Failure models
The failure models enable to to predict and analyze
risky
situations by
situation-oriented
failure analysis, namely in terms of the the system
situation and
design scope.
Models explaining operational failure
There are many explanations for the source of
system failures. Few of them are:
- Organizational factors (e.g.
Reason, 1997 ;
Dekker, 2006 ).
- Complexity (e.g.
Perrow, 1984 )
- Extreme operational conditions (e.g.
Hollnagel et al., 2006 ;
Weiler & Harel, 2011 )
- Human errors (e.g.
Norman, 1983 )
- Quality of requirement specification (e.g.
Robert et al., 1998 ;
Leveson, 2012 )
- Quality of the implementation (e.g.,
Weinberg, 1971 ;
Norman, 1990 )
- Mismatch with the operational
context (e.g.
Zonnenshain and Harel, 2009 ).
Activity models of failure
Root-cause analysis of many case studies reveals the following
activity
pattern ending up in failure:
- Latent hazards: the
operators are not aware of an
exceptional situation, such
as a component failure or inconsistent
system state, due to missing or wrong
indication. In the TMI accident, the
system did not provide indication about
the wrong state of five components, and provided wrong indication about the
state of the PORV, which was critical for handling the
situation (
Perrow, 1984 ). Related terms are latent failures and later conditions (
Eurocontrol, 2006 ).
- Delay in the recovery procedure: the
operators do not complete the
troubleshooting and the recovery procedure in time (As in the TMI accident).
- Leaks (holes ) in the
firewalls in the
design scope .
Updated on 10 Mar 2016.