Citation

de Carvalho PVR. Reliab. Eng. Syst. Safety 2011; 96(11): 1482-1498.

Copyright

(Copyright © 2011, Elsevier Publishing)

DOI

10.1016/j.ress.2011.05.009

PMID

unavailable

Abstract

The Functional Resonance Analysis Model (FRAM) defines a systemic framework to model complex systems for accident analysis purposes. We use FRAM in the mid-air collision between flight GLO1907, a commercial aircraft Boeing 737-800, and flight N600XL, an executive jet EMBRAER E-145, to investigate key resilience characteristics of the Air Traffic Management System (ATM). This ATM system related accident occurred at 16:56 Brazilian time on September 29, 2006 in the Amazonian sky. FRAM analysis of flight monitoring functions showed system constraints (equipment, training, time, and supervision) that produce variability in system behavior, creating demand resources mismatches in an attempt to perceive and control the developing situation. This variability also included control and coordination breakdowns and automation surprises (TCAS functioning). The analysis showed that under normal variability conditions (without catastrophic failures) the ATM system (pilots, controllers, supervisors, and equipment) was not able to close the control loops of the flight monitoring functions using feedback or feedforward strategies to achieve an adequate control of an aircraft flying in the controlled air space. Our findings shed some light on the resilience of Brazilian ATM system operation and indicated that there is a need of a deeper understanding on how the system is actually functioning.

Language: en