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  • 學位論文

以人因工程觀點評估陸軍直升機飛行員飛行風險因素之研究

Perspective of Human Factors on Evaluating Army Helicopter Pilot Flight Risk

指導教授 : 王正華

摘要


自FAA從1990年以來研究有關飛行組員的意外事件比例(決策錯誤、操作錯誤、知覺錯誤與違規等四項)已維持相對穩定及針對人為因素飛安事件所建立的分析與歸類系統,深入檢視飛安失事調查報告,顯示人為失誤比例介於70%與80%之間,只是相關研究調查是以民航業界為研究對象,針對直升機飛行員的研究調查資料更是少見。 根據國內外相關文獻並配合陸軍航空部隊主管機關各種飛安查核制度及飛安事件資料,尋找可能直接或間接影響陸軍直升機飛行員之飛安風險因素,並透過專家問卷調查的方式,進行風險因素的篩選與分析並藉由調查結果,提供風險管理優先處理的飛安風險因素構面,並發展適合陸軍航空部隊之「風險管理」作法和準則,並對少數易肇事因素做重點式的管理,期能達未雨綢繆之功效。 本研究針對陸軍航空部隊飛安管理階層,共發出13份專家問卷,共計回收有效問卷13份,另外針對各飛行部隊飛行員發出103份重要度表現分析問卷,經由AHP及IPA問卷綜合分析「組織運作」及「決策錯誤」等二項是飛安管理階層與飛行員所共同認為降低飛行員飛安風險較重要的關鍵因素,也是陸軍應重視且應該發展飛安風險管理因應作法的方向,但是「組織運作」在人為因素分析與歸類系統(HFACS)第四層級(組織文化的影響),此層級檢驗的重點圍繞在最易被忽略的高階組織管理階層,但也是最難發掘出潛在的「隱性失效」,因為能直接影響督導與操作者執行狀況的潛在錯誤與決策幾乎都與組織的管理、人事獎勵制度、人員之考訓與篩選有關。

並列摘要


Since 1990, the FAA has been working on the accidents ratios of flight crews, which including decision making mistake, operation mistake, perception mistake and violation in order to maintain relative stability and focus on the human errors accidents for setting up a data analysis and classify system. But looking deep into the accident reports, we can find the human errors ratios are between 70% and 80%. However, almost of reports are focused on the commercial pilots rather than on the pilots of the army. According to foreign and domestic data and combine with flight evaluation and flight accident reports from the Army Aviation, we can search the direct or indirect flight risk factors as possible as we can. Furthermore, through the way of questionnaires, which were all filled out by experts, we can filter the risk factors and analyze them. These results will provide a priority for dealing with flight safety factors and develop a SOP for Army Aviation. We hope we can take precaution before it is too late and focus on a few flight accident repeating problems to do the specific control. This research is focused on flight safety management of Army Aviation and issues 13 questionnaires, which were done by experts. Besides it, with the way of AHP and IPA questionnaires, there were 103 were filled out by the on-line pilots from all flying battalions The organizational work and decision making error were two important key factors in this questionnaire. These factors are common believed among flight safety management personnel and all pilots as a way of reducing flight risks. They also should be a spotlight for the Army Aviation; however, the organizational work is classified as level 4 in the Human Factors Analysis and Classification System (HFACS). This level emphasizes the highly ignorance of top management personnel, who are the most difficulty in digging out the implicit failure because the personnel in this level are connected with management control, awarding system, testing and selection. All of those can directly influence supervision and potential mistakes and decisions of the operators.

參考文獻


13.陳楊正光、劉魯青、王心靈(2011)。人為因素與疏失管理。危機管理學刊,8(2),101-108。
4.李文進、游重山、Don Harries、李倫文、王宏任(2008)。決策失誤與違反標準作業程序對飛安事件結果之影響。危機管理學刊, 5(1),71-78
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參考文獻

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