control? Flight Crew?? Aircraft 19

20 STPA Analysis High-level (simple) Control Structure Air Traffic Control Issue clearance to pass Feedback? Flight Crew Execute maneuver Feedback? Aircraft 20

21 STPA Analysis More complex control structure 21

22 Example High-level control structure Congress Directives, funding Reports FAA Regulations, procedures Reports ATC Instructions Acknowledgement, requests Pilots Execute maneuvers Aircraft status, position, etc Aircraft 22

23 Air Traffic Control (ATC) ATC Front Line Manager (FLM) Instructions Status Updates Instructions Status Updates Instructions Status Updates Instructions Company Dispatch Status Updates Instructions ATC Ground Controller Query Status Updates and acknowledgements ATC Radio Other Ground Controllers Execute maneuvers Pilots Pilots Pilots Pilots Aircraft Execute maneuvers Aircraft Execute maneuvers Aircraft Execute maneuvers Aircraft 23 ACARS Text Messages

24 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 24

25 Identify Unsafe Control Actions ATC Instructions Acknowledgement, requests Pilots Execute maneuvers Aircraft status, position, etc Aircraft Flight Crew Action (Role) Execute Passing Maneuver Not providing causes hazard Providing Causes hazard Pilots perform ITP when ITP criteria are not met or request has been refused [H-1] 25 Incorrect Timing/ Order Stopped Too Soon

26 Structure of a Hazardous Control Action Example: Pilots provide ITP maneuver when ITP criteria not met Source Controller Type Control Action Context Four parts of a hazardous control action Source Controller: the controller that can provide the control action Type: whether the control action was provided or not provided Control Action: the controller s command that was provided / missing Context: conditions for the hazard to occur (system or environmental state in which command is provided) 26

27 Defining Safety Constraints Unsafe Control Action Pilot performs ITP when ITP criteria are not met or request has been refused Pilot starts maneuver late after having re-verified ITP criteria Etc. Safety Constraint Pilot must not perform ITP when criteria are not met or request has been refused Pilot must start maneuver within X minutes of re-verifying ITP criteria Etc. 27

28 STPA (System-Theoretic Process Analysis) Identify accidents and hazards Draw the control structure Step 1: Identify unsafe control actions Step 2: Identify causal factors and create scenarios Control Actions Controller Controlled process Feedback (Leveson, 2012) 28

29 STPA Step 2: Causal scenarios UCA: Pilot executes maneuver when criteria are not met [H-1] From Leveson, Nancy (2012). Engineering a Safer World: Systems Thinking Applied to Safety. MIT Press, Massachusetts Institute of Technology. Used with permission. 29

30 MIT OpenCourseWare http ://ocw.mit.edu System Safety Spring 2016 For information about citing these materials or our Terms of Use, visit: http ://ocw.mit.edu/terms.