H. Bref-retour, 19 2.1.1 L'ère des facteurs techniques, p.24

.. La-démarche-induite-de-la-systémique-pour-l-'analyse-de-l-'accident, 52 2.1.1 L'émergence de la structure hiérarchique, p.54

.. Le-manque-de-contrôle-provoque-l-'accident, 60 3.1.2 Les modèles conceptuels traditionnels d'analyse des accident représentent des limites, p.60

S. Système-de-gestion-de-la-sécurité-(, 85 1.1.3 Plan d'opération interne, Intervention (PPI), p.86

.. Identification-et-déroulement-de-l-'activité-de-transfert, 97 3.2.1 Cas opération de chargement, p.98

.. Énoncer-les-exigences-et-les-contraintes-de-sécurité, 122 1.5.1 L'action commandée fournie par le contrôleur ou le système de contrôle est dangereuse, 124 1.5.2 L'action commandée fournie est appropriée et requise, cependant elle n'est pas appliquée ou exécutée correctement, p.124

.. La-structure-organisationnelle-de-contrôle-de-la-sécurité, 132 2.4.1 Structure générale de contrôle de la sécurité de l'installation 133 2.4.2 Exemple de la structure de contrôle de la sécurité de l'installation technique, p.134

C. Et-discussions-des-résultats and .. , 148 CHAPITRE 5: Modele de simulation, p.151

.. Étapes-de-modélisation-et-de-simulation, 151 1.1.1 La formulation du problème, p.153

.. La-classe-main, 167 3.3.1 Les objets utilisés pour la modélisation en système à événement discret SED dans l'interface main, p.169

. Dégradé, Les pertes de contrôle sont expliquées au travers de quatre facteurs : l'information, le temps, la compétence

. Cette-démarche-permet-À-partir-du-modèle, opérateur (Figure 5) de comprendre le processus de prise de décision qui mène à l'accident. Une analyse approfondie CAST a cependant des limites dans le sens où :1) elle nécessite de nombreuses données associées à l'ensemble du système qui peuvent difficilement être pleinement obtenues à partir des ressources disponibles ; 2) l'exploitant peut rencontrer des difficultés dans l'application des recommandations qui résultent de l'analyse, en temps opportun, Concernant le cas de cette étude, il reste sûrement encore des questions non résolues

A. L. Aas, Industrial Application of Human Factors Safety Standards, 2010.

A. Abdulkhaleq and S. Wagner, XSTAMPP: an eXtensible STAMP platform as tool support for safety engineering, 2015.

A. Abdulkhaleq, S. Wagner, A. Abdulkhaleq, and S. Wagner, Integrated Safety Analysis Using Systems- Theoretic Process Analysis and Software Model Checking Computer Safety, Reliability, and Security, Lecture Notes in Computer Science A software safety verification method based on system-theoretic process analysis, Computer Safety, Reliability, and Security, pp.121-134, 2014.

A. Abdulkhaleq and S. Wagner, Open Tool Support for System-Theoretic Process Analysis, 2014.

A. Abdulkhaleq, S. Wagner, and N. Leveson, A Comprehensive Safety Engineering Approach for Software-Intensive Systems Based on STPA, Procedia Engineering, vol.128, 2015.
DOI : 10.1016/j.proeng.2015.11.498

M. Abramovici, M. A. Breuer, and A. D. Friedman, Digital systems testing and testable design, 1990.
DOI : 10.1109/9780470544389

M. A. Alkazimi, Investigating new accident causation, risk assessment, and mitigation strategy selection tools in the petroleum industry, 2015.

H. Altabbakh, M. A. Alkazimi, S. Murray, and K. Grantham, STAMP ? Holistic system safety approach or just another risk model? J. Loss Prev. Process Ind, 2014.
DOI : 10.1016/j.jlp.2014.07.010

L. Bertalanffy and . Von, General System Theory, 1969.

D. Besnard and G. Baxter, Human compensations for undependable systems, 2003.
URL : https://hal.archives-ouvertes.fr/hal-00724110

C. Bieder, Les facteurs humains dans la gestion des risques: évolution de la pensée et des outils, 2006.

F. Bird and R. G. Loftus, Loss control management, 1976.

K. E. Boulding, General Systems Theory?The Skeleton of Science, Management Science, vol.2, issue.3, pp.197-208, 1956.
DOI : 10.1287/mnsc.2.3.197

H. Bouloiz, E. Garbolino, M. Tkiouat, and F. Guarnieri, A system dynamics model for behavioral analysis of safety conditions in a chemical storage unit, Safety Science, vol.58, 2013.
DOI : 10.1016/j.ssci.2013.02.013

URL : https://hal.archives-ouvertes.fr/hal-00816373

S. F. Budde, Modeling Blowouts During Drilling Using STAMP and STPA, 2012.

A. Cambien, Une introduction à l'approche systémique: appréhender la complexité, 2008.

J. Cambon, Vers une nouvelle méthodologie de mesure de la performance des systèmes de management de la santé-sécurité au travail -document, 2007.

J. Cambon, F. Guarnieri, and J. Groeneweg, Towards a new tool for measuring Safety Management Systems performance Learning from Diversity: Model-Based Evaluation of Opportunities for Process (Re)-Design and Increasing Company Resilience, 2006.

S. J. Carlson, NURail Project ID: NURail2012-MIT-R03 Transportation of Energy, 2015.

S. J. Carlson, Understanding government and railroad strategy for crude oil transportation in North America (Thesis), 2014.

L. W. Cullen, The Public Inquiry into the Piper Alpha Disaster, Drill. Contract, 1993.

G. Desmorat, F. Guarnieri, D. Besnard, P. Desideri, and F. Loth, Pouring CREAM into natural gas: The introduction of Common Performance Conditions into the safety management of gas networks, Safety Science, vol.54, pp.1-7, 2013.
DOI : 10.1016/j.ssci.2012.10.008

URL : https://hal.archives-ouvertes.fr/hal-00769813

S. Dobi, M. Gleirscher, M. Spichkova, and P. Struss, Model-based Hazard and Impact Analysis, 2013.

A. Dong, Application of CAST and STPA to railroad safety in China, 2012.

D. Durand, La systémique, Presses universitaires de France, 1979.

E. Fadier and M. Mazeau, L'activité humaine de maintenance dans les systèmes automatisés : problématique générale, J. Eur. Systèmes Autom, vol.30, pp.1467-1486, 1996.

B. Fahlbruch and B. Wilpert, La notion de sécurité systèmique: un nouveau domaine de recherché pour la psychologie industrielle, L'Harmattan, Collection Risques Collectifs et, 2001.

T. S. Ferry, Modern Accident Investigation and Analysis, 1988.
DOI : 10.1002/9780470172230

J. Forrester, The beginning of system dynamics. McKinsey Q, pp.4-17, 1995.

J. W. Forrester, Industrial Dynamics?After the First Decade, Management Science, vol.14, issue.7, pp.398-415, 1968.
DOI : 10.1287/mnsc.14.7.398

E. Garbolino, J. P. Chery, and F. Guarnieri, Modélisation dynamique des systèmes industriels à risques, Lavoisier, Technique & Documentation SRD -Sciences du risque et du danger : Série Notes de synthèse et de recherche, 2010.

J. Groeneweg, Controlling the controllable: preventing business upsets, 2002.

J. Groeneweg, K. N. Van-schaardenburgh-verhoeve, S. Corver, G. E. Lancioni, T. Knudson et al., Accident investigation beyond the boundaries of organizational control, Presented at the Proceedings of Esrel 2007 Conference, 2007.

F. Guarnieri, J. Cambon, and I. Boissieres, De l'erreur humaine à la défaillance organisationnelle : essai de mise en perspective historique, 2008.

F. Guenebeaud, Les représentations sociales des risques majeurs au sein de la communauté éducative du second degré, 2013.

H. Altabbakh, M. A. Alkazimi, S. Murray, and K. Grantham, STAMP ??? Holistic system safety approach or just another risk model?, Journal of Loss Prevention in the Process Industries, vol.32, 2014.
DOI : 10.1016/j.jlp.2014.07.010

K. Hardy, Decisions Management during Wildland Fires: Accidents Viewed as a Spatiotemporal Inadequacy, Am. Sci. Res. J. Eng. Technol. Sci. ASRJETS, vol.23, pp.63-77, 2016.

K. Hardy, Contribution à l'étude d'un modèle d'accident systémique, le cas du modèle STAMP : application et pistes d'amélioration -document, 2011.

K. Hardy, Contribution à l'étude d'un modèle d'accideny systémique, le cas du modèle STAMP:application et pistes d'amélioration. MINES ParisTech, 2011.

K. Hardy, Contribution à l'étude d'un modèle d'accident systémique, le cas du modèle STAMP : application et pistes d'amélioration, 2010.

K. Hardy and F. Guarnieri, Hazard Mitigation through a Systemic Model of Accident to a Socio-Technical System: A Case Study, J. Energy Power Eng, vol.7, p.775, 2013.
URL : https://hal.archives-ouvertes.fr/hal-00823248

K. Hardy and F. Guarnieri, Modelling and hazard analysis for contaminated sediments using stamp model, 14th International Conference on Process Integration, Modelling and Optimisation for Energy, Saving and Pollution Reduction, pp.737-742, 2011.
URL : https://hal.archives-ouvertes.fr/hal-00660404

K. Hardy and F. Guarnieri, Using a Systemic Model of Accident for Improving Innovative Technologies: Application and Limitations of the STAMP model to a Process for Treatment of Contaminated Substances, The 15th World Multi- Conference on Systemics, Cybernetics and Informatics: WMSCI 2011, 2011.
URL : https://hal.archives-ouvertes.fr/hal-00660426

K. Hardy and F. Guarnieri, Analyzing Contaminated Sediments through a Systemic Model of Accident, in: 41st ESReDA Seminar -Advances in Reliability- Based Maintenance Policies, 2011.

H. W. Heinrich, Industrial Accident Prevention. A Scientific Approach, 1941.

F. Hoel, Modeling Process Leaks Offshore Using STAMP and STPA, 2012.

E. Hollnagel, Safety-I and safety?II: the past and future of safety management, 2014.

E. Hollnagel, Safety Management: from protection to resilience, UIC Saf. Platf. Paris, pp.20-21, 2006.

E. Hollnagel, Barriers and accident prevention, 2004.

E. Hollnagel and D. D. Woods, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering, 2005.
DOI : 10.1201/9781420038194

E. Hollnagel, D. D. Woods, and N. Leveson, Resilience Engineering: Concepts and Precepts, ISSS, n.d. International Society for the Systems Sciences. Wikipedia Free Encycl, 2007.
URL : https://hal.archives-ouvertes.fr/hal-00572766

L. John and . Thorogood, The Macondo Inflow Test Decision: Implications for Well Control and Non-technical Skills Training, Presented at the Drilling Conference and Exhibition, Society of Petroleum Engineers or the International Association of Drilling Contractors, 2015.

W. G. Johnson, MORT Safety Assurance System -Google Scholar, 1980.

T. Kim, N. Salman, and I. Ø. Kjell, A STAMP-based causal analysis of the Korean Sewol ferry accident, Safety Science, vol.83, 2016.
DOI : 10.1016/j.ssci.2015.11.014

J. C. Knight, Safety critical systems, Proceedings of the 24th international conference on Software engineering , ICSE '02, pp.547-550, 2002.
DOI : 10.1145/581339.581406

S. S. Krauss, M. Rejzek, and C. Hilbes, Tool Qualification Considerations for Tools Supporting STPA, Procedia Engineering, vol.128, 2015.
DOI : 10.1016/j.proeng.2015.11.500

URL : http://doi.org/10.1016/j.proeng.2015.11.500

J. Larouzée and F. Guarnieri, From theory to practice: itinerary of Reasons' Swiss Cheese Model. ESREL 2015, 2015.

J. Larouzée and F. Guarnieri, Huit idées reçues sur le (s) modèle (s) de l'erreur humaine de James Reason, REE Rev. Electr. Electron, vol.5, pp.83-90, 2014.

L. Moigne and J. , La modélisation des systèmes complexes, 1990.

J. Lederer, How far have we come? A look back at the leading edge of system safety eighteen years ago, 1986.

N. Leveson, A Systems Thinking Approach to Leading Indicators in the Petrochemical Industry, 2013.

N. Leveson, A Systems Thinking Approach to Leading Indicators in the Petrochemical Industry, 2013.

N. Leveson, Engineering a Safer World: Systems Thinking Applied to Safety, 2011.

N. Leveson, A new accident model for engineering safer systems, Safety Science, vol.42, issue.4, pp.237-270, 2004.
DOI : 10.1016/S0925-7535(03)00047-X

URL : http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.141.697

N. Leveson, A new approach to system safety engineering. Manuscr. Prep, 2002.

N. Leveson, Evaluating Accident Models Using Recent Aerospace Accidents, Part 1: Event-Based Models, 2001.

N. Leveson, Software safety, ACM SIGSOFT Software Engineering Notes, vol.7, issue.2, 1986.
DOI : 10.1145/1005937.1005940

N. Leveson and N. Dulac, Safety and Risk-Based Design in Complex Systems-of-Systems, 1st Space Exploration Conference: Continuing the Voyage of Discovery, 2005.
DOI : 10.2514/6.2005-2558

N. G. Leveson, Rasmussen's legacy: A paradigm change in engineering for safety, Applied Ergonomics, vol.59, 2016.
DOI : 10.1016/j.apergo.2016.01.015

M. Llory, Accidents industriels: le coût du silence: opérateurs privés de parole et cadres introuvables, 1996.

S. Mccarthy, A System Theoretic Safety Analysis of Friendly Fire Prevention in Ground Based Missile Systems, 2013.

D. H. Meadows, The Limits to growth; a report for the Club of Rome's project on the predicament of mankind, 1972.
DOI : 10.1349/ddlp.1

R. F. Miles, Systems Concepts: Lectures on Contemporary Approaches to Systems, IEEE Transactions on Systems, Man, and Cybernetics, vol.4, issue.6, 1973.
DOI : 10.1109/TSMC.1974.4309372

E. Morin, Introduction à la pensée complexe, 2015.

H. J. Pasman, Risk Analysis and Control for Industrial Processes -Gas, Oil and Chemicals: A System Perspective for Assessing and Avoiding Low-Probability, High- Consequence Events, 2015.

L. Pelegrín, Integrating Safety into an Engineering Contractor's System Engineering process using the guidelines of STAMP (Systems-Theoretic Accident Mod el and Processes), 2012.

P. Peretti-watel, Du recours au paradigme épidémiologique pour l'étude des conduites à risque, Rev. Fr. Sociol, vol.45, pp.103-132, 2004.
DOI : 10.2307/3323183

T. V. Perneger, The Swiss cheese model of safety incidents: are there holes in the metaphor?, BMC Health Services Research, vol.17, issue.Suppl 2, pp.71-81, 2005.
DOI : 10.1093/intqhc/mzi021

L. Perrin, F. Muñoz-giraldo, O. Dufaud, and A. Laurent, Normative barriers improvement through the MADS/MOSAR methodology, Safety Science, vol.50, issue.7, 2012.
DOI : 10.1016/j.ssci.2012.02.002

URL : https://hal.archives-ouvertes.fr/hal-00738175

C. Perrow, Accidents, Normal, 1984.
DOI : 10.1016/B0-08-043076-7/04509-5

N. F. Pidgeon, Safety Culture and Risk Management in Organizations, Journal of Cross-Cultural Psychology, vol.22, issue.1, pp.129-140, 1991.
DOI : 10.1177/0022022191221009

P. Thammongkol, The system theoretic accidental analysis of a crude unit refinery fire incident (Thesis), 2014.

Z. H. Qureshi, A review of accident modelling approaches for complex sociotechnical systems, Proceedings of the Twelfth Australian Workshop on Safety Critical Systems and Software and Safety-Related Programmable Systems, pp.47-59, 2007.

&. Rasmussen and . Svedung, Proactive risk management in a dynamic society, 2000.

J. Rasmussen, Risk management in a dynamic society: a modelling problem, Safety Science, vol.27, issue.2-3, 1997.
DOI : 10.1016/S0925-7535(97)00052-0

J. Reason, Managing the Risks of Organizational Accidents, Routledge. Reason, J, 2016.

J. Reason, A systems approach to organizational error, Ergonomics, vol.40, issue.8, pp.1708-1721, 1995.
DOI : 10.2118/27846-PA

J. Reason, Human Error, 1990.

J. Reason and E. Hollnagel, Revisiting the «Swiss cheese» model of accidents, J, 2006.

S. Revet, ?Living in a safer world?: ?Natural? disasters and ?global? security, Cultures & conflits, issue.75, 2009.
DOI : 10.4000/conflits.17693

K. H. Roberts, Managing the unexpected: six years of HRO-literature reviewed, Journal of Contingencies and Crisis Management J. Contingencies Crisis Manag, 2009.

P. Rodrigo, Le jeu causal dans la Politique d'Aristote : eidétique et typique [WWW Document]. URL https://halshs.archives-ouvertes, 2011.

R. Haugen-syvertsen-rosenblueth, A. Wiener, N. Bigelow, and J. , Behavior, Purpose and Teleology, Philosophy of Science, vol.10, issue.1, pp.18-24, 1943.
DOI : 10.1086/286788

J. D. Rosnay, Le Macroscope. Vers une vision globale, 2014.

J. D. Rosnay, Le macroscope Vers une vision globale, 1975.

E. H. Sagvolden, Statistical analysis of failures and failure propagation in railway track, 2013.

J. Samadi, Development of a systemic risk management approach for CO2 capture, transport and storage projects, 2012.
URL : https://hal.archives-ouvertes.fr/pastel-00870894

J. Samadi, Development of a systemic risk management approach for CO2 capture, transport and storage projects (phdthesis) Ecole Nationale, 2012.

J. Samadi and E. Garbolino, A new dynamic risk analysis framework for CO2 Capture, Transport and Storage chain, Presented at the 29th International Conference of the System Dynamics Society, p.17, 2011.
URL : https://hal.archives-ouvertes.fr/hal-00660586

V. Sanseverino-godfrin, Le cadre juridique de la gestion des pollutions et des risques industriels, 2010.
URL : https://hal.archives-ouvertes.fr/hal-00613342

E. Sefer, B. Gallina, H. Muccini, and K. Lundqvist, A model-based safety analysis approach for high-integrity socio-technical component-based systems, 2015.

C. E. Shannon, A mathematical theory of communication, ACM SIGMOBILE Mobile Computing and Communications Review, vol.5, issue.1, pp.3-55, 2001.
DOI : 10.1145/584091.584093

. Silje-frost-budde, Modeling Blowouts During Drilling Using STAMP and STPA, 2012.

S. Skelt, Methods for accident analysis, No. ROSS (NTNU), 2002.

D. Spiegel, R. S. Hosse, J. Welte, and E. Schnieder, Integration of Petri Nets into STAMP, 2013.

R. H. Syvertsen, Modeling the Deepwater Horizon blowout using STAMP, 2012.

P. Thammongkol, The system theoretic accidental analysis of a crude unit refinery fire incident (Thesis), 2014.

J. Thomas, F. Lemos, and N. Leveson, Evaluating the safety of digital instrumentation and control systems in nuclear power plants, 2012.

J. P. Thomas, Extending and automating a systems-theoretic hazard analysis for requirements generation and analysis, 2013.
DOI : 10.2172/1044959

A. O. Torgauten, Classifying and Defining Operational and Organizational Aspects of Barriers for the Offshore Oil and Gas Industry, 2013.

E. L. Trist, Some Social and Psychological Consequences of the Longwall Method of Coal-Getting, Human Relations, vol.4, issue.1, pp.3-38, 1951.
DOI : 10.1016/S0140-6736(47)90336-X

P. Underwood, Systemic accident analysis: Examining the gap between research and practice, Accident Analysis & Prevention, vol.55, 2013.
DOI : 10.1016/j.aap.2013.02.041

P. Underwood and P. Waterson, 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, Accident Analysis & Prevention, vol.68, pp.75-94, 2014.
DOI : 10.1016/j.aap.2013.07.027

G. Unnikrishnan and A. Rajab, Integrating Systems Approach in Accident and Incident Investigations, SPE International Conference on Health, Safety, and Environment in Oil and Gas Exploration and Production, 2008.
DOI : 10.2118/111590-MS

D. Vaughn, The Challenger launch decision, 1996.

A. Villemeur, P. Caseau, and A. Harcourt, Sûreté de fonctionnement des systèmes industriels: fiabilité, facteurs humains, informatisation. Eyrolles, 1988.

J. A. Volpe, A Transportation Systems Safety Hazard Analysis Tool, 2014.

B. Wilpert and B. Fahlbruch, Safety related interventions in interorganisational fields, Saf. Manag. Chall. Change, 1998.
DOI : 10.1016/b978-008043075-1/50017-0

P. D. Woods, P. N. Leveson, and P. E. Hollnagel, Resilience Engineering: Concepts and Precepts, 2012.
URL : https://hal.archives-ouvertes.fr/hal-00572766