人爲失誤鑑別方法：階層任務分析與人爲失誤預測模組之應用

Methodology of Human Error Identification: The Application of Hierarchical Task Analysis and Human Error Template

李倫文(L.W.Li) ； 李文進(W.C.Li) ； 許悅玲(Y.L.Hsu) ； 張自安(D.A.Chang)

《危機管理學刊》 6卷1期 (2009/03) Pp. 87-94

https://doi.org/10.6459/JCM.200903_6(1).0010

摘要

人爲失誤的發生與飛機各系統的設計有著非常複雜的互動關係，儘管新一代高度自動化的飛機具備眾多優點，但新型態的[人爲失誤]亦相繼在座艙中被激發出來。［人爲失誤預測模組(HET)］是以檢查表形態，包含十二項錯誤模式，做爲預測人爲失誤之方法，並應用［階層任務分析(HTA)］，將每一個任務所需執行的步驟分析到最底層，分析者必須辨認出每一任務步驟潛在錯誤模式發生之機率，與對飛行安全影響程度之嚴重性。階層任務分析法所提供的相關訊息，更被應用於人爲失誤鑑別技術(Human ErrorIdentification, HEI)。本研究應用國際上最新發展之HET 方法，預測B-744 在預降落階段的潛在人爲失誤之模式，透過改善[軟體設計]及［硬體裝備］之效率，讓[操作環境]更適合［人］之操作，使整個系統在人－機器－環境的介面沒有代溝，以確保飛行安全。

關鍵字

人爲失誤鑑別技術 ； 人爲因素預測模組 ； 飛行安全 ； 階層任務分析

並列摘要

Human error is often the result of complex interrelationships between humans and computers. In spite of the development for new technology in the aviation domain, new types of human errors have been provoked in the modern cockpit. Human Error Template (HET) is a new approach to predict human errors in the cockpit and a checklist style approach to error prediction that comes in the form of an error pro forma containing twelve error modes. HET is applied to each bottom level task step in a hierarchical task analysis (HTA) of the task in question. The technique requires the analyst to indicate which of the HET error modes are credible for each task step, the probability of error and the criticality of error, based upon their judgment. This research applies the latest technique for Human Error Identification (HEI) to evaluate current standard operation procedures of B-744. The research aims are to predict the potential design-induced human errors in the B-744 during the landing phase of flight and provide a basis for improving software design and hardware equipment to enhance flight safety.

並列關鍵字

Aviation Safety ； Hierarchical Task Analysis ； Human Error Identification ； Human Error Template

參考文獻

hapanis, A(1999).The Chapanis Chronicles: 50 years of Human Factors Research, Education, and Design.Santa Barbara, CA:Aegean Publishing Company.

Boeing Commercial Airplanes Group(2000).Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-1999.Boeing, Seattle, WA:

Civil Aviation Authority(1998).Global Fatal Accident Review 1980-96 (CAP 681).London:Civil Aviation Authority.

Federal Aviation Administration(1996).Report on the Interfaces between Flightcrews and Modern Flight Deck Systems.Washington DC:Federal Aviation Administration.

Woods, D.,Sarter, N(1998).Institute for Ergonomics, Report ERGO-CSEL-98-02.NASA Ames CA.