{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T03:36:35Z","timestamp":1760240195204,"version":"build-2065373602"},"reference-count":35,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2019,4,4]],"date-time":"2019-04-04T00:00:00Z","timestamp":1554336000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Symmetry"],"abstract":"<jats:p>This paper aims to present the application of a fishbone sequential diagram in air traffic management (ATM) incident investigations performing as a key connection between safety occurrence analysis methodology (SOAM) and accident\/incident data reporting (ADREP) approaches. SOAM analysis is focused on organizational cause detection; nevertheless, this detection of individual causes from a complete incident scenario presents a complex analysis, and even more, the chronological relationship between causes, which is lacking in SOAM, should be tracked for post-investigation analysis. The conventional fishbone diagram is useful for failure cause classification; however, we consider that this technique can also show its potential to establish temporal dependencies between causes, which are categorized and registered with ADREP taxonomy for future database creation. A loss of separation incident that occurred in the Edmonton area (Canada) is used as a case study to illustrate this methodology as well as the whole analysis process.<\/jats:p>","DOI":"10.3390\/sym11040491","type":"journal-article","created":{"date-parts":[[2019,4,4]],"date-time":"2019-04-04T11:31:57Z","timestamp":1554377517000},"page":"491","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["A Case Study of Fishbone Sequential Diagram Application and ADREP Taxonomy Codification in Conventional ATM Incident Investigation"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8701-9059","authenticated-orcid":false,"given":"Schon Z.Y.","family":"Liang Cheng","sequence":"first","affiliation":[{"name":"School of Aerospace Engineering, Universidad Polit\u00e9cnica de Madrid (UPM), D. de Sistemas Aeroespaciales, Transporte A\u00e9reo y Aeropuertos, Plaza Cardenal Cisneros n3., 28040 Madrid, Spain"},{"name":"Aeronautic, Space &amp; Defence Division, ALTRAN Innovacion S.L., Calle Campezo, 1, 28022 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6639-6819","authenticated-orcid":false,"given":"Rosa Mar\u00eda","family":"Arnaldo Vald\u00e9s","sequence":"additional","affiliation":[{"name":"School of Aerospace Engineering, Universidad Polit\u00e9cnica de Madrid (UPM), D. de Sistemas Aeroespaciales, Transporte A\u00e9reo y Aeropuertos, Plaza Cardenal Cisneros n3., 28040 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0961-2188","authenticated-orcid":false,"given":"Victor Fernando","family":"G\u00f3mez Comendador","sequence":"additional","affiliation":[{"name":"School of Aerospace Engineering, Universidad Polit\u00e9cnica de Madrid (UPM), D. de Sistemas Aeroespaciales, Transporte A\u00e9reo y Aeropuertos, Plaza Cardenal Cisneros n3., 28040 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Francisco Javier","family":"S\u00e1ez Nieto","sequence":"additional","affiliation":[{"name":"School of Aerospace, Transport and Manufacturing, Cranfield University, Centre for Aeronautics, Cranfield MK43 OAL, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2019,4,4]]},"reference":[{"key":"ref_1","unstructured":"EASA (2018). EASA Preliminary Safety Review\u20142017, EASA."},{"key":"ref_2","unstructured":"ICAO (2013). Safety Management Manual (Doc 9859-AN\/474), ICAO."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1016\/j.ssci.2017.10.005","article-title":"Resilience engineering: Current status of the research and future challenges","volume":"102","author":"Patriarca","year":"2018","journal-title":"Saf. Sci."},{"key":"ref_4","unstructured":"Hollnagel, E. (2014). Safety I and Safety-II. The Past and the Future of Safety Management, Ashgate Publishing."},{"key":"ref_5","unstructured":"Underwood, P., and Waterson, P. (2013). Accident Analysis Models and Methods: Guidance for Safety Professionals, Loughborough University."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1098\/rstb.1990.0090","article-title":"The Contribution of Latent Human Failures to the Breakdown of Complex Systems","volume":"327","author":"Reason","year":"1990","journal-title":"Philos. Trans. R. Soc. Lond. B Biol. Sci."},{"key":"ref_7","unstructured":"EUROCONTROL (2006). Revisiting the Swiss Cheese Model of Accidents, EUROCONTROL."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Leveson, N. (2011). Engineering a Safer World: Systems Thinking Applied to Safety, MIT Press.","DOI":"10.7551\/mitpress\/8179.001.0001"},{"key":"ref_9","unstructured":"Hollnagel, E. (2012). FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-Technical Systems, Taylor & Francis Ltd."},{"key":"ref_10","unstructured":"EUROCONTROL, and FAA (2012). U.S.\/Europe Comparison of ATM-Related Operational Performance, EUROCONTROL."},{"key":"ref_11","unstructured":"ICAO Annex 13 (2016). International Standards and Recommended Practices Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, ICAO."},{"key":"ref_12","unstructured":"European Union (2014). Regulation (EU) No 376\/2014 of the European Parliament and of the Council of 3 April 2014, European Union."},{"key":"ref_13","unstructured":"European Union (2010). Regulation (EU) No 996\/2010 of the European Parliament and of the Council of 20 October 2010, European Union."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"607","DOI":"10.3390\/pharmaceutics4040607","article-title":"Signal Detection and Monitoring Based on Longitudinal Healthcare Data","volume":"4","author":"Suling","year":"2012","journal-title":"Pharmaceutics"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Hauer, E. (2015). The Art of Regression Modeling in Road Safety, Springer.","DOI":"10.1007\/978-3-319-12529-9"},{"key":"ref_16","first-page":"14974","article-title":"Root Cause Analysis of a Jet Fuel Tanker Accident","volume":"12","author":"Adekitan","year":"2017","journal-title":"Int. J. Appl. Eng. Res."},{"key":"ref_17","unstructured":"Flight Safety Foundation (2017). Level One Intensity\u2014Safety Data and Information for Risk Management within a Basic Safety Management System, Flight Safety Foundation."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Ishikawa, K. (1990). Introduction to Quality Control, Springer.","DOI":"10.1007\/978-94-011-7688-0"},{"key":"ref_19","unstructured":"EAM 2\/GUI 8 (2005). Guidelines on the Systemic Occurrence Analysis Methodology (SOAM), EUROCONTROL."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.1016\/j.ress.2006.08.010","article-title":"EUROCONTROL\u2014Systemic Occurrence Analysis Methodology (SOAM)\u2014A \u2018Reason\u2019-based organisational methodology for analysing incidents and accidents","volume":"92","author":"Licu","year":"2007","journal-title":"Reliab. Eng. Syst. Saf."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1403","DOI":"10.1111\/aas.13213","article-title":"Applying the human factors analysis and classification system to critical incident reports in anaesthesiology","volume":"62","author":"Neuhaus","year":"2018","journal-title":"ACTA Anaesthesiol. Scand."},{"key":"ref_22","first-page":"658","article-title":"Assessment of Human Factor Performance Using Bayesian Inference and Inherent Safety","volume":"845","author":"Wahab","year":"2014","journal-title":"Mater. Ind. Manuf. Eng. Res. Adv."},{"key":"ref_23","first-page":"719","article-title":"Assessment of failures in automobiles due to maintenance errors","volume":"8","author":"James","year":"2017","journal-title":"Int. J. Syst. Assur. Eng. Manag."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1016\/j.jclepro.2017.10.334","article-title":"Fishbone diagram and risk matrix analysis method and its application in safety assessment of natural gas spherical tank","volume":"174","author":"Luo","year":"2018","journal-title":"J. Clean. Prod."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.ssci.2018.04.009","article-title":"Systemic approaches to incident analysis in aviation: Comparison of STAMP, agent-based modelling and institutions","volume":"108","author":"Mogles","year":"2018","journal-title":"Saf. Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1016\/j.aap.2013.07.027","article-title":"Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models","volume":"68","author":"Underwood","year":"2014","journal-title":"Accid. Anal. Prev."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1016\/j.jlp.2016.11.016","article-title":"Understanding industrial safety: Comparing Fault tree, Bayesian network, and FRAM approaches","volume":"45","author":"Smith","year":"2017","journal-title":"J. Loss Prev. Process Ind."},{"key":"ref_28","unstructured":"ICAO Annex 11 (2016). International Standards and Recommended Practices Annex 11 to the Convention on International Civil Aviation Air Traffic Services, ICAO."},{"key":"ref_29","unstructured":"Reason, J. (1997). Managing the Risks of Organisational Accidents, Ashgate."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.jlp.2005.05.015","article-title":"A study of storage tank accidents","volume":"19","author":"Chang","year":"2006","journal-title":"J. Loss Prev. Process Ind."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1016\/j.aap.2010.12.030","article-title":"Line-of-duty deaths among US firefighters: An analysis of fatality investigations","volume":"43","author":"Kunadharaju","year":"2011","journal-title":"Accid. Anal. Prev."},{"key":"ref_32","first-page":"19","article-title":"Application of ADREP 2000 taxonomy for the analysis and the encoding of aviation accidents and incidents: A human factors approach","volume":"4","author":"Ferrante","year":"2004","journal-title":"Hum. Factor Aerosp. Saf."},{"key":"ref_33","unstructured":"ADREP Taxonomy (2010). ICAO ADREP 2000 Taxonomy, ICAO."},{"key":"ref_34","unstructured":"Transportation Safety Board of Canada (2002). LOSS OF SEPARATION NAV CANADA Edmonton Area Control Centre Edmonton, Alberta 60 nm S 27 June 2002."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Arnaldo Vald\u00e9s, R.M., Liang Cheng, S.Z., G\u00f3mez Comendador, V.F., and S\u00e1ez Nieto, F.J. (2018). Application of Bayesian Networks and Information Theory to Estimate the Occurrence of Mid-Air Collisions Based on Accident Precursors. 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