AVIATION ACCIDENTS AETIOLOGY FROM CATASTROPHE THEORY POINT OF VIEW

摘要

Human error is often cited as a major contributing factor or case of incidents and accidents. Reason proposes a view that many accidents are catalyzed by persons not present at the time of the event. In fact, it is this source of latent conditions that pose a most significant threat to the safety of complex system. Another dimension to human error in aviation are the active errors that can precipitate the alignment or trigger the latent conditions. The risk associated with aviation is a dynamic element that is affected by both latent conditions and significant factors. In our opinion this dynamics nature of risk in aviation can be described in terms of Theory of Catastrophe. Using Reason's latent failure model, we try to describe this dynamics nature using the cusp catastrophe model. In our opinion the descriptive and predictive nature of cusp catastrophe model works as a map to illustrate the nature of aviation accidents in terms of "instability" resulting from the alignment of latent conditions and influence of active errors.