基于STAMP模型的风险评估行为安全指标体系

现有的风险评估方法与模型在设计上未充分考虑风险评估行为本身对评估结果的影响,对风险评估的行为可能引入安全性风险的认识也存在较大不足。针对这个问题,首先建立风险评估行为STAMP模型,使用STPA分析方法对风险评估行为进行安全性分析,利用STAMP模型构建风险评估行为安全指标体系,并采用改进AHP方法筛选出重要指标因素。所提出的安全指标体系关注系统整体的涌现性而非单个组件的可靠性,根据造成系统安全事故发生或进入危险状态的原因,提供一种能够更加有效的构建安全指标体系的思路。     

Who is in control of road safety? A STAMP control structure analysis of the road transport system in Queensland,Australia

Despite significant progress, road trauma continues to represent a global safety issue. In Queensland (Qld), Australia, there is currently a focus on preventing the ‘fatal five’ behaviours underpinning road trauma (drug and drink driving, distraction, seat belt wearing, speeding, and fatigue), along with an emphasis on a shared responsibility for road safety that spans road users, vehicle manufacturers, designers, policy makers etc. The aim of this article is to clarify who shares the responsibility for road safety in Qld and to determine what control measures are enacted to prevent the fatal five behaviours. This is achieved through the presentation of a control structure model that depicts the actors and organisations within the Qld road transport system along with the control and feedback relationships that exist between them. Validated through a Delphi study, the model shows a diverse set of actors and organisations who share the responsibility for road safety that goes beyond those discussed in road safety policies and strategies. The analysis also shows that, compared to other safety critical domains, there are less formal control structures in road transport and that opportunities exist to add new controls and strengthen existing ones. Relationships that influence rather than control are also prominent. Finally, when compared to other safety critical domains, the strength of road safety controls is brought into question.     

The ESA/NASA SOHO mission interruption: using the STAMP accident analysis technique for a software related ‘mishap’

Mishap investigations provide important information about adverse events and are intended to help avoid any recurrence of previous failures. However, the complexity of many safety critical systems poses new challenges for mishap analysis. Similarly, the recognition that many failures have complex, systemic causes has helped to widen the scope of many mishap investigations. A new generation of mishap analysis techniques has been proposed to help investigators address these problems. For instance, Leveson has recently developed the Systems Theory Accident Modelling and Process (STAMP) approach to address some of the weaknesses associated with previous ‘chain of event’ approaches that can miss the systemic causes of adverse events. There are relatively few examples of the STAMP approach. This paper, therefore, presents the results obtained when two analysts performed an independent application of this technique to analyse the causes, including software problems, which led to the mission interruption of the joint European Space Agency (ESA) and National Aeronautics and Space Administration (NASA) Solar and Heliocentric Observatory (SOHO). Copyright © 2003 John Wiley & Sons, Ltd.     

基于 STAMP-HFACS 的建筑坍塌事故风险因素分析

为消除单一事故模型对事故报告研究的局限性和孤立性，融合STAMP（系统理论事故建模与过程）模型和HFACS（人因分析和分类系统）模型的优点，建立STAMP-HFACS 混合分析方法，对2012~2021 年的249 个坍塌事故案例报告进行分析研究，识别出了27 个坍塌事故风险因素。构建了坍塌事故网络，利用核心—边缘分析与中心性分析，识别出了未严格落实安全生产责任制、相关资质审查不到位、现场管理不到位、现场监理工作失职等关键风险因素，并且利用关联方向指数挖掘出了各个风险因素的原因结果特征。     

Use of waste plastics in cokemaking at Tata Steel

Abstract

Disposal of waste plastics is a serious global issue, and hence it is imperative to explore methods to recycle them for efficient utilisation. The coke making process is considered to be a promising area to which the thermal decomposition of waste plastics is applicable, because the process involves coal carbonisation at a high temperature under a reducing atmosphere. As an outcome of the research work carried out on a laboratory scale followed by plant trials at Tata Steel, it was found that waste plastics recycling process using stamp charged coke ovens is feasible to recover coke, tar, light oil and gas from general waste plastics mixed in coal by carbonisation in coke ovens. It has also been established in the laboratory that waste plastics up to 1% can be used in coke making without any deterioration in coke strength. Plant trials have also indicated that co-carbonisation of waste plastics with coal is a possible solution for its disposal.     

基于STAMP的地铁施工安全控制结构研究

简要回顾了事故致因与系统安全理论的发展,分析了建立地铁施工系统安全模型的挑战,在此基础上提出了基于STAMP的地铁施工安全分析方法,在明确了地铁施工系统安全需求和约束的基础上构建了地铁施工安全控制结构,识别了各建设主体之间的控制流、信息流以及对地铁施工过程的控制和反馈,为分析地铁施工中存在的控制缺陷、改进地铁施工安全状况提供方法依据。     

Modelling distributed crewing in commercial aircraft with STAMP for a rapid decompression hazard

Abstract

Changes to crewing configurations in commercial airlines are likely as a means of reducing operating costs. To consider the safety implications for a distributed crewing configuration, system theoretic accident model and processes (STAMP) was applied to a rapid decompression hazard. High level control structures for current operations and distributed crewing are presented. The CONOPS generated by STAMP-STPA for distributed crewing, and design constraints associated with unsafe control actions (UCAs) are offered to progress in the route to certification for distributed crewing, and improve safety in current operations. Control loops between stakeholders were created using system-theoretic process analysis (STPA). The factors leading to the Helios 255 incident demonstrated the redundancy that a ground station could offer without the risk of hypoxia, during a decompression incident. STPA analysis also highlighted initial UCAs that could occur within the hypothetical distributed crewing configuration, prompting consideration of design constraints and new CONOPS for ground station design.

Practitioner Summary: SPO in commercial aircraft is likely as a means to reduce costs. This paper makes a case for distributed crewing using STAMP-STPA. Comparing current operations with a distributed crewing configuration, the redundancy offered by a ground station is demonstrated. Design constraints and new CONOPs for distributed crewing, and current operations are proposed.     

基于STAMP的民航进餐推车人因设计

目的 为解决空乘人员因工作负荷大、工作环境颠簸易发生碰撞事故等导致患肌肉骨骼病概率逐年上涨的问题,对民航进餐推车造型设计过程进行研究。方法 确定民航进餐推车系统中的安全约束,构建基于层级模式的民航进餐推车事故风险控制—人因模型;识别控制模型中潜在的不安全控制行为,采用层次分析法对这些行为的综合权重值进行计算并排序;运用虚拟仿真软件进行人因分析与设计优化,得到最优方案。结果 通过民航进餐推车设计实践,验证该方法的可行性与有效性。结论 在民航进餐推车设计过程的前期,引入STAMP模型和人因工程理论,可提升空乘人员在进餐推车服务过程中的安全性与舒适性,为研制符合空乘人员行为方式的新型民航进餐推车提供新的思路。     

Applying System Thinking to Learn from Accident of Modern Automatic Control Systems

Modern societies increasingly rely on auto- matic control systems. These systems are hardly pure tech-nical systems; instead they are complex socio-technical sys- tems, which consist of technical elements and social components. It is necessary to have a systematic approach to analyze these systems because it is growing evidence that accidents from these systems usually have complex causal factors which form an interconnected network of events, rather than a simple cause-effect chain. We take railway Train control systems （TCS） as an example to demonstrate the importance of the socio-technical approach to analyze the system. The paper presents an investigation of recent high-speed railway accident by applying STAMP - one of the most notable socio-technical system analysis tech- niques, outlines improvements to the system which could avoid similar accidents in the future. We also provide our valuable feedback for the use of STAMP.