上海交通大学：《Systems Engineering 系统工程》课程教学资源（电子讲义）Lecture 11-1 Safety in Systems Engineering

JIAOTONG UNIVERSITY 1096 Systems Engineering Lecture 11-1 Safety in Systems Engineering Instructor(s) Prof.Jianjun Gao Department of Automation School of Electronic Information and Electrical Engineering 2014 Spring

Systems Engineering Instructor(s) + - 2014 Spring Safety in Systems Engineering Prof. Jianjun Gao Department of Automation School of Electronic Information and Electrical Engineering Lecture 11-1

Gao's V-Model Stakeholder Systems Engineering Lifecycle Analysis Overview Managment Requirement Cost and Schedule Commissioning Analysis Management Operations System Verification and Architecture Validation Tradespace System Integration: Interface management Exploration Human System Factor Design Definition and Safety Optimization CLGO System Engineering by J.J.Gao 2

+ - System Engineering by J. J. Gao 2 Gao’s V-Model Stakeholder Analysis Requirement Analysis System Architecture Tradespace Exploration Design Definition and Optimization System Integration: Interface management Verification and Validation Commissioning Operations Lifecycle Managment Systems Engineering Overview Cost and Schedule Management Human Factor System Safety

Today's Agenda Examples of safety and quality problem a Models of accident causality Accident causal analysis based on system theory Case:U.S.Coast Accident CLGO System Engineering by J.J.Gao 3

+ - 3 Today’s Agenda  Examples of safety and quality problem  Models of accident causality  Accident causal analysis based on system theory  Case: U.S. Coast Accident System Engineering by J. J. Gao

Class Discussion e Describe the events and offer your own explanation how did you arrive at these? Why do these kinds of errors and mistakes happen? What do these kinds of errors tell us about systems and organizations? CLGO System Engineering by J.J.Gao 4

+ - System Engineering by J. J. Gao 4

The High-Speed Train Accident 723 事故地点 州市双屿路段下路 鹿城区 瓯海区 温 鱼洲站州 据初步判断，D3115次列车 行驶至温州市双的路段时， 因誉击失去动力藏速 事故造成 多人死伤 红色：D301次列车 白色：D3115次别车 三直泰源网页 D301次列车4节车雨 D301次列车追尾接 从高架桥上掉落 上D3115次列车 人间pop 2011年7月23日20时27分 浙江温州境内发生动车追尾事故 www.people.com.cn CLGO System Engineering by J.J.Gao 5

+ - System Engineering by J. J. Gao 5 The High-Speed Train Accident : 723

The Wrong Patient Thoughts? e Nurse committed suicide after overdosing a baby: -http://www.msnbc.msn.com/id/43529641/ns/ health-health_care/t/nurses-suicide-highlights- twin-tragedies-medical-errors/#.T03twnKkDC8 CLGO System Engineering by J.J.Gao 6

+ - System Engineering by J. J. Gao 6 The Wrong Patient

Radiation Therapy Accident INCOSE Systems Engineering Handbook,page 45. ●The video CLGO System Engineering by J.J.Gao 7

+ - System Engineering by J. J. Gao 7 Radiation Therapy Accident  INCOSE Systems Engineering Handbook, page 45.  The video

Warranty Problem Investigation Powertrain Control Module HEGO Control Software Engine Calibration CLGO System Engineering by J.J.Gao 8

+ - System Engineering by J. J. Gao 8

40-1000 1000 times 30-70 times 100 1540 times 10 times 3-6 10 times 1time 1 Req. Design Code Dev.Test System Field Test peration CLGO System Engineering by J.J.Gao 9

+ - System Engineering by J. J. Gao 9

Today's Agenda Examples of safety and quality problem a Models of accident causality Accident causal analysis based on system theory Case:U.S.Coast Accident CLGO System Engineering by J.J.Gao 10

+ - 10 Today’s Agenda  Examples of safety and quality problem  Models of accident causality  Accident causal analysis based on system theory  Case: U.S. Coast Accident System Engineering by J. J. Gao