Confronting Functional Complexity Failures: The Case of a Runway Excursion in Munich

Complex systems often produce unanticipated emergent behavior as a result of the interactions between behaviorally complex sub-systems or agents. The sub-systems may be human or artificial. They may be co-located or geographically distributed and operate autonomously. Although the individual sub-systems may be tested and certified for high levels of reliability (e.g. 10-7), interactions between the sub-systems may occur so that emergent behaviors allow the system to migrate into an unsafe operating region. This may occur even when all of the sub-systems are behaving nominally and no equipment has failed. This phenomenon is called a “functional complexity failure.” In this paper, we present an analysis of a functional complexity failure that resulted in a runway excursion and discuss the options for detecting and mitigating the conditions for these “normal accidents” before the accident occurs.

• Record URL:
  • https://doi.org/10.1177/1071181319631486
• Availability:
  • Find a library where document is available. Order URL: http://worldcat.org/issn/21695067
• Supplemental Notes:
  • © 2019 by Human Factors and Ergonomics Society.
• Authors:
  • Mauro, Robert
  • Sherry, Lance
• Publication Date: 2019-11

Language

• English

Media Info

• Media Type: Web
• Features: References;
• Pagination: pp 116-120
• Serial:
  • Proceedings of the Human Factors and Ergonomics Society Annual Meeting
  • Volume: 63
  • Issue Number: 1
  • Publisher: Sage Publications, Incorporated
  • ISSN: 2169-5067
  • EISSN: 1071-1813
  • Serial URL: http://journals.sagepub.com/home/pro

Subject/Index Terms

• TRT Terms: Air transportation crashes; Airport runways; Case studies; Complex systems; Human factors
• Geographic Terms: Munich (Germany)
• Subject Areas: Aviation; Safety and Human Factors;

Filing Info

• Accession Number: 01760705
• Record Type: Publication
• Files: TRIS
• Created Date: Dec 21 2020 10:05AM