航空維修業安全查核報告之人因層級分析

A Human Factors Hierarchical Analysis of the Safety Audit Reports of a Aircraft Maintenance Organization

彭惠婍(HUEI-CHI PENG)

指導教授 ： 蕭育霖

中原大學/電機資訊學院/工業與系統工程學系/碩士(2022年)

https://doi.org/10.6840/cycu202201591

摘要

有鑑於人為疏失是飛安事件的主要肇因，探討組織現存的人因風險因子，以及因子之間的交互影響關係有其必要性，可協助組織管理者評估如何阻斷人因風險的形成。本研究使用了國內某航空維修業者提供的安全查核資料進行分析，運用「人為因素分析及分類系統（Human Factors Analysis and Classification System, HFACS）」架構，逐筆解讀與分析安全查核報告內的人因風險。後續則使用卡方檢定、費雪精確檢定、誤差比例遞減度量以及勝算比進行因子層級影響分析。分析結果顯示「組織」與「管理」層皆會對環境以及相關人員的直接疏失造成影響。其中以組織「安全監理」系統影響管理者「控制/改正行為」，進而影響到人員「不良狀態」，最後促成人員「技術型疏失」的發生是統計上最為顯著的影響路徑。如欲改善人為疏失相關因子，可考慮從組織與管理層面著手。此研究成果提供了確切的人因風險量化分析結果，可協助安全管理主管評估如何投入安全資源，促成直接人為疏失的降低。

關鍵字

人為因素分析及分類系統 ； 安全查核 ； 人為疏失

並列摘要

Given that human error is the main cause of flight accidents, it is necessary to explore the existing human risk factors in organizations and the interaction between them, which can help organizational managers evaluate how to block the formation of human risks. This research uses the safety audit data provided by a domestic aircraft maintenance company for analysis, and uses the "Human Factors Analysis and Classification System (HFACS)" framework to interpret and analyze the human risks existed in the report. In the follow-up, factor-level analysis was carried out using chi-square test, Fisher's exact test, measure of decreasing proportion of error, and odds ratio methods. The results show that both the "organization" and "management" levels have significant impacts on the environmental factors and the direct errors of the people involved. Among them, the most statistically significant influence path is as described. The organization's "safety oversight" system affects the "control/correction behavior" of managers, which in turn affects the "adverse state" of personnel, and finally contributes to the occurrence of "skill-based errors" of personnel. If you want to improve the factors related to human error, you can consider starting from the organizational management level. The results of this study provide a definitive quantitative analysis of human-related risk that can assist safety management executives in evaluating how to invest safety resources to reduce direct human error.

並列關鍵字

Human Factors Analysis and Classification System ； Safety Audit ； Human Error

參考文獻

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