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篇名 應用HFACS探討跑道安全相關事故之人為失誤
卷期 46:1
並列篇名 APPLICATION OF HFACS TO INVESTIGATE HUMAN ERRORS IN RUNWAY SAFETY RELATED OCCURRENCES
作者 楊慧華劉穎儒
頁次 085-116
關鍵字 跑道安全人為失誤人為因素分析與歸類系統Runway safetyHuman errorHuman factors analysis and classification system TSSCI
出刊日期 201703

中文摘要

有鑑於跑道安全相關事故持續占所有飛航事故最大的比例,且造成多數乘員的傷亡,因此國際民航組織(ICAO) 大會A37-6決議敦促世界各國加強跑道安全。我國飛航安全調查委員會(簡稱飛安會) 事故調查資料庫1998-2015年共調查69件渦輪定翼飛機事故,而跑道安全相關事故就占其中的35件,所占比例最大(50.7%),飛航事故依發生原因分類(causes/ factors),歷年來與人相關之事故所占比例亦為最高,因此飛航事故人為失誤之調查更顯重要。 本研究以「人為因素分析與歸類系統(HFACS)」為理論架構,運用飛安會發展出適合飛航事故調查使用之人為因素調查輔助工具「ASC-HFACS」,分析國內跑道安全33件事故,希望能從分析結果發現跑道安全相關事故中的人為因素,並於早期開始預防以增進飛航安全。從內容分析結果發現,引發事故次數最多之3項人為失誤子項目為:「技術操作的錯誤」、「決策錯誤」,以及「自然環境與物理條件」;從關聯分析發現自然環境與物理條件、操作者個人狀態、督導能力及組織文化/氣候等問題對事故較具關聯影響性;從引發技術操作及決策錯誤之「失誤影響路徑」,改善高層級隱性之人為失誤項目,應能對降低跑道安全相關事故有所助益。

英文摘要

In view of the fact that runway safety-related accidents constitute to account for the largest portion of all accidents and have resulted in a great number of fatalities, International Civil Aviation Organization (ICAO) Assembly resolution A37-6 urged states to enhance runway safety. According to the statistics of Aviation Safety Council in Taiwan, runway safety-related accidents/serious incidents take the major portion (50.7%) of all types of flight occurrences. They shared 35 out of 69 turbojet and turboprop occurrences during 1998-2015, and most cases were caused by human errors. Therefore, investigations of human errors in runway safety related occurrences will be valuable. The goal of this research is to analyze human factors resulted in aviation mishaps and developing strategies to prevent accidents. The ASC-HFACS based on HFACS model will be used to analyze human factors to 33 runway safety-related accidents to explore influence routes within flight occurrences from organizational management to individual operation level. The content analysis of the accident reports shows that skill-based errors, decision errors, and physical environment are the most frequently occurring categories influencing flight occurrences. The analysis of associations suggest that physical environment, condition of operators, supervisory competence, and organizational culture/climate issues are deemed the most potent for accident occurrences. To reduce the runway related accidents resulting from skill-base and decision errors in flight operations the “paths to failure” relating to these organizational and human factors issues must be addressed.

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