Using STAMP to Train Control System

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1 Extending the Human-controller methodology in Railway System Accident Analysis based on STAMP achenling Li,Ph.D. candidate a Tao Tang, Prof. a Ru Niu, Dr. bmaria Mikela Chatzimichailidou, Dr. c Patrick Waterson, Dr. a b c State Key Laboratory of Rail Traffic Control and Safety, Beijing Jiaotong University LRF Transport Risk Management Centre, Imperial College London Human Factors and Complex Systems Group, Loughborough University

2 Outline Background and Motivation Accident investigation and analysis Human factor analysis based on STAMP Some ideas in using STAMP analysis on human factors Extension: human controller state Human controller model s elements Analysis procedure: the Analysis Matrix for Human Error (AMHE) Case study :7.23 Yongwen railway accident The accident: human factors Analysis and results Conclusion

Background and Motivation Railway system The

circumstance of the railway system, especially

socio-technical system (Wilson et al., 2007).

Permitted speed Infrastructure Train S S S AT S S

3 Background and Motivation Railway system The complex control system and serious operation circumstance of the railway system, especially high-speed railway, make it become a typical socio-technical system (Wilson et al., 2007). Train Control V 80km/h Real speed Line limit speed Permitted speed Infrastructure Train S S S AT S S AT S VCC RCC S S Safety braking distance Railway System is complex socio-technical S

2009; Reinach, Viale, 2006). Railway signaling and interlocking (Anders, 2009) Apr. 2008.

4 Background and Motivation Accident investigation and analysis Train accidents involving collisions, derailments and fires related to human factors make up a significant proportion of all train accidents (MLTM, 2009; Reinach, Viale, 2006). Railway signaling and interlocking (Anders, 2009) Apr China JiaoJi Railway Accident.. 72 people dead, 416 injured. Human error Jul China YongWen Railway Accident. 40 people dead, 200 injured.

5 Background and Motivation Accident investigation and analysis Accident causation model STAMP Human error: system symptom Mental model (Leveson, 2012)

6 Background and Motivation Human controller model in STAMP Mental model and work process (Thornberry, 2014).) (Leveson, 2012) (France, 2017))

7 Background and Motivation Human controller model in STAMP Human controller state? (France, 2017))

8 Background and Motivation Human controller model in STAMP (Thornberry, 2014).)

9 Background and Motivation Human controller status influence? Information processing: four steps Human controller state is a essential part of human controller model

10 Background and Motivation Human controller status influence? Information processing: four steps

11 Background and Motivation Human controller status influence? Fatigue is the largest identifiable and preventable cause of accident in transport operations (Akerstedt, 2000), and now is still a fatal factors contributed to Chinese railway accidents (Taso et al., 2017). The human cognitive experiments should that the perception of mental fatigue impacted individual s persistence, attention and elabortative thought (Carkson et al., 2016).

12 Background and Motivation Human controller status influence?

13 Outline Background and Motivation Accident investigation and analysis Human factor analysis based on STAMP Some ideas in using STAMP analysis on human factors Extension: human controller state Human controller model s elements Analysis procedure: the Analysis Matrix for Human Error (AMHE) Case study :7.23 Yongwen railway accident The accident: human factors Analysis and results Conclusion

14 Extension about human controller model Human controller model Mental Model of the Human State:(What does the operator perceive about his/her own state?) Physical state Mental stae Physical/mental limitations The attitude about safety Control Actions Human Controller Control Action Selection (S) Mental Models Process State (PS) Process Behavior (PB) Environment (E) Mental Model Updates (U) Sensory Feedback & Input Human State (HS)

15 Update Recognition 轨道交通控制与安全 Extension about human controller model Analysis procedure: the procedure 3.Information detection and interpretation 2.Condition recognition 1.Decision Control Actions System operation condition and goal Decision makeing 1 2 Mental Models Process State (PS) Process Behavior (PB) Environment (E) Human State (HS) 3 Detection and Interpretation Sensory Feedback & Input

16 Update Recognition 轨道交通控制与安全 Analysis procedure: the procedure Last step factor(s) (LF) Human own character(s) (HC) Factors from other parts in the system (OF) UC A Control Actions LF 1 System operation condition and goal Decision makeing 1 2 Mental Models Process State (PS) Process Behavior OM (PB) Environment (E) Human State (HS) HC LF 2 3 Detection and Interpretation Sensory Feedback & Input

17 Analysis procedure: the Analysis Matrix for Human Error (AMHE) Last step factor(s) (LF) Human own character(s) (HC) Factors from other parts in the system (OF)

18 Extension about human controller model Analysis procedure: the content of each item

19 Extension about human controller model Analysis procedure: the content of each item Identify system(s) and system hazard(s) Document the system safety control structure Identify human errors Analysis individual human errors For organisational and regulation level analysis Recommendations (in human error level)

20 Outline Background and Motivation Accident investigation and analysis Human factor analysis based on STAMP Some ideas in using STAMP analysis on human factors Extension: human controller state Human controller model s elements Analysis procedure: the Analysis Matrix for Human Error (AMHE) Case study :7.23 Yongwen railway accident The accident: human factors Analysis and results Conclusion

21 7.23 Yongwen railway accident On the 23 July 2011 at 20:30:05 Two EMU train in same direction collided together Cause 40 deaths, 172 injuries, interruption of traffic for 32 hours and 35 minutes

7.23 Yongwen railway accident System Development System Operation Ministry of Railway Ministry of Railway Directives Progress Reports Accidents Directives Performance Reports Accidents MOR Science &

22 7.23 Yongwen railway accident System Development System Operation Ministry of Railway Ministry of Railway Directives Progress Reports Accidents Directives Performance Reports Accidents MOR Science & Technology Department MOR Transport Bureau MOR Foundation Department Requirements (including CTCS,CTCS-2 Specs) & Standard TCC Requirements CRSC Mangement Progress Reports Accidents Progress Reports Operation Assumption Operation Procedure MOR Transport Bureau Operation Regulation Shanghai Railway Bureau Mangement Operation Regulation Performance Reports Accidents Status Report Performance Reports Accidents TCC Project Management and Dev. Process(CRSCD) Project Management The Operation Process CTC Dispatching Center Maint.Req Requirements & Specs & Standards Progress Reports Design and Development Test Requirements Test Reports Performance Reports Accidents Station Operator Train Operator Verification and Validation The Physical Process:CTCS-2 System Product Quality Stds Quality Reports Manufacture SRSS Management Problem Reports Maintenance procedure Problem Status Maintenance Specifications Reports Maunfacturing Missing controls,feedbacks

23 Track train status Inform emergency Inform station status Inform emergency Report train status Report train status 轨道交通控制与安全 7.23 Yongwen railway accident Dispatcher Station operator D3115 Train driver D301 Train driver Maintenance worker Identify human errors(uca) Accelerate Decelerate Driver Input data Select mode Require station status Switch command Dispatcher Station operator Switch MA Monitor system operation Interlocking route command Switch status Report CI Train status Alarm for overspeed Station monitor MA Display Status information CI status Status Track circuit in station Operation plan TSR Operation osrder CTC centre CTC station exetention Block section information Route information Track circuit information Onboard system Maintenance command Operation status TSR status Track occupation status Station status Track circuit code TSR Track occupation information Track circuit in interval Report Maintenance command TSR TSR information TSR status Track occupation information TCC LEU TSR Active balise Report TSR status Positive balis Line data Maintenance worker Display Signaling monitoring Signal command Monitoring information Signal machine in station Signal machine status Display Train status Accelerate Decelerate Train Train status Communication between human operators Communication between technical equipment Human operators Technical equipment

24 7.23 Yongwen railway accident

25 7.23 Yongwen railway accident Dispatcher: A1:Dispatcher did not check and confirm the track condition in time

26 Outline Background and Motivation Accident investigation and analysis Human factor analysis based on STAMP Some ideas in using STAMP analysis on human factors Extension: human controller state Human controller model s elements Analysis procedure: the Analysis Matrix for Human Error (AMHE) Case study :7.23 Yongwen railway accident The accident: human factors Analysis and results Conclusion

27 Conclusion(1) Find out the causal factors contributing the unsafe control actions of human operators.

28 Conclusion(2) More clearly about analysis process Easy to track back to organistional and higher levels

29 Reference(1) Wilson, J.R., Farrington-Darby, T., Cox, G., Bye, R., Hockey, G.R. (2007). The railway as a socio-technical system: human factors at the heart of successful rail engineering. Proceedings of the Institution of Mechanical Engineers, Part F: Journal of Rail and Rapid Transit, 221(1), Reinach S, Viale A. (2006). Application of a human error framework to conduct train accident/incident investigations. Accid Anal Prev, 38, Zhan, Qingjian., Zheng, Wei., Zhao, Bobo. (2017). A hybrid human and organizational analysis method for railway accidents based on HFACS-Railway Accidents (HFACS-RAs). Safety Science, 91, Clarkson, J.J., Otto, A.S., Hassey, R., Hirt, E.R. (2016). Perceived Mental Fatigue and Self-Control. In book: Hirt, E., Clarkson, J.J., Jia, L. (Eds). Self-Regulation and Ego Control. Academic Press, Shappell, S.A., Wiegmann, D.A. (2000). The human factors analysis and classification system HFACS. Federal Aviation Administration Technical Report No. DOT/FAA/AM-00/7. National Technical Information Service, N Springfield. Thomas, J., France, M., Green, C.A., Vernacchia, M.A., Sundaram, P., D Ambrosio, J. (2016). Engineering for humans:stpa Analysis of an Automated Parking System. The 5 th MIT STAMP/STPA Workshop, MIT, March 21 th -24 th, 2017.Available at: (Last accessed August 24 th, 2017)

30 Reference(2) Thornberry, C. (2014). Extending the human controller methodology in Systems-Theoretic Process Analysis (STPA). Master thesis, Massachusetts Institute of Technology. Tsao, L., Chang, J., Ma, L. (2017). Fatigue of Chinese railway employee and its influential factors: Structural equation modelling. Applied Ergonomics, 62,

31 Q&A Thank you! Chenling Li State Key Laboratory of Rail Traffic Control and Safety Beijing Jiaotong University, Beijing, China

32 Affix(Result-part1)

33 Affix(Result-part2)

34 Affix(Result-part3)

35 Affix(Result-part4)

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m 3 m m 84 m m m m m m m 2011 8 8 155 JOURNAL OF RAILWAY ENGINEERING SOCIETY Aug 2011 NO. 8 Ser. 155 1006-2106 2011 08-0096 - 06 430063 1 2 3 U231 +. 4 A Design of Underground Space of Furong Square Station of Urban Rail Transit