Multidimensional analysis model of accident causes resulted from human factors

In order to improve air traffic safety, a multidimensional analysis model of accident causes(MAMAC)was put forward by integrating business process management(BPM), human factors analysis and classification system(HFACS), its using steps were proposed, and the accident causes of an actual case were analyzed by using the model.The result indicates that the model can lead investigators to find all holes of processes by using Swiss Cheese Model; the detailed level and completeness of business process are proportional to the detailed level and completeness of cause analysis; the degree of cause analysis hierarchy is proportional to the detailed level of analysis result; when the model is applied to the fields where business process is relatively stable, business process can be optimized, and the reliability of system can be increased; when the relationships of the causes are stored into a database, it is easy to realize event recurrence, and the data can be used in risk evaluation, safety forecast and alert.