組員資源管理系統及人因介面： 有效降低高鐵列車駕駛人為疏失行車決策關鍵因素之研究

The Crew Resource Management and the Human Factors： The Study of the Key Factors to Reduce Human Errors Effectively of the High Speed Train Drivers’ Operations Decision Making

黃威禎(Wei-Chen Huang)

指導教授 ： 楊明青

國立暨南國際大學/管理學院/高階經營管理碩士學位學程/碩士(2018年)

摘要

組員資源管理(Crew Resource Management，CRM)是一個有關人因介面的訓練，且已經廣泛的被運用在民用航空業超過35年了。在這段期間，針對有效降低因人因介面所產生的人為疏失，已被證明產生明顯的成效。
　　正如美國國家運輸安全委員會自1999年調查有關於1998年發生於印第安納州巴特勒市有關Norfolk Southern (NS)與Conrail的意外事件調查報告中，發現且奠定組員資源管理將會改善是未來類似鐵路事故有潛力發展的對策。更在之後的2004年起展開了組員資源管理訓練廣泛運用在美國鐵道業的推廣與探討，進而也引起英國、澳洲等國家的相繼推廣與響應。
　　本研究藉由對台灣高鐵公司的列車駕駛進行深度訪談及蒐集2014-2018年間有關人為疏失的案例分享的實證案例分析的方式，以不同列車運行階段的角度，歸納並逐一探討出影響列車駕駛做出正確行車決策的關鍵因素。
且研究結果顯示: 列車駕駛經驗的傳承、規章的簡單且清晰明瞭(Simple and Clear)，避免駕駛造成駕駛面臨行車決策上的遲疑及對於執勤時遭遇緊急危害的風險管理正是列車有效降低駕駛行車人為疏失的關鍵因素。
也因此，我們希望台灣高鐵公司，藉此也率先建立有關組員資源管理訓練運用於國內鐵道業的先例，將組員資管理訓練正式安排至未來列車駕駛的新人訓練及列車駕駛年度複訓中，並使得列車駕駛未來在值勤時，由於導入組員資源管理的概念後，對於面臨緊急狀況與列車故障所產生相關危害因有危機管理的正確觀念後，進而促進有效降低人為疏失的目的。

關鍵字

組員資管理系統 ； 人因介面 ； 人為疏失 ； 高鐵列車駕駛

並列摘要

Crew Resource Management (CRM) is a human factors training process that has been employed in the commercial aviation industry for over 35 years. During that time period, CRM has been credited with contributing to a marked decrease in human factors-caused accidents.
　　As the U.S. National Transportation Safety Board(NTSB) has investigated in 1999, in the case of the accident investigation of Norfolk Southern (NS) and Conrail in Butler City in 1998, it is found that the crew resource management will be a potential development strategy for similar railway accidents in the future. In the following 2004 onwards, the crew resources management training has been widely used in the United States to promote the railway industry and explore, which also caused the United Kingdom, Australia and other countries to promote and respond successively.
Through in-depth interviews with the high speed train drivers of the Taiwan High Speed Rail Corporation and collect the case studies of human errors during 2014-2018, we summarize the key factors that affect the correct driving decision making from the perspective of each train operation phase.
The results show that the transmission of train drivers’ experiences and the simplicity and clarity of the operation regulations and not let train drivers be hesitated in case of the emergency situation they meet on duty are the key factors for the train drivers to reduce the driver's human errors effectively.
Since that, We hope that the Taiwan High Speed Rail Corporation will take the lead in establishing a precedent for the application of crew resource management training to the domestic railway industry, and even arrange the CRM training into both the initial training for the new train driver trainees and the recurrent training for the qualified train drivers of the THSRC in the near future, and it would make all train drivers would reduce their human errors effectively due to they have correct concept of the CRM when they are on duty.

並列關鍵字

Crew Resource Management (CRM) System ； Human Factors ； Human Error ； High Speed Train Drivers

參考文獻

一、中文部分

孫碩昱(2010)。鐵路司機員駕駛行為分析之研究。國立成功大學交通管理科學系碩士班碩士論文。

方衛寧 郭北苑(2013)。列車駕駛介面 人因設計理論及方法。科學出版社。中國北京。

二、英文部分

Stephen S. Roop, Curtis A. Morgan, Tobin B. Kyte, Winfred, Arthur, Jr., Anton J. Villado, and Theodore Beneigh(2007). Railroad Crew Resource Management (CRM): The Business Case for CRM Training in the Railroad Industry. Federal Railroad