PUBLISHED PAPERS
2025 |
A Systemic Analysis of the TAM Airlines Flight 3054 Accident: A Hybrid STEP and SWOT Approach Proceedings Article Ester dos Santos Quintino; Guilherme Moreira; Willer Gomes; Moacyr Cardoso Resumo | Links | BibTeX | Tags: Safety, STEP, SWOT @inproceedings{Quintino2025SystemicAnalysisTam,The crash of TAM Airlines Flight 3054 on July 17, 2007, is one of Brazil’s most significant aviation disasters. While pilot error was initially identified as the primary cause, a deeper analysis reveals that the accident resulted from a complex socio-technical system operating under stress. This study employs a hybrid methodology, combining Sequentially Timed Events Plotting (STEP) and an analysis of Strengths, Weaknesses, Opportunities, and Threats (SWOT), to reconstruct the sequence of events and assess the operational environment. The critical crew error, influenced by human-automation interface flaws, triggered a series of interconnected failures, including compromised safety systems, a contaminated runway, and inadequate infrastructure. The analysis demonstrates that the catastrophic outcome was due to multiple vulnerabilities rather than a single failure. The study proposes multi-level recommendations targeting technical systems, human factors training, airport infrastructure, and regulatory oversight to enhance aviation safety and prevent future incidents. |
2017 |
ASTROS 2020 - Um estudo de caso da análise multidisciplinar da segurança Proceedings Article Moisés Silva Rodrigues; Sidnei Barbieri Resumo | Links | BibTeX | Tags: ASTROS 2020, Safety, STPA @inproceedings{Mois\'{e}s2017safetyb,Sendo a segurança, caracterizada por suas dimensões safety e security, um requisito inerente a qualquer projeto de sistemas, verifica-se ser fundamental que a mesma seja sempre objeto de análise no gerenciamento de riscos, devendo estar presente desde as fases iniciais da concepção até um eventual descarte. Assim, o presente trabalho se propõe a apresentar algumas técnicas de análise de safety, com suas diferenças e similaridades, exemplificando sua aplicação, tendo, para isso, como objeto o Sistema de lançamento múltiplo de foguetes ASTROS 2020, atualmente em desenvolvimento no Brasil. |
2011 |
A Methodology for Monitoring the Ground-Based Augmentation System (GBAS) Category I Integrity Risk Proceedings Article Paulo Elias; Osamu Saotome Resumo | Links | BibTeX | Tags: GBAS, Integrity, Risk, Safety @inproceedings{Paulo2011GBASb,This paper describes a method to accomplish the Ground-Based Augmentation System (GBAS) signal-in-space integrity risk monitoring for a ground station specified by ICAO, Annex 10, Vol. 1 and RTCA DO-245A, which is a mandatory requirement to meet the certification aspects for a Ground-Based Augmentation System (GBAS) ground station. The methodology described here is based on the Risk Tree Analysis (RTA) technique, which is an optional way to design and develop an engineering solution named as integrity risk monitor (IRM) that assures the integrity risk requirement for standard system architecture. The results demonstrated here is regarding to the qualitative and the quantitative aspects of solution, which are met through the system architecture and the system safety assessment process, in special by risk assessment concepts. Finally, the integrity risk monitor (IRM) explained here is an optional architectural solution (a practical way) which have demonstrated a satisfactory result to meet the certification basis of the Aeronautical Authorities. Keywords –- GBAS, Risk, Integrity, Safety. |