Papers and Publications

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Certification of Safety-Critical Systems
Nancy Leveson and John Thomas
Communications of the ACM
Standards, Regulation, CertificationPaper Link    Google Scholar
Oct 2023
Safety Implications of Autonomous Vehicles--System-Theoretic Process Analysis Applied to a Neural Network-Controlled Aircraft
Ryan Bowers and John Thomas
Society of Flight Test Engineers, 54th Annual International Symposium
STPA, Unmanned, UAV, UAS, Flight TestPaper Link    Google Scholar
Oct 2023
System Safety within Laboratory Data Exchanges Report
Nancy Leveson, John Thomas, Polly Harrington, and Rodrigo Rose
MIT/Synensys Technical Report to the FDA
Healthcare, STPA, OrganizationalPaper Link    Google Scholar
Sept 2023
Comparative Analysis of Hazard and Operability Study (HAZOP) and Systems Theoretic Process Analysis (STPA)
Faisal Jamal, Kamran Arif, Arooba Arooj, and John Thomas
AiCHE Safety Symposium
ComparisonPaper Link    Google Scholar
This blind study evaluates and compares STPA with the standard HAZOP method commonly used for Process Hazard Analysis (PHA). Both methods were applied by independent and qualified expert teams to uncover flaws in a real system. Neither team had any preexisting knowledge of the flaws before applying the methods. The system contained real flaws had that led to adverse events during the operation of the system, but this was not known by the teams applying HAZOP or STPA. The outcomes and recommendations of HAZOP and STPA are compared to determine what differences exist, if any, and identify whether gaps exist for modern process industry applications. The HAZOP and STPA results are also compared to the corrective actions produced after the hazardous and costly incident during operation.

The STPA method was found to capture hazardous human and automation related behaviors that were missed by HAZOP, and STPA generated critical recommendations missed by HAZOP that would have prevented the real adverse events. The STPA results anticipated the causes and corrective actions that were otherwise only discovered after the hazardous and costly event during system operation.
Aug 2022
A More Powerful Approach to Process Safety
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
An overview of why the process industry could benefit from a systems approach to safety.
Feb 2021
A Systemic Approach Toward Scalable, Reliable and Safe Satellite Constellations
Alan Kharsansky
MS Thesis, MIT, SDM Program
Other Emergent System Properties, System Engineering, Spacecraft, SpacePaper Link    Google Scholar
Aug 2020
Safety-III: A Systems Approach to Safety and Resilience
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
Recently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. This white paper describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
Jul 2020
Limitations of Safety Assurance and Goal Structuring Notation (GSN)
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
People are putting a lot of effort into figuring out how to assure a system is safe after the system design is completed. This white paper presents some of the difficulties and alternatives to emphasizing after-the-fact assurance of safety.
Jul 2020
A Design Process and Certification Strategy for Autonomous Vehicles
Michael Sebastian Schmid
MIT M.S. Thesis, Aeronautics and Astronautics
Standards, Regulation, Certification, NavalPaper Link    Google Scholar
Jun 2020
Application of hierarchy to STPA : a human factors study on vehicle automation
Rachel Cabosky (supervised by John Thomas)
MIT Master's Thesis
Paper Link    Google Scholar
Demonstrates STPA on an automotive example, including three iterations of analysis, evaluating the new scenario development process, and evaluating how much impact certain control structure errors have on the STPA results.
Jun 2020
Using STPA and CAST to Design for Serviceability and Diagnostics
Hannah M. Slominski
MIT Master's Thesis, System Design and Management
Other Emergent System Properties, System Engineering, NavalPaper Link    Google Scholar
May 2020
Are you sure your software will not kill anyone?
Nancy Leveson
Communications of the ACM
Paper Link    Google Scholar
Feb 2020
STPA Compliance with MIL-STD-882E and Army Safety Standards
Nancy G. Leveson
MIT White Paper
Standards, Regulation, Certification, Defense, MilitaryPaper Link    Google Scholar
2020
An Improved Design Process for Complex, Control-Based Systems Using STPA and a Conceptual Architecture
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
This paper proposes augmenting the standard V-model to assist in designing human-cyber-physical systems. A new process to create a Conceptual Architecture is inserted after Concept Development and Requirements Engineering and before detailed physical/logical Architecture Development.

In the standard V-model, going from a high-level conceptual view of a system or CONOPS, agreed upon by the stakeholders, to detailed requirements and then to a physical/logical architecture requires a lot of big jumps without having much assistance in making the design decisions involved. These jumps need to be simplified and assistance provided in making them if we want to produce better designs. Too often we find later that there are potential safety and security issues in the architecture generated. Changes to achieve these and other critical system properties may by then be either enormously expensive or even infeasible, requiring operational controls of limited effectiveness and reliability. Some upgrades may be impossible or very expensive.

A conceptual architecture can also augment our ability to produce user-centered designs. We blame most accidents on the operators (pilots, drivers, etc.) but have few tools that can forge an effective partnership between human factors experts who are designing system interfaces (control panels, displays, physical controls) and operator procedures and the engineers who are focusing on the physical (hardware) and logical (software) parts of the system. Too often today, these two groups work relatively independently and we end up creating systems with the potential for mode confusion, situational awareness problems, etc. These problems need not have been created if the designers could work together effectively as an integrated team. For this they need common models and language.

The process of creating a conceptual architecture will not only make it easier to design safety, security, and other emergent properties into these systems from the beginning, but also provide tremendous increases in our ability to assure, operate, maintain, and evolve these systems within reasonable cost limits. It could also have important uses in the certification of safety-critical systems.
Jan 2020
Updating the Concept of Cause in Accident Investigation
Nancy Leveson, Darren Straker, Shem Malmquist
ISASI (International Society of Air Safety Investigators)
Accident Analysis (CAST)Paper Link    Google Scholar
Sep 2019
Investigating Accidents in Highly Automated Systems: Systemic Problems Identified Through Analysis of Air France 447
Nancy Leveson, Darren Straker, Shem Malmquist
ISASI (International Society of Air Safety Investigators)
Accident Analysis (CAST), Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Sep 2019
Active STPA: Integration of Hazard Analysis into a Safety Management System Framework
Diogo Silva Castilho
Ph.D. Dissertation, Aeronautics and Astronautics
Hazard Analysis (STPA), AirlinesPaper Link    Google Scholar
Sep 2019
Shortcomings of the Bow Tie and other Safety Tools Based on Linear Causality
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
For some reason, bow tie diagrams are becoming widely used and are thought to be relatively new. Actually, they date back to the early 1970s and seem to have been rediscovered and greatly simplified in the 1990s. They are the least powerful and least useful modeling and diagramming language available. In this paper, I explain why the standard safety tools based on linear causality (including bow ties) oversimplify the cause of accidents, omitting the most important causal factors, and underestimate the level of risk in a system. Special emphasis in placed on Bow Tie diagrams, including their problems and limitations.
Sep 2019
Increasing Learning from Accidents: A Systems Approach Illustrated by the UPS Flight 1354 CFIT Accident
Shem Malmquist, Nancy Leveson, Gus Larard, Jim Perry, and Darren Straker
MIT Technical Report
Accident Analysis (CAST), Aviation, Aircraft, Military AviationPaper Link    Google Scholar
May 2019
How to Perform Hazard Analysis on a ‘System-of-Systems’
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
The term “system-of-systems” is misleading and hindering progress. This paper describes why this is true and shows how STPA can be used to perform hazard analysis on what has been labeled (erroneously) a system-of-systems using an extremely complex defense system as an example.
May 2019
Improving the Standard Risk Matrix: Part 1
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
The Risk Matrix is widely used but has many limitations. This white paper describes the problems with the standard Risk Matrix and how to improve the results obtained by using it. A second part is in preparation that suggests a change to the Matrix and the standard definition of risk.
Feb 2019
Systems Theoretic Process Analysis Applied to Manned-Unmanned Teaming
Jeremiah Robertson
MIT Master's Thesis
Hazard Analysis (STPA), Unmanned, UAV, UASPaper Link    Google Scholar
Jan 2019
An Engineering Perspective on Avoiding Inadvertent Nuclear War
Nancy Leveson
MIT White Paper
Paper Link    Google Scholar
Written for a workshop on Nuclear Command, Control, and Communication Systems and Strategy Stability.
Jan 2019
Systems Theoretic Process Analysis Applied to Air Force Acquisition Technical Requirements Development
Sarah E. Summers (Major, USAF)
MIT Master's Thesis
Hazard Analysis (STPA), Standards, Regulation, Certification, Aviation, Aircraft, Military Aviation, Unmanned, UAV, UASPaper Link    Google Scholar
Feb 2018
STPA for Continuous Controls: A Flight Testing Study of Aircraft Crosswind Takeoffs
Diogo Silva Castilho, Ligia M.S. Urbina, and Donizeti de Andrade
Safety Science
Hazard Analysis (STPA)Paper Link    Google Scholar
2018
STPA Handbook
Nancy Leveson and John Thomas
MIT
Hazard Analysis (STPA)Paper Link    Google Scholar
2018
System-Theoretic Process Analysis of Space Launch Vehicles
John Rising and Nancy Leveson
Journal of Space Safety Engineering, Elsevier
Hazard Analysis (STPA), Spacecraft, SpacePaper Link    Google Scholar
2018
The Danger of a 'Safety Case'
Nancy G. Leveson
MIT White Paper
Standards, Regulation, CertificationPaper Link    Google Scholar
2018
Safety Analysis in Early Concept Development and Requirements Generation
Nancy G. Leveson
INCOSE International Symposium
System EngineeringPaper Link    Google Scholar
2018
Requirement Generation for Highly Integrated Aircraft Systems Through STPA: An Application
Andrea Scarinci, Amanda Quilici, Danilo Ribeiro, Felipe Oliveira, Daniel Patrick, and Nancy Leveson
AIAA Information Systems Journal
System Engineering, Aviation, Aircraft, Military AviationPaper Link    Google Scholar
2018
The Underestimated Value of Safety in Achieving Organization Goals: CAST Analysis of the Macondo Accident
Maria Fernanda Tafur Munoz
MIT Engineering and Management Master’s Thesis
Accident Analysis (CAST), PetrochemicalPaper Link    Google Scholar
Jun 2017
Monitoring Safety During Airline Operations: A Systems Approach
Andrea Scarinci
MIT Master's Thesis
AirlinesPaper Link    Google Scholar
Jun 2017
Systems-Theoretic Accident Model and Processes (STAMP) Applied to a U.S. Coast Guard Buoy Tender Integrated Control System
Paul D. Stukus
MIT SDM Master's Thesis
Hazard Analysis (STPA), Accident Analysis (CAST), Cybersecurity, Comparison, Root Cause Analysis (RCA), NavalPaper Link    Google Scholar
Jun 2017
Safety Benefit Assessment, Vehicle Trial Safety and Crash Analysis of Automated Driving: A Systems Theoretic Approach
Stephanie Alvarez
Ecole Mines Paris Tech, Ph.D. Dissertation
Hazard Analysis (STPA), Accident Analysis (CAST), NavalPaper Link    Google Scholar
Jun 2017
Systems-Theoretic Process Analysis of Small Unmanned Aerial System Use at Edwards Air Force Base
Sarah A. Folse
MIT Aeronautics and Astronautics Master's Thesis
Hazard Analysis (STPA), Test and Evaluation, Unmanned, UAV, UASPaper Link    Google Scholar
Jun 2017
Systems Thinking Applied to Automation and Workplace Safety
Nathaniel Arthur Peper
MIT Master's Thesis
Hazard Analysis (STPA), Workplace SafetyPaper Link    Google Scholar
Jun 2017
Engineering for Humans: A New Extension to STPA
Megan Elizabeth France
MIT Aeronautics and Astronautics Master's Thesis
Human Factors, Human-Automation Interaction, NavalPaper Link    Google Scholar
Jun 2017
Systems-Theoretic Process Analysis and Safety-Guided Design of Military Systems
David Craig Horney
MIT Aeronautics and Astronautics Master's Thesis
System Engineering, Unmanned, UAV, UASPaper Link    Google Scholar
Jun 2017
Engineering for Humans: A New Extension to System Theoretic Process Analysis
Megan France and John Thomas
Int. Symposium on Aviation Psychology, Dayton Ohio
Human Factors, Human-Automation Interaction, Aviation, Aircraft, Military AviationPaper Link    Google Scholar
May 2017
Systems-Theoretic Safety Analyses Extended for Coordination
Kip Edward Johnson
MIT Dissertation
Hazard Analysis (STPA), Aviation, Aircraft, Military Aviation, Unmanned, UAV, UAS, Defense, MilitaryPaper Link    Google Scholar
Feb 2017
Learning from Accidents That Are a Consequence of Complex Systems
John Thomas and Shem Malmquist
ISASI Proceedings
Accident Analysis (CAST), Aviation, Aircraft, Military AviationPaper Link    Google Scholar
2017
CAST Analysis of the Shell Moerdijk Accident
Nancy G. Leveson
MIT Technical Report
Accident Analysis (CAST), PetrochemicalPaper Link    Google Scholar
2017
An Industrial Case Study on the Evaluation of a Safety Engineering Approach for Software-Intensive Systems in the Automotive Domain
Asim Abdulkhaleqa, Sebastian V¨osta, Stefan Wagner, and John Thomas
Verification, Formal MethodsPaper Link    Google Scholar
The complexity of software systems makes defining software safety requirements with traditional safety analysis techniques difficult. Based on STPA, we have developed a comprehensive software safety engineering approach in which the software and safety engineers integrate the analysis of software risks with their verification to recognize the software-related hazards and reduce the risks to a low level. In this paper, we explore and evaluate the application of our approach to a real industrial system in the automotive domain. The case study was conducted analysing the software controller of the Active Cruise Control System (ACC) from BMW Group.
Oct 2016
Safety-Guided Design Analysis in Multi-Purposed Japanese Unmanned Transfer Vehicle
Ryo Ujiie
System Design and Management Master's Thesis
Hazard Analysis (STPA), Accident Analysis (CAST), System Engineering, Spacecraft, SpacePaper Link    Google Scholar
Sep 2016
Systems Theoretic Accident Analysis of an Offshore Supply Vessel Collision
John Michael Mackovjak
Master of Science in Technology and Policy, MIT
Accident Analysis (CAST), Comparison, Root Cause Analysis (RCA), NavalPaper Link    Google Scholar
Jun 2016
STAMP Applied to Fukushima Daiichi Nuclear Disaster and the Safety of Nuclear Power Plants in Japan
Daisuke Uesako
MIT Master's Thesis, System Design and Management Program
Accident Analysis (CAST), Hazard Analysis (STPA), Organizational, Managerial, Social Analysis, Nuclear PowerPaper Link    Google Scholar
Jun 2016
Systems Theoretic Process Analysis Applied to an Offshore Supply Vessel Dynamic Positioning System
Blake Ryan Abrecht
MIT M.S. in Engineering Systems Thesis
Hazard Analysis (STPA), Accident Analysis (CAST), Comparison, MIL-STD-883, NavalPaper Link    Google Scholar
Jun 2016
Engineering for Humans: STPA Analysis of an Automated Parking System
John Thomas and Megan France
MIT Technical Report to GM
Human FactorsPaper Link    Google Scholar
An extension to STPA is proposed to anticipate potentially unsafe driver interactions, identify potential causes of these interactions, and help the engineering team develop solutions that address these interactions. An extended human controller model is developed by Thomas from previous work (Thomas, 2013) and evaluated by France on Automated Parking Assist. The extension was found to identify more complex human-automation scenarios that what is typically done otherwise.The process is applied to four different Automated Parking Assist system concepts that use different levels of automation. The scope of the analysis captures both human and automation behaviors using the same STPA approach, identifying both automated UCAs (Unsafe Control Actions) as well as human UCAs. While increasing levels of automation did reduce the impact of some human UCAs, it also introduced new types of human UCAs as well as potential for new automation UCAs. The total number of UCAs that must be prevented in the system was 50% higher for concepts with high levels of automation.
Jun 2016
Systems Theoretic Process Analysis (STPA) of an Offshore Supply Vessel Dynamic Positioning System
Blake Abrecht and Nancy Leveson
MIT Lincoln Laboratory Research Report
Hazard Analysis (STPA)Paper Link    Google Scholar
Feb 2016
A New Approach to Hazard Analysis for Rotorcraft
Blake Abrecht, Dave Arterburn, David Horney, Brandon Abel, Jon Schneider, and Nancy Leveson
Proceedings of the 2016 American Helicopter Society Technical Meeting, Huntsville, AL
Hazard Analysis (STPA), Comparison, MIL-STD-882, Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Feb 2016
Using STPA to Inform Developmental Product Testing
Major Daniel R. Montes, U.S. Air Force
MIT Ph.D. Dissertation
Hazard Analysis (STPA), Human Factors, Human-Automation Interaction, Aviation, Aircraft, Military Aviation, Test and EvaluationPaper Link    Google Scholar
Feb 2016
A Systems Approach to Analyzing and Preventing Hospital Adverse Events
Nancy Leveson, Aubrey Samost, Sidney Dekker, Stan Finkelstein, and Jai Raman
Journal of Patient Safety
Accident Analysis (CAST), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
2016
Rasmussen's Legacy: A Paradigm Change in Engineering for Safety
Nancy Leveson
Applied Ergonomics
General, Intent Specifications, Human Factors, Human-Automation InteractionPaper Link    Google Scholar
2016
Application of Systems and Control Theory-Based Hazard Analysis to Radiation Oncology
Todd Pawlicki, Aubrey Samost, Derek Brown, Ryan Manger, Gwe-Ya Kim, and Nancy Leveson
Journal of Medical Physics
Hazard Analysis (STPA), Comparison, FMEA/FMECA, Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
2016
When a Checklist Is Not Enough: How to Improve Them and What Else Is Needed
Jai Raman, Aubrey Samost, Nancy Leveson, Nikola Dobrilovic, Maggie Oldham, Sidney Dekker, and Stan Finkelstein
Journal of Thoracic and Cardiovascular Surgery
Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
2016
System Theoretic Safety Analysis of the Sewol-Ho Ferry Accident in South Korea
Yisug Kwon
MIT Master's Thesis
Accident Analysis (CAST), NavalPaper Link    Google Scholar
Dec 2015
Integrating Systems Safety into Systems Engineering During Concept Development
Cody Harrison Fleming and Nancy Leveson
Proceedings of the 2015 International Symposium on System Engineering (INCOSE), Seattle
System EngineeringPaper Link    Google Scholar
Jul 2015
Including Safety During Early Development Phases of Future Air Traffic Management Concepts
Cody H. Fleming and Nancy Leveson
Eleventh USA/Europe Air Traffic Management Research and Development Seminar (ATM2015)
Air Traffic Control (ATC)Paper Link    Google Scholar
Jun 2015
A Systems Approach to Patient Safety: Preventing and Predicting Medical Accidents Using Systems Theory
Aubrey Samost
MIT Master's Thesis
Hazard Analysis (STPA), Accident Analysis (CAST), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Jun 2015
System Theoretic Process Analysis of Electric Power Steering for Automotive Applications
Rodrigo Sotomayor Martinez
MIT Master's Thesis
Hazard Analysis (STPA), Comparison, FMEA/FMECA, NavalPaper Link    Google Scholar
Jun 2015
Managing Design Changes Using Safety-Guided Design for a Safety Critical Automotive System
John Sgueglia
MIT Master's Thesis
Hazard Analysis (STPA), System Engineering, NavalPaper Link    Google Scholar
Jun 2015
Identification of Leading Indicators for Producibility Risk in Early-Stage Aerospace Product Development
Allen J. Ball
MIT Master's Thesis
Organizational, Managerial, Social Analysis, Leading Indicators, Other Emergent System Properties, Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Jun 2015
Incorporating New Methods of Classifying Domain Information for Use in Safety Hazard Analysis
Nancy Leveson, Daniel Montes, and Leia Stirling
Proceedings of the International Symposium on Aviation Psychology, Dayton, Ohio
Human Factors, Human-Automation InteractionPaper Link    Google Scholar
May 2015
Integration of Multiple Active Safety Systems Using STPA
Seth Placke, John Thomas, and Dajiang Suo
SAE Technical Paper 2015-01-0277, doi:10.4271/2015-01-0277
Hazard Analysis (STPA), Feature Interaction, Integrating Multiple Control Systems, NavalPaper Link    Google Scholar
Apr 2015
An Integrated Approach to Requirements Development and Hazard Analysis
John Thomas, John Sgueglia, Dajiang Suo, and Nancy Leveson
SAE Technical Paper 2015-01-0274, doi:10.4271/2015-01-0277
Hazard Analysis (STPA), Feature Interaction, Integrating Multiple Control Systems, System Engineering, NavalPaper Link    Google Scholar
Apr 2015
Safety-Driven Early Concept Analysis and Development
Cody Harrison Fleming
MIT Ph.D. Dissertation
System Engineering, Air Traffic Control (ATC)Paper Link    Google Scholar
Jan 2015
A Systems Approach to Risk Management Through Leading Safety Indicators
Nancy Leveson
Journal of Reliability Engineering and System Safety, 136(4):17-34
Leading Indicators, System EngineeringPaper Link    Google Scholar
Oct 2014
The Systems Approach to Medicine: Controversy and Misconceptions
Sidney W.A. Dekker and Nancy G. Leveson
BMJ Quality and Safety
GeneralPaper Link    Google Scholar
Aug 2014
The Systems Approach to Medicine: Controversy and Misconceptions
Sidney W.A. Dekker and Nancy G. Leveson
BMJ Quality and Safety, Vol. 24, No. 1, (online version)
Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Aug 2014
Application of STPA to the Integration of Multiple Control Systems: A Case Study and New Approach
Matthew Seth Placke
Master's Thesis, Engineering Systems Division, MIT
Feature Interaction, Integrating Multiple Control Systems, NavalPaper Link    Google Scholar
Jun 2014
Improving Hazard Analysis and Certification of Integrated Modular Avionics
Cody Harrison Fleming and Nancy G. Leveson
Journal of Aerospace Information Systems, Vol. 11, No. 6
Feature Interaction, Integrating Multiple Control Systems, Software Engineering, Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Jun 2014
A Comparison of STPA and the ARP 4761 Safety Assessment Process
Nancy Leveson, Chris Wilkinson, Cody Fleming, John Thomas, and Ian Tracy
MIT Technical Report
Hazard Analysis (STPA), Standards, Regulation, Certification, Comparison, Fault Tree Analysis (FTA), Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Jun 2014
Extending the Human-Controller Methodology in Systems-Theoretic Process Analysis (STPA)
Cameron L. Thornberry
Master's Thesis, Aeronautics and Astronautics, MIT
Human Factors, Human-Automation InteractionPaper Link    Google Scholar
Jun 2014
Application of Systems-Theoretic Approach to Risk Analysis of High-Speed Rail Project Management in the U.S.
Soshi Kawakami
MIT Master's Thesis
Organizational, Managerial, Social Analysis, System Dynamics, Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Jun 2014
Application of CAST to Hospital Adverse Events
Meaghan O'Neil
MIT Master's Thesis
Accident Analysis (CAST), Comparison, Root Cause Analysis (RCA), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
May 2014
An Integrated Approach to Safety and Security Based on Systems Theory
William Young and Nancy Leveson
Communications of the ACM, Vol. 57, No. 2, pp. 31-35
CybersecurityPaper Link    Google Scholar
Feb 2014
System-Theoretic Process Analysis of the Air Force Test Center Safety Management System
Nicholas Chung
MIT Master's Thesis
Hazard Analysis (STPA), Organizational, Managerial, Social Analysis, Aviation, Aircraft, Military Aviation, Test and EvaluationPaper Link    Google Scholar
Feb 2014
Letter to Editor: Challenging the Systems Approach: Why Adverse Event Rates Are Not Improving
Philip Levitt, M.D.
BMJ Quality & Safety
General, Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
2014
Our Response: The Bad Apple Theory Won't Work: Response to 'Challenging the Systems Approach: Why Adverse Event Rates Are Not Improving
Sidney Dekker and Nancy Leveson
BMJ Quality & Safety
General, Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
2014
Applying Systems Thinking to Aviation Psychology
Nancy Leveson
Advances in Aviation Psychology: Volume 1, Ashgate Publishing
Human Factors, Human-Automation InteractionPaper Link    Google Scholar
2014
A New Approach to Risk Management and Safety Assurance in Digital Instrumentation and Control Systems
John Thomas and Nancy Leveson
American Nuclear Society Conference
Hazard Analysis (STPA), Nuclear PowerPaper Link    Google Scholar
Nov 2013
STPA Analysis of NextGen Interval Management Components: Ground Interval Management (GIM) and Flight Deck Interval Management (FIM)
Cody H. Fleming, M. Seth Placke, and Nancy Leveson
MIT Research Report for FAA and Lincoln Lab
Hazard Analysis (STPA), Comparison, Air Traffic Control (ATC)Paper Link    Google Scholar
Sep 2013
Extending and Automating a Systems-Theoretic Hazard Analysis for Requirements Generation and Analysis
John Thomas
MIT Ph.D. Dissertation
General, Hazard Analysis (STPA)Paper Link    Google Scholar
Jun 2013
A System Theoretic Safety Analysis of Friendly Fire Prevention in Ground Based Missile Systems
Scott McCarthy
MIT SDM Master's Thesis
Accident Analysis (CAST), Defense, MilitaryPaper Link    Google Scholar
Jan 2013
Safety Assurance in NextGen and Complex Transportation Systems
Cody Harrison Fleming, Melissa Spencer, John Thomas, Nancy Leveson, and Chris Wilkinson
Journal of Safety Science, 55:173-187
Comparison, Air Traffic Control (ATC)Paper Link    Google Scholar
2013
Drawbacks in Using the Term "System of Systems"
Nancy G. Leveson
MIT White Paper
GeneralPaper Link    Google Scholar
2013
Hazard Analysis of Complex Spacecraft Using Systems Theoretic Process Analysis
Takuto Ishimatsu, Nancy G. Leveson, John Thomas, Cody Fleming, Masafumi Katahira, Yuko Miyamoto, Ryo Ujiie, Haruka Nakao, Nobuyuki Hoshino
AIAA Journal of Spacecraft and Rockets
Hazard Analysis (STPA), Spacecraft, SpacePaper Link    Google Scholar
2013
Generating Formal Model-Based Safety Requirements for Complex, Software- and Human-Intensive Systems
John Thomas and Nancy Leveson
Safety-Critical Systems Club, Bristol, U.K.
Hazard Analysis (STPA), System Engineering, Intent Specifications, Software EngineeringPaper Link    Google Scholar
2013
Software and the Challenge of Flight Control
Nancy Leveson
In Space Shuttle Legacy: How We Did It/What We Learned edited by Roger Launius, James Craig, and John Krige, AIAA
Software EngineeringPaper Link    Google Scholar
2013
Assuring Safety of NextGen Procedures
Cody H. Fleming, Nancy G. Leveson, M. Seth Placke
Tenth USA/Europe Air Traffic Management Research and Development Seminar (ATM2013)
System Engineering, Air Traffic Control (ATC)Paper Link    Google Scholar
2013
Systems Theoretic Hazard Analysis (STPA) Applied to the Risk Review of Complex Systems: An Example from the Medical Device Industry
Blandine Antoine
MIT Ph.D. dissertation
Hazard Analysis (STPA), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Dec 2012
Development of a Systematic Risk Management Approach for CO2 Capture, Transport, and Storage Projects
Jaleh Samadi
L'Ecole Nationale Superieure des Mines de Paris Ph.D. dissertation
Organizational, Managerial, Social Analysis, System Dynamics, Climate ChangePaper Link    Google Scholar
Dec 2012
Evaluating the Safety of Digital Instrumentation and Control Systems in Nuclear Power Plants
John Thomas, Francisco Luiz de Lemos, Nancy Leveson
MIT/NRC Research Report: NRC-HQ-11-6-04-0060
Hazard Analysis (STPA), Standards, Regulation, Certification, Nuclear PowerPaper Link    Google Scholar
Nov 2012
Applying System Engineering to Pharmaceutical Safety
Nancy Leveson, Matthieu Couturier, John Thomas, Meghan Dierks, David Wierz, Bruce Psaty, Stan Finkelstein
Journal of Healthcare Engineering
Healthcare, Medical, Pharmaceutical, System DynamicsPaper Link    Google Scholar
Sep 2012
Integrating Safety into an Engineering Contractor's System Engineering Process Using the Guidelines of STAMP
Lorena Pelegrin
Master's Thesis, Herriot-Watt University
Organizational, Managerial, Social Analysis, Intent Specifications, PetrochemicalPaper Link    Google Scholar
Aug 2012
A CAST Analysis of a U.S. Coast Guard Aviation Mishap
Jon Hickey
MIT Master's Thesis, supervised by Dr. Qi van Eikema Hommes
Accident Analysis (CAST), Comparison, HFACS, Aviation, Aircraft, Military Aviation, NavalPaper Link    Google Scholar
May 2012
Engineering Financial Safety: A System-Theoretic Case Study from the Financial Crisis
Melissa Spencer
MIT TPP (Technology and Policy Program) Master's Thesis
Accident Analysis (CAST), FinancialPaper Link    Google Scholar
May 2012
Application of CAST and STPA to Railroad Safety
Airong Dong
MIT Master's Thesis
Hazard Analysis (STPA), Accident Analysis (CAST), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
May 2012
A System Theoretic Analysis of the "7.23" Yong-Tai-Wen Railway Accident
Dajiang Suo
1st MIT STAMP/STPA Workshop
Healthcare, Medical, Pharmaceutical, Accident Analysis (CAST)Paper Link    Google Scholar
Apr 2012
A Systems Theoretic Application to Design for the Safety of Medical Diagnostic Devices
Vincent Balgos
MIT SDM Master's Thesis, supervised by Dr. Qi van Eikema Hommes
Accident Analysis (CAST), Comparison, FMEA/FMECA, Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Feb 2012
Engineering a Safer World: Applying Systems Thinking to Safety
Nancy Leveson
MIT Press
GeneralPaper Link    Google Scholar
Jan 2012
Safety Assessment of Complex, Software-Intensive Systems
Nancy Leveson, Cody Harrison Fleming, Melissa Spencer, John Thomas, Chris Wilkinson
SAE International Journal of Aerospace-V121-1EJ
Hazard Analysis (STPA)Paper Link    Google Scholar
2012
Safety Assurance in NextGen
Cody Harrison Fleming, Melissa Spencer, Nancy Leveson, and Chris Wilkinson
NASA Research Report NASA/CR-2012-217553
Intent Specifications, Air Traffic Control (ATC)Paper Link    Google Scholar
2012
The Use of Safety Cases in Certification and Regulation
Nancy Leveson
Journal of System Safety
Standards, Regulation, CertificationPaper Link    Google Scholar
Nov 2011
Performing Hazard Analysis on Complex, Software- and Human-Intensive Systems
John Thomas and Nancy Leveson
ISSC Proceedings
Hazard Analysis (STPA)Paper Link    Google Scholar
Oct 2011
Safety-Guided Spacecraft Design Using Model-Based-Specifications
Cody Fleming, Takuto Ishimatsu, Yuko Miyamoto, Haruka Nakao, Masa Katahira, Nobuyuki Hoshino, John Thomas, and Nancy Leveson
International Association for the Advancement of Space Safety Conference
Hazard Analysis (STPA), System Engineering, Intent Specifications, Spacecraft, SpacePaper Link    Google Scholar
Oct 2011
Safety-Guided Design of Crew Return Vehicle in the Concept Design Phase Using STAMP/STPA
Haruka Nakao, Masa Katahira, Yuko Miyamoto, and Nancy Leveson
Conference of the International Association for the Advancement of Space Safety, Versailles, France
System Engineering, Spacecraft, SpacePaper Link    Google Scholar
Oct 2011
Application of a System Safety Framework in Hybrid Socio-Technical Environment of Eurasia
Azamat Abdymomunov
MIT SDM Thesis
Accident Analysis (CAST), Organizational, Managerial, Social AnalysisPaper Link    Google Scholar
2011
Accident Analysis and Hazard Analysis for Human and Organizational Factors
Margaret Stringfellow
MIT PhD. Dissertation
Hazard Analysis (STPA), Accident Analysis (CAST), Organizational, Managerial, Social Analysis, Comparison, HFACS, Unmanned, UAV, UASPaper Link    Google Scholar
Oct 2010
A Case Study of Vioxx Using STAMP
Matthieu Couturier
MIT Technology and Policy Master’s Thesis
Accident Analysis (CAST), Healthcare, Medical, PharmaceuticalPaper Link    Google Scholar
Jun 2010
Modeling and Hazard Analysis Using STPA
Takuto Ishimatsu, Nancy Leveson, John Thomas, Masa Katahira, Yuko Miyamoto, Haruka Nakao
Conference of the International Association for the Advancement of Space Safety, Huntsville, Alabama
Comparison, Fault Tree Analysis (FTA), Spacecraft, SpacePaper Link    Google Scholar
May 2010
Applying Systems Thinking to Analyze and Learn from Events
Nancy Leveson
Safety Science, Vol. 49, No. 1, pp. 55-64
Accident Analysis (CAST)Paper Link    Google Scholar
Jan 2010
Systems Approach to Accident Analysis
Nancy Leveson, Margaret Stringfellow, and John Thomas
IT Technical Report
Accident Analysis (CAST)Paper Link    Google Scholar
2009
Comparison of SOAM and STAMP for ATM Incident Investigation
Richard Arnold
Master's Thesis, Lund University, Sweden, supervised by Prof. Sidney Dekker
Accident Analysis (CAST), Comparison, Air Traffic Control (ATC)Paper Link    Google Scholar
2009
Software Challenges in Achieving Space Safety
Nancy Leveson
Journal of the British Interplanetary Society, Vol. 62
Software EngineeringPaper Link    Google Scholar
2009
A STAMP Analysis of the LEX Comair 5191 Accident
Paul S. Nelson
Master's Thesis, Lund University, Sweden, supervised by Prof. Sidney Dekker
Accident Analysis (CAST), Aviation, Aircraft, Military AviationPaper Link    Google Scholar
Jun 2008
Application of a Safety-Driven Design Methodology to an Outer Planet Exploration Mission
Brandon D. Owens, Margaret Stringfellow Herring, Nicholas Dulac, Nancy Leveson, Michel Ingham, and Kathryn Ann Weiss
IEEE Aerospace Conference, Big Sky, Montana
Intent Specifications, Spacecraft, SpacePaper Link    Google Scholar
Mar 2008
A Framework for Dynamic Safety and Risk Management Modeling in Complex Systems
Nicolas Dulac
MIT Ph.D. Dissertation
Organizational, Managerial, Social Analysis, System Dynamics, Spacecraft, SpacePaper Link    Google Scholar
Feb 2007
Safety-Driven Model-Based System Engineering Methodology Part I: Methodology Description
Brandon Owens, Margaret Stringfellow Herring, Nancy Leveson (MIT) and Mitch Ingham, Kathryn Weiss (JPL)
MIT Technical Report
Intent Specifications, Spacecraft, SpacePaper Link    Google Scholar
2007
Safety-Driven Model-Based System Engineering Methodology Part II: Application of the Methodology to an Outer Planet Exploration Mission
Brandon Owens, Margaret Stringfellow Herring, Nancy Leveson (MIT) and Mitch Ingham, Kathryn Weiss (JPL)
MIT Technical Report
Intent Specifications, Spacecraft, SpacePaper Link    Google Scholar
2007
Technical and Managerial Factors in the NASA Challenger and Columbia Losses: Looking Forward to the Future
Nancy Leveson
Handelsman and Kleinman (editors), Controveries in Science and Technology, University of Wisconsin Press
Organizational, Managerial, Social AnalysisPaper Link    Google Scholar
2007
Demonstration of a New Dynamic Approach to Risk Analysis for NASA's Constellation Program
Nicolas Dulac, Brandon Owens, Nancy Leveson
MIT Technical Report
Organizational, Managerial, Social Analysis, System Engineering, System Dynamics, Spacecraft, SpacePaper Link    Google Scholar
2007
A System-Theoretic Hazard Analysis Methodology for a Non-Advocate Safety Assessment of the Ballistic Missile Defense System
Steve Pereira, Grady Lee, and Jeffrey Howard
Proceedings of the 2006 AIAA Missile Sciences Conference, Monterey, CA
Hazard Analysis (STPA), Defense, MilitaryPaper Link    Google Scholar
Nov 2006
Engineering Spacecraft Mission Software Using a Model-Based and Safety-Driven Design Methodology
Kathryn Anne Weiss, Nicolas Dulac, Stephanie Chiesi, Mirna Daouk, David Zipkin, and Nancy Leveson
AIAA Information Systems Journal
Software EngineeringPaper Link    Google Scholar
2006
Risk Analysis of NASA Independent Technical Authority
Nancy Leveson and Nicolas Dulac (co-investigators include John Carroll, Joel Cutcher-Gershenfeld, Betty Barrett, David Zipkin)
MIT Technical Report
Organizational, Managerial, Social Analysis, Spacecraft, SpacePaper Link    Google Scholar
Feb 2005
A Systems-Theoretic Approach to Safety in Software-Intensive Systems
Nancy Leveson
IEEE Trans. on Dependable and Secure Computing
Software EngineeringPaper Link    Google Scholar
Jan 2005
A New Accident Model for Engineering Safer Systems
Nancy Leveson
Safety Science
GeneralPaper Link    Google Scholar
Apr 2004
Intent Specifications: An Approach to Building Human-Centered Specifications
Nancy Leveson
IEEE Transactions on Software Engineering, Vol. 26, No. 1
Intent SpecificationsPaper Link    Google Scholar
Jan 2000
Intent Specifications: An Approach to Building Human-Centered Specifications
Nancy Leveson and Jon Reese
MIT Technical Report
Intent SpecificationsPaper Link    Google Scholar
1999
Analyzing Software Specifications for Mode Confusion Potential
Nancy Leveson, L. Denise Pinnel, Sean David Sandys, Shuichi Koga, and Jon Damon Reese
First International Workshop on Human Error and System Development, Glascow
Intent Specifications, Human Factors, Human-Automation InteractionPaper Link    Google Scholar
Mar 1997
Safeware: System Safety and Computers
Nancy Leveson
Addison Wesley
GeneralPaper Link    Google Scholar
1995




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