The Alaska Airlines Flight 261 accident: A systemic analysis of functional resonance
2007 (English)In: International Symposium on Aviation Psychology ISAP,2007, Dayton, OH: Wright State University , 2007, 763- p.Conference paper (Refereed)
On January 31, 2000, Alaska Airlines flight 261, an MD-83, crashed into the Pacific Ocean; after airplane pitch
control was lost as a result of the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's acme
nut threads (NTSB, 2003). Accident investigation revealed a wide range of human, technical, and organizational
factors contributing to this tragic event, providing a case where popular linear models and methods have difficulty
addressing the full complexity of the processes leading up to the accident. This paper treats each of the steps of
analysis according to the Functional Resonance Accident Model (FRAM; Hollnagel, 2004), a systemic non-linear
modeling method, and discusses how functional resonance occurred through the variability in functions performed
by joint human, technical, and organizational systems. It thereby aims to facilitate a better understanding of how
functional variability in design, certification, limited and inadequate maintenance, negligent safety culture,
economic factors, and human performance together can resonate and contribute to accidents. In this way it aims to
contribute to accident prevention and the engineering of more resilient complex dynamic systems.
Place, publisher, year, edition, pages
Dayton, OH: Wright State University , 2007. 763- p.
IdentifiersURN: urn:nbn:se:liu:diva-39655Local ID: 50585OAI: oai:DiVA.org:liu-39655DiVA: diva2:260504