A system theoretic safety analysis of friendly fire prevention in ground based missile systems

摘要

This thesis used Dr. Leveson's STAMP (Systems-Theoretic Accident Model and Process) model of accident causation to analyze a friendly fire accident that occurred on 22 March 03 between a British Tornado aircraft and a US Patriot Missile battery. This causation model analyzes system constraints, control loops, and process models to identify inadequate control structures leading to hazards and preventative measures that may be taken to reduce the effect of these hazards. By using a system-based causation model like STAMP, rather than a traditional chain of events model, this thesis aimed to identify systemic factors and component interactions that may have contributed to the accident, rather than simply analyzing component failures. Additionally, care was taken to understand the rationale for decisions that were made, rather than assigning blame. The analysis identified a number of areas in which control flaws or inadequacies led to the friendly fire incident. A set of recommendations was developed that may help to prevent similar accidents from occurring in the future.