The emergence of a catastrophe: an analysis of the 2006 Brazil mid-air collision
We use a systemic framework to investigate the en route mid-air collision that occurred in the clear afternoon Amazon sky in which 154 people lost their lives to understand how and why this tragedy happened. In our research method we search for the mid-air collision antecedents traced through the concurrence of performances of the several actors (pilots and controllers) and their interaction with the contextual conditions of the several ATM subsystems. Data and evidences, antecedents and consequences from this mid-air collision come from a wide range of public available sources. These sources include official government documents, congressional hearings, including controllers, pilots, and air traffic management authorities testimonies, video tapes, audio tapes of many media centers, press releases, newspaper clippings, flight plans, regulations, maps, directives and so forth. Our findings emphasize that small and normal variations in the system behavior embedded in the equipment, people and organizational daily functioning jeopardize the active problem-solving behavior needed in an air traffic control management system, highlighting how the day-to-day functioning of the system can make monitoring and awareness difficult, and shape the cognitive strategies and decisions trade offs that operators have developed to deal with overall system behavior.
Paulo Victor Rodrigues de Carvalho Jose Orlando Gomes Mario Cesar Vidal
Nuclear Engineering Institute, National Nuclear Energy Commission, Rio de Janeiro, RJ, Brazil Post-G Post-Graduate Program in Informatics-NCE&IMC, Federal University of Rio de Janeiro, RJ, Brazil Luis Alberto Coimbra Research Institute, COPPE, Federal University of Rio de Janeiro, RJ, Brazil
国际会议
17th World Congress on Ergonomics(第十七届国际人类工效学大会)
北京
英文
1-10
2009-08-09（万方平台首次上网日期，不代表论文的发表时间）