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Introduction of the Concept of Functional Resonance in the Analysis of a Near-Accident in Aviation.

Abstract : The analysis of complex events shows that the performance of crew members and/or air traffic controllers, as well as the aircraft and its systems, may vary within different time frames. Thus, the understanding of the current situation can differ significantly within the crew and between the cockpit and the ground, as well as be at odds with the aircraft's real position and attitude over time. Further, these components interact throughout the flight. This paper presents a proposal for how better to model these complex interdependencies, using the principles of the Functional Resonance Accident Model (FRAM). The outcomes of this modelling can conveniently be shown by means of open source software, the FRAM Visualizer. Using an incident initiated where the Captain selected the wrong HSI track, we explore the many factors that influenced the situation when the crew put the aircraft into descent but failed to intercept the localizer. This led to a crisis that they had to manage, departing significantly from Standard Procedures, and without being fully aware of their proximity to the ground when they initiated a go-around. Our aim is to develop new analytical tools in order to better characterize and understand how the flight evolved beyond acceptable safety margins, and how the crew recovered from a critical situation. Some of the factors and their comparative interactions identified in this manner may reveal inherent risks that are still present but also preventable.
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Submitted on : Wednesday, August 10, 2011 - 2:30:31 PM
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  • HAL Id : hal-00614258, version 1

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David Nouvel, Sébastien Travadel, Erik Hollnagel. Introduction of the Concept of Functional Resonance in the Analysis of a Near-Accident in Aviation.. 33rd ESReDA Seminar: Future challenges of accident investigation, Nov 2007, Ispra, Italy. 9 p. ⟨hal-00614258⟩

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