決策失誤與違反標準作業程序對飛安事件結果之影響

The Results of Flight Accidents Influenced by Decision Error and Violating Standard Operation Procedures

李文進(W. C. Li) ； 游重山(C. S. Yu) ； Don Harries ； 李倫文(L. W. Lee) ； 王宏任(H. J. Wang)

《危機管理學刊》 5卷1期 (2008/03) Pp. 71-78

https://doi.org/10.6459/JCM.200803_5(1).0008

摘要

決策是一複雜的認知過程，受狀況與環境因素影響極大；然而，探討「決策錯誤」與「違犯規定」之關聯性的論述並不多見。本研究以「人爲因素分析與歸類系統(HFACS, Human Factors Analysis and Classification System)」爲架構，並運用內容分析方法進一步分析98 起同時含蓋HFACS 理論架構之「決策錯誤」及「違犯規定」兩個子項目的飛航意外事件，以探究兩者之間的關聯性。其中55起列屬第一級意外事件者，計有49起（佔約89.1%）飛行員違規行爲是受到決策錯誤所誘發；而當決策錯誤與違犯規定同時在失事事件發生時，則有56.1%屬致命性意外事件。研究發現，決策錯誤所造成的衝擊可能被低估，且決策錯誤應可被視爲違犯規定的前兆。因此，決策訓練不僅可提升飛行員決策能力，同時亦可避免飛行員違規飛行，進而提昇飛航安全。

關鍵字

決策錯誤 ； 違犯規定 ； 飛航安全

並列摘要

Decision-making is a complex cognitive process and affected by situational and environmental conditions. However, the link between decision-errors and violation was little addressed. A number of violations were made by pilots' specific decision. This research was based on the HFACS framework. The qualitative approach of content analysis was also applied to analyze 98 accident reports related to both decision error and violation. Class-A mishaps were found that 49 cases (89.1%) of pilots' violations were induced by decision errors. Also, there was 56.1% of fatality or aircraft crash when decision errors and violations were occurred simultaneously. The findings suggested that the impact of decision errors were probably underestimated, and decision errors could be deemed as the precursor of violations. To improve aviation safety, the training for making timely and appropriate decisions is not only to promote pilots' decision-making ability, but also to avoid pilots' violation.

並列關鍵字

decision error ； violation ； aviation safety

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