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Systems-Theoretic Accident Model and Processes (STAMP) Applied to a U.S Systems-Theoretic Accident Model and Processes (STAMP) Applied to a U.S. Coast Guard Buoy Tender Integrated Control System by Paul D. Stukus B.S. Naval Architecture and Marine Engineering United States Coast Guard Academy (1994) M.S. Naval Architecture and Marine Engineering University of Michigan (1998) M.S. Mechanical Engineering University of Michigan (1998) Submitted to the System Design and Management Program in Partial Fulfillment of the Requirements for the Degree of Master of Science in Engineering and Management at the Massachusetts Institute of Technology June 2017 ©2017 Paul D. Stukus. All rights reserved. The author hereby grants to MIT permission to reproduce and to distribute publicly paper and electronic copies of this thesis document in whole or in part in any medium now known or hereafter created. Signature of Author: ____________________________________________________________________ Paul Stukus System Design and Management Program May 10, 2017 Certified by: __________________________________________________________________________ Nancy Leveson Professor of Aeronautics and Astronautics Thesis Supervisor Accepted by: __________________________________________________________________________ Joan Rubin Executive Director System Design & Management Program 1 Systems-Theoretic Accident Model and Processes (STAMP) Applied to a U.S. Coast Guard Buoy Tender Integrated Control System by Paul D. Stukus Submitted to the System Design and Management Program in Partial Fulfillment of the Requirements for the Degree of Master of Science in Engineering and Management ABSTRACT The Systems-Theoretic Accident Model (STAMP) developed by MIT’s Dr. Nancy Leveson was applied in this thesis to a ship navigation control system used on U.S. Coast Guard buoy tenders. The legacy system installed on the Service’s 16 sea-going buoy tenders experienced numerous incidents that had potential to be hazardous to the ships and their crews. Faced with the dual needs of ensuring safety of mission execution and restoring confidence in the overall ship control system, yet faced with a limited budget, Coast Guard decision-makers elected to conduct a partial recapitalization of the system’s hardware and software. This thesis explores the application of system safety methods to analyze the legacy system on the sea- going buoy tenders. An accident analysis of a particular incident was conducted using STAMP methodologies, and its results were compared/contrasted with the results of a more traditional root cause failure analysis that was contracted by the Coast Guard following the incident. Several added insights pertaining to system safety and process improvement were obtained by using STAMP. Additionally, a hazard analysis was performed on the control system using STAMP techniques. This hazard analysis yielded 92 specific design requirements that may be incorporated into future system upgrades on these or similar vessels. The thesis concludes that STAMP methodologies are appropriate to generate actionable recommendations for future control system upgrades on U.S. Coast Guard buoy tenders. It also concludes that STAMP techniques may lead to safer controls in the greater hierarchical control structure for shipboard buoy tending operations. Finally, suggestions are made for future research/application of STAMP principles in the Coast Guard’s management of operational safety, asset acquisition, and cybersecurity. Thesis Supervisor: Nancy Leveson Title: Professor of Aeronautics and Astronautics 2 Acknowledgements I must first thank God above for granting me the fortitude to not only pursue an advanced degree from MIT, but to finish all degree requirements in nine months. The past several months have been grueling and rewarding in equal measure, and I know He was with me every step of the way. I am deeply appreciative of the opportunity provided by the U.S. Coast Guard for me to continue to further my education – I hope that the contributions I make in my future military service proves the investment to have been worthwhile. I am truly fortunate to be a member of such an outstanding organization. Along these lines, particular thanks go to Chief Warrant Officers Alfonso “Ponch” Mejia and Sean Gabriel of the Coast Guard Surface Forces Logistics Center, who put up with my multiple requests for technical data in support of this thesis and delivered every time I asked. Thanks are also due to LCDR John Singletary, Commanding Officer of USCGC Juniper, who advised me from a system operator’s perspective. My studies at MIT exposed me to several academic departments, and one denominator was common to them all: exceptionally bright, energetic, and dedicated teaching staff – from the newest teaching assistants to the longest tenured professors. In particular, I earnestly thank Dr. John Thomas, who kindled my interest in STPA and then stoked it – all in one high-octane three-hour lecture. The timely and extremely valuable feedback that he provided while I drafted this thesis was indispensable. I am also thankful to Professor Nancy Leveson for taking me on as a thesis advisee and providing insightful guidance to maximize my learning experience. I also learned much from my exceptional colleagues within the 2016 MIT System Design and Management Cohort. It was both a rare opportunity and a fulfilling experience to “rub elbows” with such intellectual and entrepreneurial giants. I additionally thank Professor Amedeo Odoni, whose wise counsel helped me to organize my thoughts after I completed an exhausting schedule of seven courses during the Fall 2016 semester and then arrived at the realization that I needed to quickly devote some serious thought to a thesis topic and advisor. Special thanks is due to Joan Rubin, whose flexibility and big-picture perspective as SDM Executive Director allowed me to maximize the “MIT experience” while minimizing negative impacts on my family. “Lifetime achievement” recognition is due to my mother and late father, Pauline and Peter Stukus. They raised me through my formative years without providing any external pressure (that I can recall) to work hard and succeed – I merely had to follow their example. Years of consistent moral support from my exceptional parents, siblings, and in-laws enabled me to complete this chapter of my life’s journey. To my children: Megan, Madeleine, and Cole – I am grateful to you for bravely enduring the family separation that resulted from my “deployment” to Cambridge. Once you got over the initial hilarity associated with the idea of your dad “going back to school,” your love and unwavering support for me was overwhelming, and you continued to do great things without my presence at home. I suppose that shows that you really don’t need me around in order to thrive and succeed, which is a condition that would make any parent very proud. Still, I missed you tremendously while I was away. Finally, I sincerely thank my wife and best friend, Natalie. You pushed me to accept the opportunity to go back to school when it was offered, and you stalwartly anchored the family through numerous tempests (including several that were surely unknown to me) over the past nine months. To be clear: you own a big part of this degree; it would have been “unobtainium” without your efforts on the home front. Your unselfishness humbles me daily, and I am very lucky to be your husband. I love you! 3 Table of Contents List of Acronyms ........................................................................................................................................... 7 Chapter 1 – Introduction and Background ................................................................................................ 10 1.1 Chapter Overview ....................................................................................................................... 10 1.2 U.S. Aids to Navigation Overview and Historical Background .................................................... 10 1.3 Thesis Motivation ....................................................................................................................... 11 1.4 Background of WLB Control System Issue .................................................................................. 12 1.5 Research Questions .................................................................................................................... 13 Chapter 2 – Literature Search .................................................................................................................... 15 2.1 Chapter Overview ....................................................................................................................... 15 2.2 The Roots and Evolution of System Safety Analysis ................................................................... 15 2.3 Accident Models ......................................................................................................................... 15 2.3.1 Chain of Event Models ........................................................................................................ 16 2.3.1.1 Heinrich’s Domino Model ............................................................................................... 16 2.3.1.2 Bird and Loftus’ Domino Model ...................................................................................... 17 2.3.1.3 Reason’s Swiss Cheese Approach ................................................................................... 19 2.3.2 Hierarchical Approaches ....................................................................................................
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