16.863J | Spring 2016 | Graduate

System Safety

Readings

[ESW] = Buy at MIT Press Leveson, Nancy G. Engineering a Safer World: Systems Thinking Applied to Safety. MIT Press, 2012. ISBN: 9780262016629. This book is available for purchase or as a free download from the MIT Press website. [Preview with Google Books]

[Safeware] = ———. Safeware: System Safety and Computers. Addison-Wesley Professional, 1995. ISBN: 9780201119725. [Preview with Google Books]

SES # CLASS TOPICS READINGS
1 Introduction, Causality, Bhopal, Hindsight Bias

[ESW] Chapters 1 and 2.

[Safeware] Chapter 1.

2

Part 1—Chapters 1–2 Questions
Accident Models, STAMP, Systems Theory

Part 2—Ethics Discussion

[Safeware] pp. 129–35, 185–93, 197, 202–4, and 145–55.

[ESW] Chapters 3 and 4.

Tank Overflow Accident Report

3 CAST and Accident Analysis

[Safeware] pp. 39–48 and 53–88.

[ESW] Chapters 5 and 11.

4 Traditional HA, Lecture on Quantification [Safeware] pp. 305–11, 313–26, 327–32, 341–44, 350–58
5 Systems Theoretic Process Analysis (STPA) Introduction, Basic Components (hazard, constraints, HCS) [ESW] Chapters 6 and 7 (only pp. 211–30).
6 STPA, How to Do It [ESW] Chapter 8.
7 Design for Safety

[Safeware] Chapter 16, Follensbee.

[ESW] pp. 263–73.

8 Human Factors

Automation Complacency Paper

[Safeware] pp. 204–24 (Human error models).

[ESW] pp. 273–306.

9 Cyber Security Young and Leveson paper
10 Operations, Regulation

[ESW] Chapters 12.

Other readings (assigned in class)

11 Guest Lecture  
12 Management, SUBSAFE [ESW] Chapters 13 and 14.
13 Presentations of Class Projects  

Optional Readings and Materials

Bogdanich, Walt, and Kristina Rebelo. “New York Times on Radiation Accidents Article,” The NewYork Times, December 28, 2010.

AF 447 Accident Report (PDF - 26.7MB), Final Repot (2012).

Leveson, Nancy G. “Technical and Managerial Factors in the NASA Challenger and Columbia Losses: Looking Forward to the Future.” In Controveries in Science and Technology Vol. 2: From Climate to Chromosomes. Edited by Kleinman, Cloud-Hansen, Matta, and Handelsman. Mary Ann Liebert Incorportaion, 2008. ISBN: 9780913113424.

Dekker. “Just Culture: Who Gets to Draw the Line?.” Cognition, Technology & Work 11, no. 3 (2009): 177–85.

Lowy, Joan. “AP IMPACT: Automation in the Air Dulls Pilot Skill,” The Washington Times, August 30, 2011. (Impact of Computers on Pilot Error)

Follensbee on PRA

Colonial Pipeline Safety Philosophy (PDF)

CAST Analysis of ComAir Accident (PDF)

Leveson, Nancy G. “Applying System Thinking to Analyze and Learn from Events.” Safety Science 49, no. 1 (2011): 55–64.

———. “The Role of Software in Spacecraft Accidents.” Journal of Spacecraft and Rockets 41, no. 4 (2004): 564–75.

CAST Tank Overflow Accident (PDF)

Black Hawk STPA Analysis (PDF - 1.2MB)

Navy System STPA Analysis (PDF - 2.4MB)

HTV Hazard Analysis Paper (PDF - 1.1MB)

Course Info

Learning Resource Types
Lecture Notes
Online Textbook
Written Assignments
Activity Assignments