Integrating causal analysis based on system theory with network modelling to enhance accident analysis

Area of Science:

• Aviation Safety and Human Factors
• Systems Engineering and Risk Management
• Accident Investigation Methodologies

Background:

• Aviation ground handling operations are complex, involving numerous critical tasks.
• Accidents in ground handling, particularly involving Passenger Boarding Steps (PBS), pose significant safety risks.
• Existing accident analysis methods may not fully capture the systemic and interactive nature of these incidents.

Purpose of the Study:

• To integrate Causal Analysis based on System Theory (CAST) with network modelling for enhanced aviation accident analysis.
• To identify critical control actions and contributory factors in Passenger Boarding Steps (PBS)-related incidents.
• To improve the understanding of accident causation and inform risk management strategies in aviation ground handling.

Main Methods:

• Analysis of 117 Passenger Boarding Steps (PBS)-related incident reports using Causal Analysis based on System Theory (CAST).
• Integration of network modelling techniques with CAST to visualize causal pathways and interactions.
• Identification of critical control actions, loss types, and contributory factors.

Main Results:

• CAST analysis identified 74 flaws across 40 control actions, leading to four types of losses.
• Approaching, inspecting, adjusting, and repositioning PBS were identified as the most critical control actions.
• Key contributory factors included training, workload, situational awareness, organizational culture, procedures, and equipment maintenance.

Conclusions:

• Combining CAST with network modelling provides deeper insights into aviation accident causation by visualizing complex interactions.
• The integrated approach enhances the understanding of safety risks in aviation ground handling.
• This study supports evidence-based decision-making for aviation safety professionals and improves ground handling risk management.