Comparison of the WB- and STAMP-Analyses. Analyses of the Brühl accident. 2. Bieleschweig Workshop. Dipl.-Ing. Oliver Lemke. Lemke,

Transkript

1 Comparison of the WB- and STAMP-Analyses Analyses of the Brühl accident 2. Bieleschweig Workshop Dipl.-Ing. Oliver Lemke Braunschweig, Lemke,

2 Contents Identifying those aspects covered by both analyses Aspects only covered by STAMP analysis Aspects only covered by WBA Conclusions Lemke,

3 Contents Identifying those aspects covered by both analyses Aspects only covered by STAMP analysis Aspects only covered by WBA Conclusions Lemke,

4 STAMP control structure I Lemke,

5 STAMP control structure I No ATC installation present Lemke,

6 STAMP control structure I No ATC installation present Driver lacks training Lemke,

7 STAMP control structure I No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Lemke,

8 STAMP control structure I No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Lemke,

9 STAMP control structure I No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Unusual use of Zs1 Lemke,

10 STAMP control structure II Lemke,

11 STAMP control structure II Non mandatory instructions to inform driver by cab-radio Lemke,

12 STAMP control structure II Non mandatory instructions to inform driver by cab-radio Concerns about mode of operation were ignored Lemke,

13 STAMP control structure II Non mandatory instructions to inform driver by cab-radio Concerns about mode of operation were ignored Lack of knowledge of track layout Lemke,

14 The WB-Graph Lemke,

15 The WB-Graph No ATC installation present Lemke,

16 The WB-Graph No ATC installation present Driver lacks training Lemke,

17 The WB-Graph No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Lemke,

18 The WB-Graph No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Lemke,

19 The WB-Graph No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Unusual use of Zs1 Lemke,

20 The WB-Graph No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Unusual use of Zs1 Concerns about mode of operation were ignored Lemke,

21 The WB-Graph No ATC installation present Driver lacks training Non mandatory instructions to inform driver by cab-radio Confusing La entries Unusual use of Zs1 Concerns about mode of operation were ignored Lack of knowledge of track layout Lemke,

22 Contents Identifying those aspects covered by both analyses Aspects only covered by STAMP analysis Aspects only covered by WBA Conclusions Lemke,

23 Aspects covered only by STAMP analysis Lemke,

24 Aspects covered only by STAMP analysis Aspects only found by STAMP analysis Lemke,

25 Aspects covered only by STAMP analysis Aspects only found by STAMP analysis Lemke,

26 Aspects covered only by STAMP analysis Aspects only found by STAMP analysis Lemke,

27 Contents Identifying those aspects covered by both analyses Aspects only covered by STAMP analysis Aspects only covered by WBA Conclusions Lemke,

28 Aspects covered only by WBA Lemke,

29 Aspects covered only by WBA Aspects covered by both analyses Lemke,

30 Aspects covered only by WBA Aspects covered by both analyses Aspects only covered by WBA Lemke,

31 Contents Identifying those aspects covered by both analyses Aspects only covered by STAMP analysis Aspects only covered by WBA Conclusions Lemke,

32 Conclusions Aspects only covered by WBA Aspects covered by both analyses Aspects only covered by STAMP Lemke,

33 Conclusions Aspects only covered by WBA Aspects covered by both analyses Those aspects are part of a faulty control structure AND are causal factors for the accident: The inadequate control structure directly contributed to the accident. Aspects only covered by STAMP Lemke,

34 Conclusions Aspects These only aspects covered are by part WBAof faulty control structures but did not affect this particular accident. But an accident may rise out of Aspects covered by both analyses this faulty control structures under different circumstances. Aspects only covered by STAMP Lemke,

35 Conclusions Aspects only covered by WBA Those aspects are causal factors for the accident Aspects but mostly covered describe by both analyses processes / situations in compliance with rules and regulations or properties of the environment. They are not part of a faulty control structure. Aspects only covered by STAMP Lemke,

36 Conclusions Lemke,

37 Conclusions The most important aspects are found in both analyses Lemke,

38 Conclusions The most important aspects are found in both analyses Both methods reveal additional factors: Lemke,

39 Conclusions The most important aspects are found in both analyses Both methods reveal additional factors: Additional factors that form a kind of necessary environment of the accident are found in the WBA Lemke,

40 Conclusions The most important aspects are found in both analyses Both methods reveal additional factors: Additional factors that form a kind of necessary environment of the accident are found in the WBA Additional inadequate control structures that did not directly contribute to this particular accident are revealed in the STAMP analysis Lemke,

41 Conclusions The most important aspects are found in both analyses Both methods reveal additional factors: Additional factors that form a kind of necessary environment of the accident are found in the WBA Additional inadequate control structures that did not directly contribute to this particular accident are revealed in the STAMP analysis Only the combination of both methods leads to a comprehensive analysis! Lemke,

42 Remaining questions Lemke,

43 Remaining questions Are those conclusions true for any incident or are they Brühl-specific? Lemke,

44 Remaining questions Are those conclusions true for any incident or are they Brühl-specific? Would the result (of the comparison!) have been different if the analyses (STAMP and WBA) had been performed by different people ( Reproducibility )? Lemke,

45 Remaining questions Are those conclusions true for any incident or are they Brühl-specific? Would the result (of the comparison!) have been different if the analyses (STAMP and WBA) had been performed by different people ( Reproducibility )? Do we get a different result if we perform another analysis, e.g. with SOL? Lemke,

46 Remaining questions Are those conclusions true for any incident or are they Brühl-specific? Would the result (of the comparison!) have been different if the analyses (STAMP and WBA) had been performed by different people ( Reproducibility )? Do we get a different result if we perform another analysis, e.g. with SOL? Lemke,

47 The End Thank you for your attention! Lemke,