Analysis of Comair flight 5191 with the functional resonance accident model

Erik Hollnagel (1) , Shawn Pruchnicki (2) , Rogier Woltjer (3) , Shawn Etcher (2)

1 CRC - Centre de recherche sur les Risques et les Crises
2 Air Line Pilots Association
3 Department of Computer and Information Science - Linköping University

The goal of an accident investigation is to determine why a certain combination of conditions, events, and actions led to the specific outcome. Accidents in complex high risk operations, such as aviation, are frequently explained as the result of system failures, but few methods exist that can adequately be used to investigate how the variability of individual, technical, and organisational performance in combination may lead to an adverse outcome. The Functional Resonance Accident Model (FRAM) provides an approach to identify these elements and determine their interrelationship. This paper presents the principles of FRAM and illustrates how it was used to analyse a highly publicized aviation accident, the crash of Comair Airlines (Delta Connection) flight 5191 in Lexington, KY on August 27th, 2006. The use of FRAM provided details that were not found in the NTSB analysis and as such this approach model may help future investigations better elucidate causal factors and yield improved safety recommendations.

Mots clés: accident; risk; aviation

Domaines: Gestion des risques et des crises

Erik Hollnagel, Shawn Pruchnicki, Rogier Woltjer, Shawn Etcher. Analysis of Comair flight 5191 with the functional resonance accident model. 8th International Symposium of the Australian Aviation Psychology Association, Apr 2008, Sydney, Australia. 8 p. ⟨hal-00614254⟩