CAUSES and IMPACTS on SYSTEM RISK Thiago Tinoco
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ABSTRACT Title of Dissertation: ORGANIZATIONAL INTERFACES: CAUSES AND IMPACTS ON SYSTEM RISK Thiago Tinoco Pires, Doctor of Philosophy, 2017 Dissertation directed by: Dr. Ali Mosleh, Mechanical Engineering Organizational Interfaces exist when two or more organizations interact with each other in order to achieve objectives that would not be possible or feasible by operating independently. When organizations become interdependent an entire new class of vulnerabilities emerge, and understanding these is vital. Ideally, probabilistic risk assessments (PRAs) account for the reliability of hardware, software, humans and the interfaces among them. From a reliability and PRA disciplines perspective, very little is available in terms of methodologies for estimating the chances that OIs problems can contribute to risks. The objectives of this work are to address the following questions: 1) Are OIs important contributors to risks? 2) What are the ways/means of OI failures? 3) Can causal model of OI failures be developed? 4) Can improvements in the reliability discipline be made to incorporate the effects of OI failures? The importance of OIs as contributors to risks were confirmed through an investigation on past accidents in different industrial and service sectors and identifying the evidence on how OI failures played a role. A set of OIs characteristics that provide an understanding of how deficiencies and enhancements in such characteristics can lead to or mitigate/prevent OI failures were proposed. These are derived from insights gained from the accidents reviewed, and from a review on organizational behavior theories and models. The OI characterization was used to propose a Bayesian Belief Network causal model of OI failures for communication transfer. The model is built by means of a study conducted to gather empirical evidence on whether OI failures can be dependent on the OI characteristics. The evidence was gathered through a survey questionnaire to study causal factors of OI failures. The OI characterization was also used to develop OI Failure Mode and Effects Analysis (OI-FMEA) to be utilized as tool to incorporate the effects of OI failures in systems failure. The OI-FMEA was exercised to test if it provides enhancements on current Dynamic Position FMEA practices in the deepwater oil and gas well drilling industry. The exercise demonstrated that the OI-FMEA concepts were a powerful tool to identify serious risk scenario not realized previously. ORGANIZATIONAL INTERFACES FAILURES: CAUSES AND IMPACTS ON SYSTEM RISK by Thiago Tinoco Pires Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2017 Advisory Committee: Professor Ali Mosleh, Chair Professor Mohamed Modarres Professor Gary Pertmer Professor Monifa Vaughn-Cooke Professor Mohamad Al-Sheikhly, Dean’s Representative © Copyright by Thiago Tinoco Pires 2017 Table of Contents Table of Contents .......................................................................................................... ii List of Figures .............................................................................................................. iv List of Tables ................................................................................................................ v Chapter 1: Introduction ................................................................................................. 1 Chapter 2: Historical Evidence on OI Failures ............................................................. 6 OI Failures in the civil air transportation industry .................................................... 6 The Tenerife Airport Disaster ............................................................................... 7 The Ozark Air Lines Flight 650 accident, 1983 ................................................... 9 The Avianca Flight 52 accident, 1990 ................................................................ 10 Northwest Airlines Flight 1482 accident, 1990 .................................................. 12 Continental Express Flight 2574 accident, 1991 ................................................ 13 Überlingen mid-air collision, 2002 ..................................................................... 13 Other commercial air transportation OI failures ................................................. 14 OI failures in healthcare systems ............................................................................ 17 Electric Power Grid OI Failure ............................................................................... 20 OI Failure in the Oil and Gas Industry - Piper Alpha 1983 .................................... 23 Product design OI failures ...................................................................................... 25 The loss of the NASA Mars climate orbiter ....................................................... 25 Tokyo Disneyland Space Mountain derailment .................................................. 26 Commercial Nuclear Power Plant OI failures ........................................................ 27 Observations on Historical Evidence ...................................................................... 31 Chapter 3: Organizational Interface Characterization ................................................ 33 OI Characteristics.................................................................................................... 33 Communication ....................................................................................................... 40 Collaboration........................................................................................................... 45 Coordination ........................................................................................................... 48 Organizational Design ........................................................................................ 48 Organizational Environment Complexity ........................................................... 54 Organizational Culture ........................................................................................ 59 OI Failure Modes and Potential Causes/Influencing Factors ................................. 64 Conclusion .............................................................................................................. 66 Chapter 4: OI Failure Causal Model and Empirical Research .................................... 67 Chapter 5: Organizational Interfaces Failure Modes and Effect Analysis (OI-FMEA) ..................................................................................................................................... 77 Case study: Mobile Offshore Drilling Unit (MODU) Loss of Position (LOP) OI FMEA ..................................................................................................................... 79 Problem Statement .............................................................................................. 79 Dynamic Positioning (DP) Systems.................................................................... 80 MODU LOP causes and contributing factors ..................................................... 84 Current DP FMEA Practices ............................................................................... 90 ii DP OI-FMEA application ................................................................................... 93 Conclusion ............................................................................................................ 101 Chapter 6: Limitations and future research ............................................................... 103 Chapter 7: OI causal model applications on Probabilistic Risk Assessment ............ 107 Loss of Position PRA ............................................................................................ 108 Leg amputation PRA............................................................................................. 114 Product design PRA .............................................................................................. 116 Chapter 8: Discussion and Conclusions .................................................................... 120 Appendix - Questionnaire ......................................................................................... 124 Bibliography ............................................................................................................. 128 iii List of Figures Figure 1 - Simplified map of runway, taxiways, and aircraft. The red star indicates the location of impact. Not to scale. ................................................................................... 7 Figure 2 - CANUSE OI System (Wren, 1967) ........................................................... 23 Figure 3 - Simple BBN example ................................................................................. 68 Figure 4 - Chi-square contingency tables (observed and expected) ........................... 70 Figure 5 - IKTrF BBN model ..................................................................................... 75 Figure 6 - DP system structure.................................................................................... 81 Figure 7 - DP control system ...................................................................................... 84 Figure 8 - LOP depiction ............................................................................................ 85 Figure 9 - Root causes