An Event of German Chapter of System Safety Society
12-13 February 2004
Center of Interdiciplinary Research (ZiF), University of Bielefeld
Thursday 12.02.2004: Root-Causal Analysis |
|
1000-1015 | Welcoming Comments (Ladkin) |
1015-1115 | Peter Ladkin, Jörn Stuphorn (RVS, Uni Bielefeld): Analysis of a Friendly Fire Accident with WBA |
1115-1200 | Babette Fahlbruch (TU Berlin): Analysis of the Brühl Rail Accident with SOL-VE |
1200-1330 | Lunch (ZiF Restaurant) |
1330-1415 | Jens Braband, Ernesto de Stefano, Sonja-Lara Kurz (Siemens TS): Comparison of Event-Based Root Cause Analysis Models |
1415-1500 | Timm Grams (FH Fulda): The Three Dimensions of Risk |
1500-1530 | Coffee Break (ZiF Restaurant) |
1530-1600 | Oliver Lemke (IfEV, TU Braunschweig), Bernd Sieker (RVS, Uni Bielefeld): Causal ML and its ciedit-Tools |
1615-1800 | Discussion: RCA Technique Comparison Criteria Revisited |
2000 - late | Dinner at Wernings Weinstube |
Friday 13.02.2004: Risk Analysis |
|
0900-0945 | Jens Braband (Siemens TS): A Remedy for a Serious Flaw in the Risk Priority Number Concept |
0945-1030 | Michael Miller (FH Gelsenkirchen): Probabilistic Risk Analysis and the Concept of Bayesian Networks |
1030-1100 | Coffee Break (ZiF Restaurant) |
1100-1145 | Claire Blackett (UC Dublin): Analysis of the Royal Majesty Grounding Using SOL |
1145-1230 | Roman Slovak (IVA, TU Braunschweig): Risk Analysis with the PROFUND Modelling Approach |
1230-1400 | Lunch (ZiF, as yesterday) |
1400-1430 | Christina Junge (FH Gelsenkirchen): Analyse der Midair-Collision bei Überlingen (WBA) |
1430-1600 | Discussion: Visualisation |
1600 | End of Workshop |
Scott Snook analysed the 1994 shootdown by USAF F-15 aircraft over Northern
Iraq of two US Army UH-60 helicopters ferrying leaders of Operation Provide
Comfort between meetings with local residents. He provided a cursory "causal
analysis" based on the Counterfactual Test, then considered in detail
the social and psychological determinants of the individual factors (the
F-15s' misidentification of the helicopters), the group factors (the failure
to intervene of the "supervisory" AWACS command aircraft), the
organisational factors (that the helos were not integrated into the Operation
Provide Comfort flight planning), and formulated an additional theory that
he felt to be useful. In previous work, we have identified and corrected
significant mistakes in Snook's causal reasoning, and will present that
again in the first talk. Then we shall show how the WBA approach represents
straightforwardly the social and psychological factors posited by Snook,
and allows some consistency and coherence checks previously unavailable
to social theorists constructing social explanations of complex events.
Slides (PDF) | Hand
Out (PDF) | Paper (PDF)
No Abstract available
Three widely used event-based root cause analysis methods (SOL, ECF and
MES) are applied to the Warngau railway accident and the Herold of Free
Enterprise ferry acccident. The strengths and weaknesses of the methods
are compared and discussed. Recommendations and directions are given
for further research, in particular for a hybrid approach based on
event-based techniques and WBA or STAMP.
Slides (PDF)
The talk presents an analysis of the grounding accident to the cruise
ship Royal Majesty, using the method Safety through Organisational
Learning (SOL). The analysis is based on the U.S. National
Transportation Safety Board report MAR-97-01, and may be compared with
the Why-Because Analysis of the same accident presented at the Second
Bieleschweig Workhop.
Slides (PDF)
CausalML is a XML-based file format for storing causal relationship data. Causal relationships are one of the results of a Why-Because-Analysis and are usually displayed as a Why-Because-Graph. CausalML provides a standarised platform-independent way to store causal relationship data. One may also say that CausalML is a data exchange format for Why-Because-Graphs (WB-Graphs). It allows handling of the following information entities:
The developments of the theory an application areas for Bayesian
probabilistic nets or Bayesian belief networks has been and is still
evolving rapidly. It is at present possible to utilise the technique
for almost any aspect of probabilistic modelling and decision making,
ranging from inference problems, model building and data mining over to
pre-posterior decision analysis. In the following some of the most
basic aspects of Bayesian probabilistic networks will be presented. The
presentation is far from complete and should be seen as a very first
instruction to the application of Bayesian nets for Risk Analysis.
Slides (PDF)
The talk is on my 2002/4 R&D activities aiming at a broader understanding
of the concept of risk. Starting point is the proposition ?Risk has three
dimensions?: technics, man and society. The notion of risk can only be understood
through an interdisciplinary approach. At a colloquium held in Fulda, experts
in engineering (Adolf Birkhofer, Munich) , psychology (Ortwin Renn, Stuttgart)
and sociology (Klaus Japp, Bielefeld) discussed the various aspects of risk.
The proceedings and some further material can be found on the page http://www.fh-fulda.de/fb/et/Brett2002/Kolloquium.htm.
As a resume I published the essay "Risk-optimization versus risk-limitation"Analysis
of an old and ongoing policy dispute? (Automatisierungstechnische Praxis
atp (2003 ) 8, 50-57). (All publications are in German.)
Slides (PDF)
Today one deficit of CENELEC-standards for Railway applications (EN 50
126, EN 50 128, EN 50 129) is that while providing comprehensive guidance
regarding the achievement of particular safety targets (Safety Integrity
Levels - SIL), they do not precisely define the method and rules for deriving
SIL's for system elements from system safety targets or tolerable operational
risk.
The process for definition of safety targets for all components of the
train control system is firstly based on the risk evaluation resulting
from its operational behaviour and secondly on the system design
analysis carried out under consideration of a concrete technical system
solution. A risk analysis assumes a functional specification which must
result from the well defined control task of the system in the railway
traffic process.
Application of universal railway operation control systems designed in
order to fulfil the highest safety requirements is related with high
cost of investment, operation and maintenance. The new operation risk
based safety definition of the standard EN 50126 theoretically allows
deriving the safety targets of the system according to the expected
traffic densities. It is the question of a sensitivity analysis to
quantify the relation between several stochastic processes.
The talk presents a formal approach to the integrated safety system
design named PROFUND (Process Function Dependability Modeling) using
Petri Nets taking an example of a level crossing. Using the method
based on a stochastic analysis of Extended and Deterministic Stochastic
Petri Nets the quantitative value of operational risk can be evaluated
and compared with the given risk acceptance criterion. It will be
shown, how a Petri net model can be used for the sensitivity analysis
with the aim to find the traffic parameters of the controlled
operational process and system functions with the highest risk
relevance. An approach for integration of human behaviour in the risk
analysis will be presented. Finally the potential of the use of formal
description of stochastic Petri nets by the design and analysis of
railway operation control systems will be given.
Ziel des Vortrags ist es, die Zusammenhänge, die zum Eintreten der
Midair-Collision bei Überlingen geführt haben, darzustellen. Es
werden die Grundursachen herausgearbeitet, die sich aufgrund der WB-Analyse
für den Unfall ergeben haben. Darüber hinaus erfolgt ein kurzer
Ausblick auf bereits realisierte bzw. noch zu realisierende Gegenmaßnahmen
zur Vermeidung eines ähnlichen Unfalls in der Zukunft.
Slides (PDF) | WBGraph
(Visio) | Diplomarbeit at FH Gelsenkirchen
(PDF)
Participants who attend Third Bieleschweig Workshop were (arranged alphabeticaly) :
No | Name of Participant | Institution | |
1 | Andre Döring | Uni Bielefeld RVS | andre_at_rvs_dot_uni-bielefeld_dot_de |
2 | Avinanta Tarigan | Uni Bielefeld RVS | avinanta_at_rvs_dot_uni-bielefeld_dot_de |
3 | Babette Fahlbruch | TU Berlin | bfahlbr_at_gp_dot_tu-berlin_dot_de |
4 | Bernd Sieker | Uni Bielefeld RVS | bsieker_at_freenet_dot_de |
5 | Bernhard Wilpert | TU Berlin | Bernhard_dot_Wilpert_at_tu-berlin_dot_de |
6 | Christina Junge | FH Gelsenkirchen | christina_dot_junge_at_web_dot_de |
7 | Claire Blackett | University College Dublin | claire_dot_blackett_at_ucd_dot_ie |
8 | Dieter Meisner | DB AG | Dieter_dot_Meisner_at_bahn_dot_de |
9 | Enrico Anders | TU Dresden | enrico_dot_anders_at_mailbox_dot_tu-dresden_dot_de |
10 | Ernesto de Stefano | Siemens TS | ernesto_dot_destefano_at_siemens_dot_com |
11 | Gunnar Bosse | TU Braunschweig IfEV | g_dot_bosse_at_tu-bs_dot_de |
12 | I Made Wiryana | Uni Bielefeld RVS | mwiryana_at_rvs_dot_uni-bielefeld_dot_de |
13 | Jan Hennig | Uni Bielefeld RVS | jhennig_at_rvs_dot_uni-bielefeld_dot_de |
14 | Jan Sanders | Uni Bielefeld RVS | jsanders_at_TechFak_dot_uni-bielefeld_dot_de |
15 | Jan-Tecker Gayen | TU Braunschweig IfEV | j_dot_gayen_at_tu-bs_dot_de |
16 | Jens Braband | Siemens TS | jens_dot_braband_at_siemens_dot_com |
17 | Jörg May | TU Braunschweig IVA | may_at_iva_dot_ing_dot_tu-bs_dot_de |
18 | Jörn Drewes | TU Braunschweig IVA | drewes_at_iva_dot_ing_dot_tu-bs_dot_de |
19 | Jörn Stuphorn | Uni Bielefeld RVS | joern_at_stuphorn_dot_de |
20 | Marc Fezer | FH Gelsenkirchen | marc_dot_fezer_at_gmx_dot_de |
21 | Michael Miller | FH Gelsenkirchen | michael_dot_miller_at_fh-gelsenkirchen_dot_de |
22 | Oliver Lemke | TU Braunschweig IfEV | o_dot_lemke_at_tu-bs_dot_de |
23 | Peter Ladkin | Uni Bielefeld RVS | ladkin_at_rvs_dot_uni-bielefeld_dot_de |
24 | Robert Lehmann | DE.Consult | Robert_dot_Lehmann_at_de-consult_dot_de |
25 | Roman Slovak | TU Braunschweig IVA | r_dot_slovak_at_tu-bs_dot_de |
26 | Sonja-Lara Kurz | Siemens TS | Sonja-Lara_dot_Kurz_at_bwg1_dot_siemens_dot_de |
27 | Stefanie Schwartz | DLR | Stefanie_dot_Schwartz_at_dlr_dot_de |
28 | Timm Grams | FH Fulda | Timm_dot_Grams_at_et_dot_fh-fulda_dot_de |
29 | Ulrich Maschek | TU Dresden | u_dot_maschek_at_mailbox_dot_tu-dresden_dot_de |
Photos from Third Bieleschweig Workshop can be found in RVS Photo Album