AVIATION ACCIDENTS AETIOLOGY FROM CATASTROPHE THEORY POINT OF VIEW

摘要

Human error is often cited as a majorrncontributing factor or case of incidents andrnaccidents. Reason proposes a view that manyrnaccidents are catalyzed by persons not presentrnat the time of the event. In fact, it is this sourcernof latent conditions that pose a most significantrnthreat to the safety of complex system. Anotherrndimension to human error in aviation are thernactive errors that can precipitate the alignmentrnor trigger the latent conditions. The riskrnassociated with aviation is a dynamic elementrnthat is affected by both latent conditions andrnsignificant factors. In our opinion this dynamicsrnnature of risk in aviation can be described inrnterms of Theory of Catastrophe. Using Reason'srnlatent failure model, we try to describe thisrndynamics nature using the cusp catastrophernmodel. In our opinion the descriptive andrnpredictive nature of cusp catastrophe modelrnworks as a map to illustrate the nature ofrnaviation accidents in terms of "instability"rnresulting from the alignment of latent conditionsrnand influence of active errors.