在JAL516与JA722A碰撞中，SHEL元素之间的相互作用不足-安全管理中缺乏safety - ii方法。

IF 2.4 3区工程技术 Q3 ENGINEERING, INDUSTRIAL

Ergonomics Pub Date : 2025-08-14 DOI:10.1080/00140139.2025.2546521

Atsuo Murata, Konrad Szocik, Waldemar Karwowski

{"title":"在JAL516与JA722A碰撞中，SHEL元素之间的相互作用不足-安全管理中缺乏safety - ii方法。","authors":"Atsuo Murata, Konrad Szocik, Waldemar Karwowski","doi":"10.1080/00140139.2025.2546521","DOIUrl":null,"url":null,"abstract":"Based on the identified facts, inferences, and doubts about the collision between JAL516 and JA722A on January 2, 2024, this study attempted to explore why the miscommunication between air traffic control (ATC) and JA722A was not compensated by other actors (ATC and JAL516) from the perspective of the inadequacy of interactions between related actors (JA722A, JAL516, and ATC) and each element (Software, Hardware, Environment, and Liveware) of the SHEL model. We also demonstrated that safety management at Haneda Airport was apparently lacking in Safety-II and pre-mortem approaches. Based on such an approach to the interaction analysis of the collision, the progress report of the Japan Transport Safety Board, and the interim report of the CPAC (Committee for Proposing Accident Countermeasures), we discuss why the collision occurred (why the misunderstanding of JA722A was not corrected by ATC and JAL516) and how similar collisions should be avoided during landing and takeoff.","PeriodicalId":50503,"journal":{"name":"Ergonomics","volume":" ","pages":"1-14"},"PeriodicalIF":2.4000,"publicationDate":"2025-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Inadequate interactions between elements of SHEL in JAL516 collision with JA722A - lack of Safety-II approach in safety management.\",\"authors\":\"Atsuo Murata, Konrad Szocik, Waldemar Karwowski\",\"doi\":\"10.1080/00140139.2025.2546521\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"Based on the identified facts, inferences, and doubts about the collision between JAL516 and JA722A on January 2, 2024, this study attempted to explore why the miscommunication between air traffic control (ATC) and JA722A was not compensated by other actors (ATC and JAL516) from the perspective of the inadequacy of interactions between related actors (JA722A, JAL516, and ATC) and each element (Software, Hardware, Environment, and Liveware) of the SHEL model. We also demonstrated that safety management at Haneda Airport was apparently lacking in Safety-II and pre-mortem approaches. Based on such an approach to the interaction analysis of the collision, the progress report of the Japan Transport Safety Board, and the interim report of the CPAC (Committee for Proposing Accident Countermeasures), we discuss why the collision occurred (why the misunderstanding of JA722A was not corrected by ATC and JAL516) and how similar collisions should be avoided during landing and takeoff.\",\"PeriodicalId\":50503,\"journal\":{\"name\":\"Ergonomics\",\"volume\":\" \",\"pages\":\"1-14\"},\"PeriodicalIF\":2.4000,\"publicationDate\":\"2025-08-14\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Ergonomics\",\"FirstCategoryId\":\"5\",\"ListUrlMain\":\"https://doi.org/10.1080/00140139.2025.2546521\",\"RegionNum\":3,\"RegionCategory\":\"工程技术\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q3\",\"JCRName\":\"ENGINEERING, INDUSTRIAL\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Ergonomics","FirstCategoryId":"5","ListUrlMain":"https://doi.org/10.1080/00140139.2025.2546521","RegionNum":3,"RegionCategory":"工程技术","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"ENGINEERING, INDUSTRIAL","Score":null,"Total":0}

引用次数: 0

摘要

基于对2024年1月2日JAL516与JA722A碰撞事件的识别事实、推断和质疑，本研究试图从相关参与者（JA722A、JAL516和ATC）与SHEL模型中每个元素（软件、硬件、环境和Liveware）之间的交互不足的角度，探讨为什么空中交通管制（ATC）与JA722A之间的错误沟通没有得到其他参与者（ATC和JAL516）的补偿。我们还证明了羽田机场的安全管理显然缺乏安全ii和事前分析方法。基于这种碰撞的相互作用分析方法，结合日本交通安全委员会的进展报告和CPAC（事故对策建议委员会）的中期报告，我们讨论了碰撞发生的原因（为什么ATC和JAL516没有纠正对JA722A的误解）以及在着陆和起飞过程中应该如何避免类似的碰撞。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

查看原文本刊更多论文

Inadequate interactions between elements of SHEL in JAL516 collision with JA722A - lack of Safety-II approach in safety management.

Based on the identified facts, inferences, and doubts about the collision between JAL516 and JA722A on January 2, 2024, this study attempted to explore why the miscommunication between air traffic control (ATC) and JA722A was not compensated by other actors (ATC and JAL516) from the perspective of the inadequacy of interactions between related actors (JA722A, JAL516, and ATC) and each element (Software, Hardware, Environment, and Liveware) of the SHEL model. We also demonstrated that safety management at Haneda Airport was apparently lacking in Safety-II and pre-mortem approaches. Based on such an approach to the interaction analysis of the collision, the progress report of the Japan Transport Safety Board, and the interim report of the CPAC (Committee for Proposing Accident Countermeasures), we discuss why the collision occurred (why the misunderstanding of JA722A was not corrected by ATC and JAL516) and how similar collisions should be avoided during landing and takeoff.

求助全文

通过发布文献求助，成功后即可免费获取论文全文。去求助

来源期刊

Ergonomics 工程技术-工程：工业

CiteScore

4.60

自引率

12.50%

发文量

147

审稿时长

6 months

期刊介绍： Ergonomics, also known as human factors, is the scientific discipline that seeks to understand and improve human interactions with products, equipment, environments and systems. Drawing upon human biology, psychology, engineering and design, Ergonomics aims to develop and apply knowledge and techniques to optimise system performance, whilst protecting the health, safety and well-being of individuals involved. The attention of ergonomics extends across work, leisure and other aspects of our daily lives. The journal Ergonomics is an international refereed publication, with a 60 year tradition of disseminating high quality research. Original submissions, both theoretical and applied, are invited from across the subject, including physical, cognitive, organisational and environmental ergonomics. Papers reporting the findings of research from cognate disciplines are also welcome, where these contribute to understanding equipment, tasks, jobs, systems and environments and the corresponding needs, abilities and limitations of people. All published research articles in this journal have undergone rigorous peer review, based on initial editor screening and anonymous refereeing by independent expert referees.