dissertation Alfred Roelen

250 Pages·2008·5.39 MB·English

Causal risk models of air transport

Comparison of user needs and model capabilities

Alfred Roelen

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Causal risk models of air transport

Comparison of user needs and model capabilities

Proefschrift

ter verkrijging van de graad van doctor
aan de Technische Universiteit Delft,
op gezag van de Rector Magnificus prof. dr. ir. J.T. Fokkema,
voorzitter van het College voor Promoties,
in het openbaar te verdedigen op maandag 10 november 2008 om 15:00 uur

door

Alfred Lambertus Cornelis ROELEN

ingenieur in de Luchtvaart en Ruimtevaart
geboren te Vught
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Dit proefschrift is goedgekeurd door de promotor:
Prof. dr. A.R. Hale

Samenstelling promotiecommissie:
Rector Magnificus voorzitter
Prof. dr. A.R. Hale Technische Universiteit Delft, promotor
Prof. dr. B.J.M. Ale Technische Universiteit Delft
Prof. dr. ir. M.J.L. van Tooren Technische Universiteit Delft
Prof. dr. A. Mosleh University of Maryland
Prof. dr. ir. A.C. Brombacher Technische Universiteit Eindhoven
Dr. H.A.P. Blom Nationaal Lucht- en Ruimtevaartlaboratorium

© 2008 The author and IOS Press

All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, without prior permission from the publisher.

ISBN

Keywords: Safety, risk modelling, aviation, safety management.

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“People in those days fancied, as people generally fancy when they catch sight for the first
time of a new problem, that it was far easier and simpler than was actually the case; they
did not know till experience taught them how painfully they would be compelled to advance
from step to step, and to unravel the intricate chain of causes which have gone to bring the
earth into its present shape; and still less how one principal result of the enquiry would
prove that the most interesting questions lay outside the reach of human knowledge”.

Leslie Stephen, The playground of Europe, Fredonia Books, Amsterdam, The Netherlands,
2004, reprint from the 1910 edition.
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Acknowledgements

A PhD study has been compared with running a marathon, where every ten kilometres
symbolise one year of research [Roelen 1997]. Although this is an interesting comparison, I
believe that a PhD study is better compared with climbing a mountain; even though the
route in general might be known, you’ll have to find your way while you go along and
some bits are easy going, but other sections require all your strength and technical abilities.
You’ll often think you have the peak in sight, only to discover the mountain continuing
beyond the ridge you believed to be the top. Perhaps more importantly, running a marathon
is a solitary effort, but climbing a mountain is a group endeavour. The rope group is vitally
important for the probability of success. The connecting and life-saving rope allows the
weaker to find support from the stronger member of the team [Harrer 1988]. A
commonality between running, climbing and a PhD study is of course the inverse relation
between ‘distance remaining’ and ‘desire to finish’. But then, even a bit unexpectedly,
you’ll find yourself near the summit. ‘A few more whacks of the ice-axe in the firm snow
and we stood on top’ [Hunt 1953]. It is here, on the top of the mountain, that one shakes
hands with all members of the rope-group, acknowledging their contribution to the success.
First of all many thanks to Andrew Hale for persuading me to start this endeavour for being
such a thoughtful and kind promotor. John Lapointe and Kathy Fazen of the FAA Tech
Center in Atlantic City and Hok Goei of the Transport and Water Management Inspectorate
provided the first opportunity for me to do some serious research on risk modelling for air
transport. Ali Mosleh kindly shared his knowledge from the field of nuclear safety
engineering and his wisdom in many other disciplines, and this helped me a lot in getting a
firm grip on the subject. The CATS people were indispensable for further development of
resulting ideas and insights, so thank you Ben Ale, Roger Cooke, Dorota Kurowicka, Pei-
Hui Lin, Oswaldo Morales-Napoles, Linda Bellamy, Louis Goossens, Dan Ababei, John
Spouge, John Cooper and Rob van der Boom. While being involved in the various projects
that were directly or indirectly related to the research topic, I have enjoyed working
together with my colleagues at NLR, in particular Peter van der Geest, Gerard van Es,
Rombout Wever, Gerben van Baren, Bart Klein Obbink, Hans de Jong, Bas van Doorn,
Jelmer Scholte, Hans Post, Jeroen van der Zee, Mariken Everdij, Sybert Stroeve, Lennaert
Speijker, Juan Coelho, Harry Smit, Arjen Balk, Joram Verstraeten, Johan Weijts, Ton
Nieuwpoort, Arun Karwal, Carolynne Montijn, Margriet Klompstra, Bert Bakker, Koen de
Jong, Udo Dees, Tom van Birgelen, Patricia Sijaranamual and Anna Kurlanc. Marijn
Giesberts and Job Smeltink deserve special recognition for being such cheerful roommates!
Henk Blom conducted a much appreciated review of an early draft of this thesis and Michel
Piers and Alex Rutten encouraged me start and also to complete the work.

While the rope group is fighting its way up the mountain slope, the people in base camp
actually make it all possible. They provide the necessary supplies and allow the climber to
recover from his efforts. I would like to thank the people of my base camp; Rob & Ellen
and Jim & Henriëtte for their friendship and Caroline Veugelers for always being interested
in the topic of my research. Dear mom, thank you for being the best mother in the world.
Bernard and Susana are my base camp heroes. Obviously, the most important member of
the base camp is my partner Mijntje Pikaar. I am very grateful for sharing my life with you.

Harrer, H. (1988). Das Buch vom Eiger, Pinguin Verlag, Innsbruck, Austria.
Roelen, B. (1997). TGF-βs and their receptors in early mammalian development, Febodruk
B.V., Enschede.
Hunt, J. (1953). The ascent of Everest, Hodder & Stoughton, London.
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Table of contents

List of abbreviations.................................................................................................4
Chapter 1. Introduction............................................................................................7
1.1. Research question....................................................................................9
1.2. Scope.......................................................................................................9
1.3. Directions for the reader........................................................................11
Chapter 2. Fundamentals of risk............................................................................12
2.1. Definition of safety...............................................................................12
2.2. Risk perception......................................................................................13
2.3. Risk metrics...........................................................................................14
2.4. Risk criteria...........................................................................................17
2.5. Theories about accident causation.........................................................19
2.6. Risk analysis and risk modelling...........................................................20
2.7. Conclusions for this section..................................................................21
Chapter 3. Fundamentals of causation and probability..........................................23
3.1. What is causation?.................................................................................23
3.2. Conditional independence.....................................................................26
3.3. Causation to predict the future..............................................................27
3.4. Singular and generic causal relations....................................................28
3.5. Strong and weak causal relations..........................................................29
3.6. The beginning and the end of causation................................................29
3.7. What is a causal model?........................................................................30
3.8. Conclusions for this section..................................................................31
Chapter 4. User needs............................................................................................33
4.1. A brief history of aviation safety...........................................................33
4.2. Who are the users?................................................................................43
4.3. Perspectives on aviation safety.............................................................43
4.3.1. Airlines..................................................................................................43
4.3.2. Repair stations.......................................................................................45
4.3.3. Aircraft manufacturer............................................................................47
4.3.4. Air navigation service provider.............................................................49
4.3.5. Airports.................................................................................................51
4.3.6. Policy makers and regulatory bodies....................................................52
4.3.7. Passengers.............................................................................................58
4.3.8. People living or working in the vicinity of airports..............................60
4.4. Summary of user requirements and discussion on consistency.............62
4.5. User expectations: lessons from CATS.................................................72
4.6. Conclusions for this section..................................................................74
Chapter 5. Examples of aviation safety analyses...................................................78
5.1. Safety of mixed VFR/IFR air traffic at Geneva Airport.......................78
5.2. Safety assessment of parallel approaches at Helsinki-Vantaa Airport..79
5.3. Safety assessment of offset steep approaches at Lugano Airport..........80
5.4. Reduced vertical separation minimum in Europe.................................81
5.5. VEMER ATM System increment 2002................................................83
5.6. Conclusions for this section..................................................................84
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Chapter 6. Risk models in other industries............................................................86
6.1. Nuclear power.......................................................................................86
6.2. Manned spaceflight...............................................................................87
6.3. Offshore industry..................................................................................88
6.4. Process industry....................................................................................90
6.5. Rail transport.........................................................................................90
6.6. Health care............................................................................................91
6.7. Conclusions for this section..................................................................93
Chapter 7. Modelling.............................................................................................95
7.1. Model representation.............................................................................95
7.2. Modelling techniques............................................................................97
7.2.1 Boolean Trees.......................................................................................97
7.2.2 Bayesian Belief Nets...........................................................................101
7.2.3 Petri nets..............................................................................................105
7.3. Size, depth, complexity and uncertainty.............................................106
7.4. Time dependency................................................................................107
7.5. Conclusions for this section................................................................108
Chapter 8. Quantification....................................................................................110
8.1. Measurements, quantities, units and values........................................110
8.2. The need for ratio scales......................................................................114
8.3. Uncertainty..........................................................................................115
8.4. Model assumptions..............................................................................116
8.5. Data sources........................................................................................117
8.5.1 Accident or incident data?...................................................................117
8.5.2 Accident investigation.........................................................................118
8.5.3 Incident reporting................................................................................119
8.5.4 In-flight recorded data.........................................................................122
8.5.5 Expert judgement................................................................................124
8.5.6 Empirical studies.................................................................................124
8.5.7 Safety audits........................................................................................126
8.6. Denominator data................................................................................128
8.7. Using the data......................................................................................129
8.8. Conclusions for this section................................................................132
Chapter 9. Modelling challenges.........................................................................134
9.1. Modelling human operators................................................................134
9.2. Modelling safety management............................................................140
9.3. Complexity, completeness and dependencies.....................................148
9.4. Conclusions for this section................................................................157
Chapter 10. Model validation..............................................................................159
10.1. Introduction.........................................................................................159
10.2. Validation of the generic accident scenarios.......................................160
10.2.1. Validation of take-off and landing overrun probability estimates......160
10.2.2. Completeness of the accident scenarios..............................................161
10.3. Validation of a model for missed approaches: case validity...............161
10.3.1. Qualitative description of the model...................................................161
10.3.2. Quantification of the model variables (the parent nodes)...................163
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10.3.3. Dependencies......................................................................................168
10.3.4. Comparison of model results with observations in practice...............169
10.4. Face validity and peer review..............................................................171
10.5. Assumption analysis............................................................................171
10.6. Conclusions for this section................................................................172
Chapter 11. Summary, discussion and conclusions.............................................173
References............................................................................................................186
Summary...............................................................................................................214
Samenvatting........................................................................................................217
Appendix A: The history of third party risk regulation at Schiphol.....................221
Background.......................................................................................................221
Stand still for Schiphol risk..............................................................................222
New law for Schiphol.......................................................................................222
Causal model as a solution?..............................................................................224
Appendix B: The aviation system.........................................................................225
A typical flight..................................................................................................226
Subsidiary processes.........................................................................................231
Flight crew training..........................................................................................231
Air Traffic Control...........................................................................................231
Aircraft design and certification.......................................................................232
Aircraft maintenance........................................................................................233
Airport processes..............................................................................................235
Safety regulation and oversight........................................................................237
Appendix C: Causal Model for Air Transport Safety (CATS).............................241
Curriculum Vitae..................................................................................................243
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List of abbreviations
AC Advisory Circular
ACC Area Control Centre
AD Airworthiness Directive
ADREP Accident/Incident Reporting System
ALARA As Low As Reasonably Achievable
ALARP As Low As Reasonably Practicable
ANS Air Navigation System
ANSP Air Navigation Service Provider
AOC Air Operator Certificate
ATC Air Traffic Control
ATCo Air Traffic Controller
ATHEANA A Technique for Human Event Analysis
ATIS Automatic Terminal Information System
ATL Aircraft Technical Log
ATM Air Traffic Management
BBN Bayesian Belief Net
BFU Büro für Flugunfalluntersuchungen
CAA Civil Aviation Authority
CATS Causal Model for Air Transport System
CFIT Controlled Flight Into Terrain
CIL Critical Item List
CREAM Cognitive Reliability and Analysis Method
CRM Crew Resource Management
CS Certification Specification
CTR Control Zone
CVR Cockpit Voice Recorder
DME Distance Measuring Equipment
EASA European Aviation Safety Agency
EC European Commission
ECCAIRS European Co-ordination Centre for Aviation Incident Reporting Systems
EMF Electric and Magnetic Field
EPC Error Producing Condition
ESARR Eurocontrol Safety Regulatory Requirement
ESD Event Sequence Diagram
EU European Union
FAA Federal Aviation Administration
FANOMOS Flight Track and Aircraft Noise Monitoring System
FAR Federal Aviation Regulation
FAS Final Approach Speed
FDR Flight Data Recorder
FHA Functional Hazard Assessment
FMECA Failure Modes Effects and Criticality Analysis
FMS Flight Management System
FOCA Federal Office for Civil Aviation
FSF Flight Safety Foundation
GGR Gesommeerd Gewogen Risico (summed weighted risk)
GPS Global Positioning System
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