Aviation accident aetiology: catastrophe theory perspective

摘要

Human error is often cited as a major contributing factor or cause of incidents and accidents. Incident surveys in aviation have attributed 70 per cent of incidents to crew error. Although a large proportion of the accidents can be attributed to human error, 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 systems. 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 situational factors. This dynamic nature is presented here using the cusp model from catastrophe theory. Using Reason's latent failure model, the descriptive and predictive nature of the cusp 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. The SwissAir 111 tragedy of 2 September 1998 is used as a case study to illustrate this model.