FRAM for systemic accident analysis: a matrix representation of functional resonance

Due to the inherent complexity of nowadays Air Traffic Management (ATM) system, standard methods looking at an event as a linear sequence of failures might become inappropriate. For this purpose, adopting a systemic perspective, the Functional Resonance Analysis Method (FRAM) originally developed by Hollnagel, helps identifying non-linear combinations of events and interrelationships. This paper aims to enhance the strength of FRAM-based accident analyses, discussing the Resilience Analysis Matrix (RAM), a user-friendly tool that supports the analyst during the analysis, in order to reduce the complexity of representation of FRAM. The RAM offers a two dimensional representation which highlights systematically connections among couplings, and thus even highly connected group of couplings. As an illustrative case study, this paper develops a systemic accident analysis for the runway incursion happened in February 1991 at LAX airport, involving SkyWest Flight 5569 and USAir Flight 1493. FRAM confirms itself a powerful method to characterize the variability of the operational scenario, identifying the dynamic couplings with a critical role during the event and helping discussing the systemic effects of variability at different level of analysis.