1. FRAM ANALYSIS
OF THE
KEGWORTH AIR
DISASTER
ROSS APTED

2. FRAM ANALYSIS
0. Define the purpose of modeling and describe the situation
being analyzed. An event that has occurred (incident/accident) or a
possible future scenario (risk).
1. Identify the essential functions in the event ('foreground'
functions when things go right); characterize each by six basic
aspects.
2. Characterize the actual / potential variability of 'foreground'
functions and 'background' functions (context). Consider both
normal and worst case variability.
3. Define functional resonance based on potential / actual
dependencies (couplings) among functions.
4. Propose ways to monitor and dampen performance
variability(indicators, barriers, design / modification, etc.)

3. Non-normal event
(Engine Failure)
Non-normal
procedures
Air conditioning High engine
smoke vibrations
Air conditioning High engine
smoke procedures vibrations
procedures
Engine shutdown
Engine shutdown Divert to nearest
checklist airport
Landing procedure Review any engine
shutdown decisions
Landing

4. T C
T C
Non-normal
T C
event
I (Engine O
Failure) High engine
I vibrations O
Non-normal
I procedures O
P R
P R
P R
T C
T C
High engine
Air
I vibrations O
I conditioning
O procedures
smoke
T C P
P R
R
T C
Divert to
I nearest
O
Air airport
conditioning
I smoke O T C
procedures
P R
Review any
P engine
R I O
shutdown
T C decisions
T C
P R
Engine
I shutdown O T C
Landing
I procedure O
T C
Engine
P I shutdown
R O
checklist
P R
I Landing
O
P R
P R

5. CHARACTERISTICS OF
FUNCTION I
Control
Time Non-normal procedures ,
Time in which the system Commander and first officers’
is operational T C Actions.
Non-normal
I event Output
Input O
(Engine Failure) Input to:
Non-normal procedures
P
R
Resource
Precondition Functioning system(
System fault engine system)

6. CHARACTERISTICS OF
FUNCTION II
Control
Time Commander and first officer
Priority while non-
normal event is active. T C
I Non-normal Output
Input O
procedures Input to:
Non-normal event Air conditioning smoke
High engine vibrations
Review any engine shutdown-
P
R decisions
Resource
Precondition Commanders and first officers’
attention and time.

7. CHARACTERISTICS OF
FUNCTION III
Control
Time Non-normal procedures ,
Time in which the system Commander and first officers’
is operational T C Actions.
Air conditioning Output
Input I O
smoke Input to:
Non-normal Air conditioning smoke
procedures procedures
P
R
Resource
Precondition Functioning system(
System fault Air conditioning)
Failing system(engine)

8. CHARACTERISTICS OF
FUNCTION IV
Control
Time Commander and first officer
Must be completed Non-normal procedures
before crew are T C
adversely affected.
Air conditioning Output
Input I O
smoke Input to:
Air conditioning procedures Engine shutdown
smoke Divert to nearest airport
P
R
Resource
Precondition Commanders and first officers’
Any procedure that have a attention and time.
higher priority level
must be taken care of.

9. CHARACTERISTICS OF
FUNCTION V
Control
Time Commander and first officer
Must be completed Engine shutdown checklist
immediately if T C Boeing 737 operations
emergency. (engine fire). Manual.
I Output
Input Engine shutdown O
Input to:
Air conditioning Engine shutdown checklist
smoke
procedures
P
R
Precondition Resource
Appropriate engine Commanders and first officers’
non-normal procedures attention and time.
completed An engine

10. CHARACTERISTICS OF
FUNCTION VI
Control
Time Commander and first officer
Time must be taken to Boeing 737 operations
evaluate every stage of T C Manual.
checklist
Engine shutdown Output
Input I O
checklist
Engine shutdown
P
R
Precondition Resource
Appropriate engine Commanders and first officers’
non-normal procedures attention and time.
completed

11. CHARACTERISTICS OF
FUNCTION VII
Control
Time Non-normal procedures ,
Must divert immediately, Commander and first officers’
top priority. T C Actions. Boeing 737 operations
Manual.
I Divert to nearest Output
Input O
airport Input to:
Air conditioning Landing procedure
smoke procedures
P
R
Resource
Precondition Commanders and first officers’
Air traffic control clearance attention and time, cabin crews
attention, air traffic control and
ground crew manpower

12. CHARACTERISTICS OF
FUNCTION VIII
Control
Time Air traffic control,
Must be complete at top Commander and first officers’
priority if in emergency T C Actions. Boeing 737 operations
situation Manual.
Landing Output
Input I O
procedure Input to:
Landing Landing
P
R
Precondition Resource
Commanders and first officers’
attention and time.
Flight crew time and attention.
Air traffic control coordination

13. CHARACTERISTICS OF
FUNCTION IX
Control
Time Air traffic control,
Must be in time allocated Commander and first officers’
by air traffic control, must T C Actions.
not conflict with other
tasks.
Landing Output
Input I O
Landing procedure
P
R
Precondition Resource
Landing procedures have Commanders and first officers’
be completed, attention and time, cabin crews
air traffic control clearance, attention, air traffic control and
ground crew ready ground crew manpower

14. CHARACTERISTICS OF
FUNCTION X
Control,
Time Commander and first officers’
Time in which the system Actions.
is operational T C
.
High engine Output
Input I O
vibrations Input to:
Non-normal High engine vibrations
procedures procedures
P
R
Precondition Resource
System fault Failing system(engine)

15. CHARACTERISTICS OF
FUNCTION XI
Control,
Time Commander and first officers,
Must be completed Non-normal procedures,
before crew or craft are T C Boeing 737 operations
adversely affected. Manual.
High engine
I vibrations Output
Input O
High engine procedures
vibrations
P
R
Precondition Resource
Any procedure that have a Commanders and first officers’
higher priority level attention and time.
must be taken care of Engine thrust(will decrease)

16. CHARACTERISTICS OF
FUNCTION XII
Control,
Time Commander,
Must be completed after Non-normal procedures,
every procedure that T C
requires engine
shutdown, must not
conflict with other tasks.
. Review any
I engine shutdown Output
Input O
Non-normal decisions
procedures
P
R
Precondition Resource
A procedure that requires Commanders’
an engine shutdown attention and time.

17. T C T C
Non-normal
event High engine Pilots did not know of
I (Engine O I
T C vibrations O newly introduced
Failure) Pilots experienced engine vibration
Left engine
malfunctioned symptoms of engine procedure
failure
P R Non-normal P
I O R
procedures
Engine vibration
producers were not
Engine vibration
P carried out
producers were not
R
carried out
symptoms stopped
Pilots experienced
symptoms of engine T C
T C failure
High engine
Air I vibrations O
I conditioning procedures
O T C
smoke
Divert to P R
P R nearest
I O
airport
T C
Flight crews chose to
deal with smoke P Review any
R
Shut down of right engine
T C I shutdown O
Flight crews attention engine was not
symptoms stopped reviewed decisions
focused on diverting
Air to nearest airport
conditioning
I P R
smoke O
T C T C
procedures Determined that right High cabin workload
engine was cause
Pilots were
P Engine required to
R Landing land a review
T C I shutdown I
O procedure O T C
checklist engine
shutdown
decisions
Engine
I shutdown O P R P R I Landing
O
P R P R