台灣航空業者飛安評議案件之人因分析

「安全」一直以來都是航空運輸業者的最注重的環節，要維持良好的飛安紀錄，必須仰賴各層面資源的投入與努力維持。數十年來，因為機械因素造成的飛安事故大幅降低，轉而凸顯出人為因素對飛航安全的重要影響，飛行事故肇因也多從原本「機械」因素為主，轉變為「第一線人員」。近十多年來，針對人員方面，已不再僅著重於「第一線人員」的疏失，而開始探究管理與組織階層是否也會對飛安造成影響。因此，本研究將運用民航局針對國內航空業者疑似違反法規所執行之飛安評議案件作為原始分析資料，使用HFACS-MA模型進行人為因素探討。HFACS-MA共分為四個大項目，包括組織影響(Organizational Influences)、不安全管理行為(Unsafe Supervision)、不安全行為影響因素(Preconditions For Unsafe Acts)以及不安全行為(Unsafe Acts)。經過原始資料分析轉換為量化數據後，除利用統計方法分類表述之外，也使用統計檢定探討各人因類別之間的關聯性與影響關係。分析後共找到23項人為疏失的連結關係，例如：組織資源管理對規劃組織行為、安全文化對常慣性違規、領導協調行為對團隊合作狀態及不良狀態對技術型疏失等等。未來可將此研究結果與其他研究之人為疏失資料進行比對探討，用以建立國內航空業之人為因素影響連結，甚或各類人為疏失之根本原因分析，找出人為疏失對飛安之影響關聯，進而透過改善根本原因，提升飛航安全。

關鍵字

人為因素；飛航安全；飛安評議；人為因素分析與歸類系統

並列摘要

Even though "Flight Safety" is the most important matter for the air transportation industry, keeping a good safety record is full of challenge and requires lots of resources and efforts from all the stakeholders. Since the major cause of aircraft accident has shifted from the mechanical factors to human factors (HF) for decades, the aviation industry has begun to investigate the complicated relationships between human errors and safety events. Many research have argued that finding the errors of the first line workers is not enough for accident prevention but required more exploration of the management and the organization. Therefore, in order to enhance the above research topic, in this study, we tried to adopt the classification framework of HFACS-MA to analyze the flight safety assessment events that were retrieved from the Civil Aviation Administration of Taiwan. HFACS-MA constructs with four categories of human factors, that includes Organizational Influences, Unsafe Supervision, Preconditions for Unsafe Acts and Unsafe Acts. Three HF analysts examined and classified the original narrative of the events into quantitative number of human errors. Statistical methods such as odd ratio and chi-squared were utilized to study the relationships and influences between human errors. Of the result, we have found 23 connections among various categories of human factors, for instance, Resource Management is the antecedent of Planning & Organizing, Safety Culture to Routine Noncompliance of Supervision, Leading & Coordinating to Teamwork and Adverse States to Skill-based Errors. The findings of the study could be integrated with the results of other types of flight safety data to ratify the common causal relationships of human errors that could be specifically applied to advance management of flight safety.

並列關鍵字

Human Factor ； Flight Safety ； Flight Safety Assessment Events ； HFACS-MA

參考文獻

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15. 葉佳明. (2016). 以馬可夫鏈建立航空人為疏失與意外事件預測模式.

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2. Christine Chauvina,∗, Salim Lardjaneb, Gaël Morela,. (2013). Human and organisational factors in maritime accidents: Analysis of collisions at sea using the HFACS. ELSEVIER.

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台灣航空業者飛安評議案件之人因分析

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