- 學位論文
應用HFACS探討跑道事故之人為失誤
The Application of HFACS for Runway Occurrence with Human Errors
摘要
有鑑於跑道安全相關事故持續佔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事故調查資料庫1998~2015年共調查56件渦輪定翼飛機事故，而跑道安全相關事故就佔其中的35件，所佔比例最大（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佔比例亦為最高，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，運用飛航安全調查委員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，引發事故頻率次數最多之五項人為失誤子項目為：「技術操作錯誤」、「決策錯誤」，以及「自然環境與物理條件」；從關聯分析發現，每一高層級子項目，多數可測得較低層級子項目（τ值，p<0.5）之預測效果，程度均介於3%~23.5%之間；另以勝算比（odds ratio）分析，亦發現高層級子項目出現對低層級子項目出現的機率介於0.1~46.125倍之間。本研究結果顯示高層級隱性之人為失誤引發低層級顯性人為失誤之預測效果，可以供相關單位政策制定及訓練改善參考。
並列摘要
Whereas runway safety-related accidents constitute a large 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 take the major portion of all types of accidents. They shared 35 out of 56 turbojet and turboprop accidents during 1998~2015, and most cases were caused by human errors. Therefore, investigations of human errors for accident/incident investigation 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 such probable human factors and influence routes within flight accidents 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 accident occurrences. The categories at higher levels have predicted power between 3% and 23.5% toward the categories at lower levels. The values of odds ratio were found between 0.1 and 46.125 The results might provide aviation authorities for improving aviation safety by define the factors of higher level human errors how to causes low level aviation affairs.