Extending the Human-controller methodology in Railway System Accident … · 2017. 11. 28. ·...

轨道交通控制与安全国家重点实验室(北京交通大学)STATE KEY LAB OF RAIL TRAFFIC CONTROL & SAFETY

Extending the Human-controller

methodology in Railway System

Accident Analysis based on STAMP

Chenling Li ，Ph.D. candidate

Tao Tang, Prof.

Ru Niu, Dr.

Maria Mikela Chatzimichailidou, Dr.

Patrick Waterson, Dr.

State Key Laboratory of Rail Traffic Control and Safety, Beijing Jiaotong University

LRF Transport Risk Management Centre, Imperial College London

Human Factors and Complex Systems Group, Loughborough University

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Outline

Background and Motivation– Accident investigation and analysis

– Human factor analysis based on STAMP

Some ideas in using STAMP analysis on human

factors– Extension: human controller state

– Human controller model’s elements

– Analysis procedure: the Analysis Matrix for Human Error (AMHE)

Case study :7.23 Yongwen railway accident– The accident: human factors

– Analysis and results

Conclusion


Background and Motivation

Railway system

The complex control system and serious operation circumstance of

the railway system, especially high-speed railway, make it become a

typical socio-technical system (Wilson et al., 2007) .

S

S SAT

CS S

S

SVC

S

S SAT

CS S

S

SRC

Safety braking distance

V

80km/h Permitted

speedReal speed

Line limit speed

TrainInfrastructure

Train Control

Railway System is complex socio-technical S



Accident investigation and analysis

Jul. 2011. China YongWen Railway Accident. 40 people dead, 200 injured.

Apr. 2008. China JiaoJi Railway Accident.. 72 people dead, 416 injured.

Train accidents involving collisions, derailments and fires related to

human factors make up a significant proportion of all train accidents

(MLTM, 2009; Reinach, Viale, 2006).

Railway signaling and

interlocking (Anders, 2009)

Human error



Accident investigation and analysis

Accident causation model

(Leveson, 2012)

STAMP

Human error: system symptom

Mental model



Human controller model in STAMP

Mental model and work process

(Leveson, 2012)

(Thornberry, 2014).)

(France, 2017))




(France, 2017))

Human controller state?




(Thornberry, 2014).)



Human controller status influence?

Information processing: four steps

Human controller state is a

essential part of human

controller model




Information processing: four steps




The human cognitive experiments should that the perception

of mental fatigue impacted individual’s persistence, attention

and elabortative thought (Carkson et al., 2016).

Fatigue is the largest identifiable and preventable cause of

accident in transport operations (Akerstedt, 2000) , and now

is still a fatal factors contributed to Chinese railway accidents

(Taso et al., 2017).





Outline









Conclusion


Human controller model

Extension about human controller model

Human Controller

Mental Models

Process Behavior

(PB)

Environment

(E)

Process State

(PS)Mental

Model

Updates

(U)

Control

Action

Selection

(S) Sensory

Feedback

& Input

Control

Actions

Human State

(HS)

Mental Model of the Human

State:(What does the

operator perceive about

his/her own state?)

Physical state

Mental stae

Physical/mental limitations

The attitude about safety

…


Analysis procedure: the procedure

Control

Actions

Detection and

InterpretationDecision

makeing

Sensory

Feedback

& Input

Mental Models

Process Behavior

(PB)

Environment

(E)

Process State

(PS)

Human State

(HS)

Up

dat

e

System operation

condition and goal

Reco

gn

itio

n

1

2

3

3.Information detection and

interpretation

2.Condition recognition

1.Decision



Analysis procedure: the procedure

Control

Actions

Detection and

InterpretationDecision

makeing

Sensory

Feedback

& Input

Mental Models

Process Behavior

(PB)

Environment

(E)

Process State

(PS)

Human State

(HS)

Up

dat

e

System operation

condition and goal

Reco

gn

itio

n

1

2

3

Last step factor(s)

(LF)

Human own

character(s) (HC)

Factors from other

parts in the system

(OF)

HCUC

A

LF

1

OM

LF

2


Analysis procedure: the Analysis Matrix for Human

Error (AMHE)

Last step factor(s)

(LF)

Human own

character(s) (HC)

Factors from other

parts in the system

(OF)


Analysis procedure: the content of each item



Analysis procedure: the content of each item

Identify system(s) and system hazard(s)

Document the system safety control structure

Analysis individual human errors

For organisational and regulation

level analysis

Recommendations (in human error level)

Identify human errors



Outline









Conclusion


7.23 Yongwen railway accident

On the 23 July 2011 at 20:30:05

Two EMU train in same direction collided together

Cause 40 deaths, 172 injuries, interruption of traffic for 32 hours and

35 minutes


Ministry of Railway

MOR Science & Technology Department

MOR Transport Bureau

MOR Foundation Department

CRSC Mangement

Project Management

TCC Project Management and Dev.

Process(CRSCD)

System Development System Operation

Verification and Validation

Directives Progress Reports

Accidents

Requirements

(including

CTCS,CTCS-2 Specs)

& Standard

Progress Reports

Accidents

Progress Reports

Design and Development

Requirements & Specs

& StandardsProgress Reports

Test Requirements Test Reports

Ministry of Railway

MOR Transport Bureau

Shanghai Railway Bureau

Mangement

Directives Performance Reports

Accidents

Operation

Regulation

Performance Reports

Accidents

CTC Dispatching Center

The Operation Process

Operation

RegulationPerformance Reports

Accidents

Station Operator

Train Operator

The Physical Process:CTCS-2 System

Maintenance

StatusProblem

Operation Assumption

Operation Procedure

Problem Reports

Maintenance procedure

Maint.Req

Status Report

Missing controls,feedbacks

Performance Reports

Accidents

TCC Requirements

Manufacture SRSS Management

Maunfacturing

Product

Quality Stds

Quality

Reports

Specifications Reports



Dispatcher

CTC centre

Station operator

Station monitor

CTC station exetention

TCC

Onboard system

Driver

Train

Maintenance

worker

TSR

Interlocking

route

command Block section

information

Route

information

TSR

information

Track

circuit

information

Display

Operation plan

TSR Operation

status

TSR status

Track occupation status

Station status

TSR status

Track occupation

information

CI status

Train status

Alarm for overspeed

Input

data

Select

mode

Accelerate

DecelerateTrain

status

Accelerate

Decelerate

Train

status

Display

Status

information

MA

Monitor system

operation Display

MA

Operation

osrder

Maintenance

command

Report

Line

data

Require

station

status

Report

Report train status

Track train status

Inform em

ergency

Report train status

Inform station status

Inform em

ergency

Track circuit in

interval

LEU

Active

balise

Monitoring

information

Track

circuit

code

Track

occupation

information TSR

Positive

balis

Signaling

monitoring

TSRTSR

status

CI

Signal machine

in stationSwitch

Track circuit

in station

Status

Switch

command

Switch

status

Signal

command

Signal

machine

status

Communication

between human

operators

Communication

between technical

equipment

Human

operatorsTechnical

equipment

Maintenance

command

Report

Dispatcher

Station operator

D3115 Train driver

D301 Train driver

Maintenance worker


Identify human

errors(UCA)




Dispatcher: A1:Dispatcher did not check

and confirm the track condition in time



Outline









Conclusion


Conclusion(1)

Find out the causal factors contributing the

unsafe control actions of human operators.


Conclusion(2)

More clearly about analysis process

Easy to track back to organistional and higher

levels


Reference(1)Wilson, J.R., Farrington-Darby, T., Cox, G., Bye, R., Hockey, G.R. (2007). The railway as a socio-technical

system: human factors at the heart of successful rail engineering. Proceedings of the Institution of

Mechanical Engineers, Part F: Journal of Rail and Rapid Transit, 221(1), 101-115.

Reinach S, Viale A. (2006). Application of a human error framework to conduct train accident/incident

investigations. Accid Anal Prev, 38, 396–406.

Zhan, Qingjian., Zheng, Wei., Zhao, Bobo. (2017). A hybrid human and organizational analysis method for

railway accidents based on HFACS-Railway Accidents (HFACS-RAs). Safety Science, 91, 232-250.

Clarkson, J.J., Otto, A.S., Hassey, R., Hirt, E.R. (2016). Perceived Mental Fatigue and Self-Control. In book:

Hirt, E., Clarkson, J.J., Jia, L. (Eds). Self-Regulation and Ego Control. Academic Press, 185-202.

Shappell, S.A., Wiegmann, D.A. (2000). The human factors analysis and classification system – HFACS.

Federal Aviation Administration Technical Report No. DOT/FAA/AM-00/7. National Technical Information

Service, N Springfield.

Thomas, J., France, M., Green, C.A., Vernacchia, M.A., Sundaram, P., D’Ambrosio, J. (2016). Engineering

for humans:STPA Analysis of an Automated Parking System. The 5th MIT STAMP/STPA Workshop, MIT,

March 21th-24th, 2017.Available at: http://psas.scripts.mit.edu/home/wp-

content/uploads/2016/04/Thomas,France-Engineering_for_Humans.pdf (Last accessed August 24th, 2017)

http://psas.scripts.mit.edu/home/wp-content/uploads/2016/04/Thomas,France-Engineering_for_Humans.pdf


Thornberry, C. (2014). Extending the human controller methodology in Systems-Theoretic Process Analysis

(STPA). Master thesis, Massachusetts Institute of Technology.

Tsao, L., Chang, J., Ma, L. (2017). Fatigue of Chinese railway employee and its influential factors: Structural

equation modelling. Applied Ergonomics, 62, 131-141.

Reference(2)


State Key Laboratory of Rail Traffic Control and Safety

Beijing Jiaotong University, Beijing, China

Q&A

Thank you!

Chenling Li

[email protected] [email protected]

mailto:[email protected]

mailto:[email protected]


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