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首页> 外文会议>Human Factors and Ergonomics Society;Human Factors and Ergonomics Society annual meeting >Surprise, Attraction, and Propagation: An Aircraft is No Place for a Catastrophe
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Surprise, Attraction, and Propagation: An Aircraft is No Place for a Catastrophe

机译：惊喜，吸引力和传播：飞机无处可逃

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The management of off-normal operational events, such as an aircraft in-flight loss of control, present a formidable challenge to the stakeholders ofcommercial aviation. This paper posits that present solutions to off-normal events are grounded in linear models of accident causation that are insufficientin today’s complex socio-technical domain—where change propagates through systems to produce instability and system state shifts. Theseprior methods of system safety are predominately predicated upon the notion that system failure can be mitigated to acceptable levels of risk by usingdefenses, constraints, and controls in design and practice; such perspectives also influence post-accident investigation and remediation. This paperprovides a new theory of aircraft accident causation, Catastrophic Information Entropy Theory (CIET), which offers that an increase in informationentropy during an off-normal event, produces emergent changes in system state that prevent a return to normal flight. Therefore, in the face of runtimeaccident factor propagation, surprise, and attractors, the management of off-normal events, utilizing rigid feed forward procedures may makerecovery inaccessible. CIET suggest that existing safety strategies need to be expanded to include the recognition of the time-critical role of the pilot,who must attempt to understand and control a complex system which is behaving in a novel and emergent way. CIET offers a theoretical perspectivefrom which aviation stakeholders can design tools for actionable solutions for pilots during real time emergent events and tools for post-event analyticapproaches.
机译：非正常运行事件的管理，例如飞机飞行中的失控，给航空器的利益相关者提出了严峻的挑战 商业航空。本文假设，针对异常事件的解决方案基于不充分的事故因果线性模型 在当今复杂的社会技术领域中，变化在系统中传播，从而产生不稳定和系统状态变化。这些 以前的系统安全方法主要是基于这样的观念，即通过使用以下方法可以将系统故障降低到可接受的风险水平 设计和实践中的防御，约束和控制;这些观点也会影响事故后的调查和补救。这篇报告 提供了一种新的飞机事故原因理论，灾难性信息熵理论（CIET），该理论提供了更多的信息 非正常事件期间的熵会在系统状态中产生紧急变化，从而阻止返回正常飞行。因此，面对运行时 意外因素的传播，突击和吸引子，异常事件的管理，利用严格的前馈程序可能使 恢复无法访问。 CIET建议，需要扩展现有的安全策略，以包括对飞行员至关重要的任务的认可， 必须尝试理解和控制以新颖新颖的方式运行的复杂系统。 CIET提供了理论视角 航空利益相关者可以从中为实时紧急事件期间的飞行员设计可行的解决方案工具，以及事后分析工具 方法。

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