以人因層級分析探討航空維修組織之安全危害分析報告

Investigating the Safety Hazard Assessment Reports of an Aircraft Maintenance Organization via the HFACS Framework

李品萱(PIN-SYUAN LEE)

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/cycu202201649

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危害(Hazard)因子，以及因子之間的交互影響關係有其必要性，可用以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危害分析報告，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危害類型。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。其中最為顯著的影響路徑之一，為組織「安全監理」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」；影響路徑之二則為組織「組織資源管理」影響管理「規劃/組織」工作，進而再影響到人員「工作任務」後，造成第一線人員發生「技術型疏失」問題。此研究成果提供了確切的人因危害量化分析結果，可協助安全管理主管評估在那些環節投入安全資源，促成直接或間接人為疏失的降低。

關鍵字

人為疏失 ； 危害識別 ； 人為因素分析及分類系統

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 used the safety audit data provided by a domestic aircraft maintenance company for analysis, and used the "Human Factors Analysis and Classification System (HFACS)" framework to interpret and analyze the human risks existed in the reports. 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 of the analysis showed that both the "organization" and the "management" levels have an impact on the environment and the direct negligence of those involved. One of the most significant impact paths is from the "Safety Oversight" of the organization level to the "Controlling/Correcting" of management level, which in turn affects the "Adverse States" of precondition level, and finally contributes to "Skill-based Errors" of first line workers. The second impact path is that the "Resource Management" of organization level affects the "Planning/Organizing" of managers and the "Task Demands" of precondition level, resulting in the occurrence of "Skill-based Errors" of front-line personnel. 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 and indirect human error in the future.

並列關鍵字

Human Error ； Hazard Identification ； HFACS

參考文獻

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