fram analysis - kegworth

FRAM ANALYSIS OF THE KEGWORTH AIR DISASTERROSS APTED

FRAM ANALYSIS0. Define the purpose of modeling and describe the situation being analyzed. An event that has occurred (incident/accident) or a possible future scenario (risk).

1. Identify the essential functions in the event ('foreground' functions when things go right); characterize each by six basic aspects.

2. Characterize the actual / potential variability of 'foreground' functions and 'background' functions (context). Consider both normal and worst case variability.

3. Define functional resonance based on potential / actual dependencies (couplings) among functions.

4. Propose ways to monitor and dampen performance variability(indicators, barriers, design / modification, etc.)

Non-normal event(Engine Failure)

Non-normal procedures

Air conditioning smoke

High engine vibrations

Engine shutdown checklist

High engine vibrations procedures

Air conditioning smoke procedures

Engine shutdown

Divert to nearest airport

Landing procedure

Landing

Review any engine shutdown decisions

T

O

C

RP

I

Non-normal event

(Engine Failure)

T

O

C

RP

I Non-normal procedures

T

O

C

RP

I

Air conditioning

smoke

T

O

C

RP

IHigh engine vibrations

T

O

C

RP

I

Air conditioning

smoke procedures

T

O

C

RP

IEngine

shutdown T

O

C

RP

I


T

O

C

RP

I


T

O

C

RP

ILanding

procedureT

O

C

RP

I Landing

T

O

C

RP

I High engine

vibrations procedures

T

O

C

RP

I

Review any engine

shutdown decisions

CHARACTERISTICS OF FUNCTION I

T

O

C

RP

INon-normal

event(Engine Failure)

ControlNon-normal procedures ,Commander and first officers’Actions.

OutputInput to:Non-normal procedures

Resource Functioning system(engine system)

PreconditionSystem fault

Input

TimeTime in which the system

is operational

CHARACTERISTICS OF FUNCTION II

T

O

C

RP


ControlCommander and first officer

OutputInput to:Air conditioning smoke

High engine vibrationsReview any engine shutdown-

decisions

Resource Commanders and first officers’ attention and time.

Precondition

InputNon-normal event

TimePriority while non- normal

event is active.

CHARACTERISTICS OF FUNCTION III

T

O

C

RP

IAir conditioning

smoke

ControlNon-normal procedures ,Commander and first officers’Actions.

OutputInput to:Air conditioning smoke procedures

Resource Functioning system(Air conditioning)Failing system(engine)


InputNon-normal procedures


is operational

CHARACTERISTICS OF FUNCTION IV

T

O

C

RP

IAir conditioning

smoke procedures

ControlCommander and first officerNon-normal procedures

OutputInput to:

Engine shutdownDivert to nearest airport


PreconditionAny procedure that have a

higher priority level must be taken care of.

InputAir conditioning

smoke

TimeMust be completed

before crew are adversely affected.

CHARACTERISTICS OF FUNCTION V

T

O

C

RP

I Engine shutdown

ControlCommander and first officerEngine shutdown checklistBoeing 737 operationsManual.

OutputInput to:Engine shutdown checklist

Resource Commanders and first officers’ attention and time.An engine

PreconditionAppropriate engine

non-normal procedures completed


smoke procedures


immediately if emergency. (engine fire).

CHARACTERISTICS OF FUNCTION VI

T

O

C

RP

IEngine shutdown

checklist

ControlCommander and first officerBoeing 737 operationsManual.

Output


PreconditionAppropriate engine

non-normal procedures completed

InputEngine shutdown

TimeTime must be taken to

evaluate every stage of checklist

CHARACTERISTICS OF FUNCTION VII

T

O

C

RP

I Divert to nearest airport

ControlNon-normal procedures ,Commander and first officers’Actions. Boeing 737 operationsManual.

OutputInput to:Landing procedure

Resource Commanders and first officers’ attention and time, cabin crews attention, air traffic control and ground crew manpower

PreconditionAir traffic control clearance


smoke procedures

TimeMust divert immediately,

top priority.

CHARACTERISTICS OF FUNCTION VIII

T

O

C

RP

ILanding

procedure

ControlAir traffic control,Commander and first officers’Actions. Boeing 737 operationsManual.

OutputInput to:Landing

Resource Commanders and first officers’ attention and time.Flight crew time and attention.Air traffic control coordination

Precondition

InputLanding

TimeMust be complete at top

priority if in emergency situation

CHARACTERISTICS OF FUNCTION IX

T

O

C

RP

ILanding

ControlAir traffic control,Commander and first officers’Actions.

Output

Resource Commanders and first officers’ attention and time, cabin crews attention, air traffic control and ground crew manpower

InputLanding procedure

TimeMust be in time allocated by air traffic control, must

not conflict with other tasks.

CHARACTERISTICS OF FUNCTION X

T

O

C

RP


Control,Commander and first officers’Actions.

OutputInput to:High engine vibrationsprocedures

Resource Failing system(engine)


InputNon-normal procedures


is operational.

CHARACTERISTICS OF FUNCTION XI

T

O

C

RP


procedures

Control,Commander and first officers,Non-normal procedures,Boeing 737 operationsManual.

Output

Resource Commanders and first officers’ attention and time.Engine thrust(will decrease)

PreconditionAny procedure that have a

higher priority level must be taken care of

InputHigh engine

vibrations


before crew or craft are adversely affected.

CHARACTERISTICS OF FUNCTION XII

T

O

C

RP

I Review any

engine shutdown decisions

Control,Commander,Non-normal procedures,

Output

Resource Commanders’ attention and time.

PreconditionA procedure that requires

an engine shutdown

Input Non-normal procedures

TimeMust be completed after

every procedure that requires engine

shutdown, must not conflict with other tasks.

.

T

O

C

RP

I

Non-normal event

(Engine Failure)

T

O

C

RP


T

O

C

RP

I

Air conditioning

smoke

T

O

C

RP


T

O

C

RP

I

Air conditioning

smoke procedures

T

O

C

RP

IEngine

shutdown

T

O

C

RP

I


T

O

C

RP

I


T

O

C

RP

ILanding

procedure T

O

C

RP

I Landing

T

O

C

RP

I High engine

vibrations procedures

T

O

C

RP

I

Review any engine

shutdown decisions

Left engine malfunctioned

Engine vibration producers were not

carried out

Pilots experienced symptoms of engine

failure

Pilots experienced symptoms of engine

failure

High cabin workload

Shut down of right engine was not

reviewed

Pilots did not know of newly introduced engine vibration

procedure

Engine vibration producers were not

carried out

Pilots were required to

land a review engine

shutdown decisions

Flight crews attention focused on diverting to

nearest airport

Flight crews chose to deal with smoke

Determined that right engine was cause

symptoms stopped

symptoms stopped

fram analysis - kegworth

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