以情境知覺模型探討飛行員常見溝通失誤之人為因素

Investigation on Pilot Communication Errors Using Situation Awareness Model

管順婷(Shun-Ting Kuan)

指導教授 ： 王明揚 教授

國立清華大學/工學院/工業工程與工程管理學系/碩士(2007年)

https://doi.org/10.6843/NTHU.2007.00364

摘要

我國近十年來民航事業蓬勃發展，飛航安全逐漸受到重視，而從過去的文獻中可發現情境知覺是影響飛航安全的重要因素之一。由於飛行員的工作性質特殊，身負航機安全的重大責任，因此一旦遇到緊急狀況時，其壓力可想而知。根據美國聯邦航空總署(Federal Aviation Administration, FAA ASD-100)的統計資料顯示，有27%的操作性失誤、40%的飛行員偏離航道以及15%的空中接近事件是由於航管通話失誤所造成。在Prinzo(1995)的研究中，也明確的指出飛行員對話中有超過59%至少包含一項通話失誤，而分析美國國家運輸安全委員會所公布的事件調查(Endsley, 1995a)，可以發現其中有88%的意外事件來自於情境知覺的不完整。因此，以溝通失誤事件發生的嚴重性與頻率而言，飛行員與航管人員間溝通品質對於飛航安全而言是相當重要的因素。
本研究以錄音抄件分析、實驗模擬和問卷的方式來探討造成口語溝通失誤類型的人為因素。針對國內發生頻率高的違規飛安事件—隔離不足與跑道入侵，以Endsley(1995a)提出之情境知覺模型進行案例情境知覺的分析，整理歸納出十八項失誤類型，並予以統計發生次數，最後推論出其關鍵的影響人為因子。
由本研究結果可得知有六項飛行員失誤類型（不完整的呼號、不完整的聆聽/覆誦、語法格式錯誤、術語誤用、不完整的資訊以及沒有回應）發生的頻率遠高於其它幾項；而從模擬實驗的SAGAT問卷分析得到的結果，可發現飛行員在飛航過程中的情境知覺表現的確會受到緊急情境的影響，當作業複雜性增加，飛行員的情境知覺正確率便降低。透過問卷和錄音抄件的結果整理出可能影響情境知覺和失誤類型的根本人為因子，可發現當遇到緊急情況時，訓練背景的差異甚至經驗都會影響其情境知覺的完整性，進而影響其語言的使用，導致無法因應狀況使用完整的術語進行溝通，而影響雙方溝通的效率。

關鍵字

情境知覺 ； 飛航管制 ； 模擬實驗 ； 人為因素 ； 失誤類型

並列摘要

Due to vigorous development of the commercial aviation enterprises, aviation safety becomes more and more important. From the literature review, it was found that situation awareness has a great influence on aviation safety. Since the occupational characteristics of pilots are quite special, including great responsibility for aviation safety, once they encounter an emergency situation, they have to deal with higher mental stress than ordinary level. According to the statistic data from Federal Aviation Administration, there were 27% operational errors, 40% orbit aviation and 15% approaching accidents resulting from communication errors. In the study of Prinzo(1995), it indicates that over 59% pilots have at least one communication error during their communications; from the report of NTSB (Endsley, 1995a), 88% accidents come from situation awareness failures. Consequently, communication qualities between pilots and controllers are very important for aviation safety as the severity and frequency of accidents involved in communication errors.
This study investigates the human factors resulting in communication errors by the transcript analysis, aviation simulation experiment and questionnaire. We analyze the situation awareness by the SA model from Endsley and calculate the times of eighteen error types. In the end of the research, we inference to the human factors from cases which the accident types involved were those happened most frequently in the past few years.
From the results, it was found that there are six most frequent error types of pilots (incomplete call sign, incomplete hearback/readback, wrong grammar, wrong terminology, incomplete information and no response). And it was also found that SA performance will be influenced by emergency situations. As the work complexity increase, the correction of situation awareness decrease from the SAGAT.
As the result of key human factors affecting situation awareness and error types from the questionnaire and transcript analysis, differences of training background and experience might affect the completeness of SA and communication efficiency when pilots face emergency situations which causes in incorrect terminologies and wrong grammar.

並列關鍵字

Situation Awareness ； Air Traffic Control ； Simulation Experiment ； Human Factors ； Communication Errors

參考文獻

蔡秋月，「從心理學的觀點如何減少人為失誤」，航空醫學會刊，第11 卷，

Damos, D., and Wickens. C. D. (1980). The acquisition and transfer of time-sharing skills. Acta Psychologica, 6, 569-577.

Endsley, M. R. (1987). SAGAT: A methodology for the measurement of situation awareness (NOR DOC 87-83). Hawthome, CA: Northrop Corp.

Endsley, M. R., & Rodgers, M. D. (1994). Situation Awareness Global Assessment Technique (SAGAT): En route air traffic control version user's guide (Draft). Lubbock: Texas Tech University.

Endlsey, M. R., (1995a). Toward a theory of situation awareness in dynamic-systems. Hum. Factors 37 (1), 32–64.