Safety Analysis of Systemic Accidents Triggered by Performance Deviation

Although autopilots are contributing much to reducing human workloads in aviation, they may induce a new type of aircraft accidents, i.e., "automation induced surprises". This paper proposes a systematic approach to this issue from a perspective of safety management. We employ Hollnagel\´s FRAM (functional resonance accident model) to figure out possible collapses in a series of operational procedures due to variable cockpit conditions. It is analyzed how the performance deviation in a particular operation does affect on the others, and when and where the expected scenario breaks down as a result of nonlinear interactions of multiple performance shaping factors