Study of Commercial Aviation Incidents applying the Functional Resonance Analysis Method (FRAM) to identify Commonalities in Human Factors for Aviation Safety

In a context characterized by rapid changes and strong economic and technological influences, safety remains the top priority in the aviation sector. Risk assessment and incident analysis are fundamental tools needed to improve Flight Safety, representing a central focus of multiple academic and industrial studies. The purpose of this thesis is to explore and expand the Functional Resonance Analysis Method (FRAM), an innovative methodology born to this end. By embracing the Safety-II philosophy, FRAM enables the analysis of complex non-linear socio-technical systems as well as the interactions within it, offering an integrated approach by complementing more traditional methods, which are, instead, based on a linear and proportional framework. The work focused on studying the performance variability of the different functions that describe the FRAM model of an aircraft during the approach phase. The goal was to look for commonalities between them, ultimately aiming at evaluating which human factors might play a crucial role, in order to adopt specific safety measures to further improve aviation safety. To this end, the analysis considered a near-miss event that occurred on February 9, 2003, involving a Boeing 737-36N during its approach to Oslo Gardermoen Airport under adverse weather conditions, with malfunctions of ground infrastructures, poor avionics and degraded ATC communications. The results were then compared to other occurrences also examined, classified under the Controlled Flight Into Terrain (CFIT) category, to draw relevant conclusions