A Systems Modeling Approach for Risk Management of Command File Errors

Abstract

The main cause of commanding errors is often (but not always) due to procedures. Either lack of maturity in the processes, incompleteness of requirements or lack of compliance to these procedures. Other causes of commanding errors include lack of understanding of system states, inadequate communication, and making hasty changes in standard procedures in response to an unexpected event. In general, it's important to look at the big picture prior to making corrective actions. In the case of errors traced back to procedures, considering the reliability of the process as a metric during its' design may help to reduce risk. This metric is obtained by using data from Nuclear Industry regarding human reliability. A structured method for the collection of anomaly data will help the operator think systematically about the anomaly and facilitate risk management. Formal models can be used for risk based design and risk management. A generic set of models can be customized for a broad range of missions.