Application of a Systems-Theoretic Approach to Risk Analysis of High-speed Rail Project Management in the US by Soshi Kawakami M.E., Mechanical Engineering, Kyoto University, 2005 B.E., Mechanical Engineering, Kyoto University, 2003 Submitted to the Engineering Systems Division in partial fulfillment of the requirements for the degree of Master of Science in Engineering Systems at the Massachusetts Institute of Technology JUNE 2014 © 2014 Soshi Kawakami. 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: ____________________________________________________________________ Engineering Systems Division May 9, 2014 Certified by: __________________________________________________________________________ Nancy G. Leveson Professor of Aeronautics and Astronautics and Engineering Systems Thesis Supervisor Certified by: __________________________________________________________________________ Joseph M. Sussman JR East Professor of Civil and Environmental Engineering and Engineering Systems Thesis Supervisor Accepted by: _________________________________________________________________________ Richard Larson Mitsui Professor of Engineering Systems Chair, ESD Education Committee 2 Application of a Systems-Theoretic Approach to Risk Analysis of High-speed Rail Project Management in the US by Soshi Kawakami Submitted to the Engineering Systems Division on May 9, 2014 in Partial Fulfillment of the Requirements for the Degree of Master of Science in Engineering Systems ABSTRACT High-speed rail (HSR) is drawing attention as an environmentally-friendly transportation mode, and is expected to be a solution for sociotechnical transportation issues in many societies. Currently, its market has been rapidly expanding all over the world. In the US, the Federal Railroad Administration (FRA) released a strategic vision to develop new HSRs in 2008, specifically focusing on 10 corridors, including the Northeast Corridor (NEC) from Boston to Washington D.C. With such rapid growth, safety is a growing concern in HSR projects; in fact, there have been two HSR accidents over the past three years. In developing a new HSR system, it is crucial to conduct risk analysis based on lessons learned from these past accidents. Furthermore, for risk analysis of complex sociotechnical systems such as HSR systems, a holistic system-safety approach focusing not only on physical domains but also on institutional levels is essential. With these perspectives, this research proposes a new system-based safety risk analysis methodology for complex sociotechnical systems. This methodology is based on the system safety approach, called STAMP (System-Theoretic Accident Model and Processes). As a case study, the proposed HSR project in the NEC is analyzed by this methodology. This methodology includes steps of conducting STAMP-based accident analysis, developing a safety model of the HSR system in the NEC, and analyzing safety risks of it based on lessons learned from the analyzed accidents, with a specific focus on the institutional structure. As a result of this analysis, 58 NEC-specific risks are identified, and with them, weaknesses of safety-related regulations applied to the project are discussed. Additionally, this research introduces System Dynamics to analyze further detailed causal relations of the identified risks and discusses its potential usage for risk analysis. Thus, this thesis research concludes with specific recommendations about safety management in the project in the NEC, making a point that the proposed methodology can be valuable for the actual project processes as a “safety-guided institutional design” tool. Thesis Supervisor: Nancy G. Leveson Title: Professor of Aeronautics and Astronautics and Engineering Systems Thesis Supervisor: Joseph M. Sussman Title: JR East Professor of Civil and Environmental Engineering and Engineering Systems 3 4 ACKNOWLEDGEMENTS I would like to express my sincere gratitude to my thesis advisor, Professor Nancy G. Leveson, who has supported this thesis work and has kept me inspired with her novel, insightful, and immense views on safety and engineering systems. Her STAMP-based approach has drastically changed my view toward safety. Without her guidance and persistent help, I would not fulfill my academic goal at the MIT. I would like to express my great appreciation to the other thesis advisor, Professor Joseph M. Sussman, who has kept me highly motivated throughout my thesis work with his patient and enthusiastic support whilst allowing me the room to work in my own way. His broad and deep knowledge about transportation has dramatically broadened my perspective on railway system and management, which I believe will drive my productivity in my future career as a railway system integrator in international fields. In my daily work, I have been blessed with friendly and cheerful fellow researchers: I thank Ryan J. Westrom, S. Joel Carlson, Iori Mori, Andrés F. Archila, Maite Peña-Alcaraz, Naomi Stein, Guineng Chen, Rebecca J. Heywood, Samuel Levy, Heather Jones, Evelien van der Hurk, and Aleksandr Prodan in Regional Transportation Planning and High-speed Rail Research Group for the stimulating discussions about transportation issues, and I thank Dajiang Suo, Seth Placke, Cameron Thornberry, Cody Harrison Fleming, John Douglas Helferich, John P. Thomas, Nicholas Connor Dunn, William Edward Young, Dan Montes, Adam David Williams, Kip Edward Johnson, Aubrey Lynn Samost, Jonas Bianchini Fulindi, Meaghan Marie Oneil, and Nicholas Chung in Systems Engineering Research Laboratory for giving insightful advice on my safety analysis. Finally, I would like to express my heartfelt appreciation to my family: my parents Masakazu and Hitomi, my siblings Chihiro and Keishi, my wife Shizu, my daughter Sae, and my newborn son Hiroaki. In particular, I would like to show my best gratitude and love to Shizu, who gave birth to Hiroaki on October 10, 2013. Although the delivery unfortunately enforced her to go through a severe surgery, she always motivated me with sacrificing support and love even after the tough time. Shizu’s inexhaustible support, Sae’s cheerful smile, and Hiroaki’s great birth gave me unmeasurable energy to accomplish this thesis. In acknowledgment of their contribution and love, I dedicate this thesis to Shizu, Sae, and Hiroaki. Soshi Kawakami Cambridge, Massachusetts May 2014 5 6 TABLE OF CONTENTS Page LIST OF TABLES .................................................................................................................. 9 LIST OF FIGURES .............................................................................................................. 11 LIST OF ACRONYMS AND ABBREVIATIONS .............................................................. 13 CHAPTER 1. Introduction ................................................................................................. 15 1.1 Motivation and Purpose ...................................................................................... 15 1.2 Background 1: High-speed rail and Rail Safety in the US ................................... 18 1.3 Background 2: Institutional Structure in Railway Industries ............................... 22 CHAPTER 2. Methodology ............................................................................................... 27 2.1 STAMP-based Analysis ...................................................................................... 27 2.1.1 Terminology ................................................................................................. 27 2.1.2 Reviews of Traditional Risk Analysis Tools and Accident Models .............. 29 2.1.3 Application of Risk Analysis in Rail Sectors ................................................ 32 2.1.4 Systems-Theoretic Accident Model and Process (STAMP) .......................... 35 2.1.5 System-Theoretic Process Analysis (STPA) ................................................. 39 2.1.6 Causal Analysis based on STAMP (CAST) .................................................. 43 2.1.7 Examples of STAMP-based Risk Analysis ................................................... 44 2.2 Proposed Methodology ....................................................................................... 46 CHAPTER 3. Accident Analysis ....................................................................................... 51 3.1 Case 1 – Hatfield Derailment – ........................................................................... 51 3.1.1 Summary of the Accident ............................................................................. 51 3.1.2 Analysis ........................................................................................................ 52 3.1.3 Conclusion .................................................................................................... 64 3.2 Case 2 – Wenzhou Train Collision – ................................................................... 65 3.2.1 Summary of the Accident ............................................................................. 65 3.2.2 Analysis ........................................................................................................ 69 3.2.3 Conclusion .................................................................................................... 75 3.3 Key Lessons Learned from the Two CAST Analyses ........................................