從空軍建立作業風險管理機制探討提升飛航安全之作法

A Study on the Enhancement of Aviation Safety --- A case of the Operational Risk Management Mechanism of the ROC Air Force

陳肇敏(Chao-Min Chen)

指導教授 ： 黃崇興教授

國立臺灣大學/管理學院/高階公共管理組/碩士(2006年)

https://doi.org/10.6342/NTU.2006.10342

摘要

空軍為擔負國防第一線「捍衛者」的重要角色，換句話說，空軍戰力的有效發揮，直接維繫著台海的安全與和平，更因戰機與飛行員皆是國家不易在短時間內獲得或培訓的珍貴資產，故任何一次飛安事件發生，對國家、社會、家庭以及個人都造成嚴重傷害，折損國軍戰力至鉅。
民國八十九年余擔任空軍總司令任內，即大力推展「作業風險管理」至空軍各飛行單位，目前在飛安工作上獲致之成效與累積的成果，深獲全軍一致的肯定，並且在管理上逐步形成優良文化。大家都知道，飛安預防工作即使投入再多的心力，仍很難百分之百防制危安事件的發生，這更喚起大家重視與警惕；因此，如何針對危安因素進行有效控管與防範，建立優質飛安文化，提升整體戰力，空軍應持續列為工作重點，並朝政策、機制及執行面戮力改善，期能將危安事件之發生降至最低，甚至「零」失事率，當然一旦不幸發生飛安事件，其損失亦應控制在可承受之範圍內。
回顧民航空難事件，造成航空公司、產險業者以及旅客生命財產之損失不可數計，更損及國家之國際形象及飛安聲譽。近年來民航局在歷次年度飛航檢討會議中，雖己積極探討我國民航機飛行失事率居高不下的主要因素，也採行「成立飛航安全委員會」等改善方案，然觀諸1999年以來連續幾起重大飛安事件，顯示出我國飛航安全管理仍需進一步檢討與改善。是以本文研究動機係結合「風險管理之概念、願景、目標、原則、程序及失事預防政策」等，深入探討空軍推行作業風險管理五年來對飛機失事預防之成效，本「事前防範重於事後處理」的危機與風險管理觀念，分析飛安管理缺失與罅隙，並提出具體改進建議，期能將空軍執行風險管理之經驗與方法，供國內民航業管及業界參考運用，以建構具體完整之模式，提升整體飛航安全。
本研究另一主要目的，即在闡述空軍實施作業風險管理機制之執行步驟及管理文化，對飛機失事預防提供參考，重點包括：飛行訓練、飛航規則、人員生活考管、飛機修護督察、機場場面設施管理、天氣狀況掌握、鳥害防制等作業風險管理工作，針對主要控制變因做深入探討與瞭解，期在有限資源，透過風險辨識、確認、評估、控制、預防與檢討等步驟，以經濟且有效預防作為，不斷落實督導與考核，
本文透過飛航風險因素確認、風險因素評估、風險控制方法、風險控制與決策、執行風險控制及監督與檢討並佐以成功與失敗案例探討，評估空軍推展作業風險管理之成效，並比較軍方與民航業推動風險管理作法之異同與可行性，俾擷長補短，相互激勵、觀摩、學習，期能有效提升我國整體飛航安全，共同朝向「飛安零缺點」之目標邁進。

關鍵字

作業風險管理 ； 風險管理 ； 個案研究 ； 飛航 ； 風險

並列摘要

The ROC Air Force is the frontline defender of the country. Whether its combat capability can be effectively exerted is directly linked to the maintenance of peace and security in the Taiwan Strait. In addition, it is a lengthy process acquiring advanced warplanes and training pilots, which are both valuable assets to the Air Force. Therefore, any aviation safety incident could result in severe loss to the country, society, families and the involved individuals.
Since 2000, when I assumed the Commander in chief of Air Force, I have been devoted to implement “Operational Risk Management” in the Air Force. The efficiency demonstrated so far and the accumulated achievements have been widely recognized within the service and helped to create a refined managerial culture. It is an undeniable fact that, no matter how much effort is invested, it is difficult to achieve a zero percent incident rate. This should, however, raise higher awareness and vigilance in guarding against aviation safety incident. The top priorities of the Air Force should be establishing effective control and prevention based on possible dangers to aviation safety, cultivate an impeccable safety environment, and enhance overall combat capabilities. Ideally, aviation safety incidents should be extinguished. When they do take place, the damage should be controlled within a manageable scale.
Past incidents have caused incalculable losses to airlines, insurance companies, and especially the lives and properties of passengers. They can also smear the image and reputation of a country. At the recent annual review meetings of the Civil Aeronautics Administration, primary factors obstructing the reduction of incidents were examined, while various improvements such as establishing an Aviation Safety Committee were also made. However, several major incidents since 1999 indicated that there are still rooms for improvement. This study attempted to integrate the concepts, visions, objectives, and principles of risk management with prevention policies. It then reviewed the effectiveness of the Air Force utilizing operational risk management for incident prevention in the past five years. Based on the concept of “prevention is better than remedy,” deficiencies in management were analyzed and concrete methods for improvement were proposed. The purpose was to provide the lessons learned and methodologies of the risk management of the Air Force to be used as references for the civil aviation authorities and private airlines as they establish a well-rounded model for enhancing overall aviation safety.
Another objective of this study was to provide a sketch of the procedures and management culture of the risk management mechanism of the Air Force. The focuses were on fly training, aviation regulations, personnel disciplines, supervision on aircraft maintenance, management of airfield facilities, monitoring weather conditions, bird strike prevention, etc. Primary controllable variants were explored in depth. Though resources are limited, a better efficiency in incident prevention nevertheless has to be achieved through the buildup of stronger awareness on potential crisis and clearer concepts of risk. Therefore, economical and effective prevention has to be in place along with stringent supervision and assessment through procedures including risk identification, confirmation, evaluation, control, and prevention.
This study assessed the efficiency of Air Force risk management through risk factor identification, risk factor assessment, risk control measures, risk control and policy, as well as risk control implementation, supervision, and review. Success stories and failures were also examined. In addition, risk management of the civil aviation sector were cited for comparison and feasibility study, so as to find the best practice and create opportunities for mutual inspiration, observation, and learning. The overall objective of this study is to refine Taiwan’s aviation safety to its perfection.

並列關鍵字

Operational Risk Management ； Risk Management ； Case Study ； Aviation ； Risk

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