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題名:應用HFACS探討跑道安全相關事故之人為失誤
書刊名:運輸計劃
作者:楊慧華劉穎儒
作者(外文):Yang, Hui-huaLiu, Ying-ru
出版日期:2017
卷期:46:1
頁次:頁85-116
主題關鍵詞:跑道安全人為失誤人為因素分析與歸類系統Runway safetyHuman errorHuman factors analysis and classification systemHFACS
原始連結:連回原系統網址new window
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  • 被引用次數被引用次數:期刊(1) 博士論文(0) 專書(0) 專書論文(0)
  • 排除自我引用排除自我引用:1
  • 共同引用共同引用:69
  • 點閱點閱:7
有鑑於跑道安全相關事故持續占所有飛航事故最大的比例,且造成多數乘員的傷亡,因此國際民航組織 (ICAO) 大會A37-6決議敦促世界各國加強跑道安全。我國飛航安全調查委員會 (簡稱飛安會) 事故調查資料庫1998-2015年共調查69件渦輪定翼飛機事故,而跑道安全相關事故就占其中的35件,所占比例最大 (50.7%),飛航事故依發生原因分類 (causes/ factors),歷年來與人相關之事故所占比例亦為最高,因此飛航事故人為失誤之調查更顯重要。 本研究以「人為因素分析與歸類系統 (HFACS)」為理論架構,運用飛安會發展出適合飛航事故調查使用之人為因素調查輔助工具「ASC-HFACS」,分析國內跑道安全33件事故,希望能從分析結果發現跑道安全相關事故中的人為因素,並於早期開始預防以增進飛航安全。從內容分析結果發現,引發事故次數最多之3項人為失誤子項目為:「技術操作的錯誤」、「決策錯誤」,以及「自然環境與物理條件」;從關聯分析發現自然環境與物理條件、操作者個人狀態、督導能力及組織文化/氣候等問題對事故較具關聯影響性;從引發技術操作及決策錯誤之「失誤影響路徑」,改善高層級隱性之人為失誤項目,應能對降低跑道安全相關事故有所助益。
In view of the fact that runway safety-related accidents constitute to account for the largest portion of all accidents and have resulted in a great number of fatalities, International Civil Aviation Organization (ICAO) Assembly resolution A37-6 urged states to enhance runway safety. According to the statistics of Aviation Safety Council in Taiwan, runway safety-related accidents/serious incidents take the major portion (50.7%) of all types of flight occurrences. They shared 35 out of 69 turbojet and turboprop occurrences during 1998-2015, and most cases were caused by human errors. Therefore, investigations of human errors in runway safety related occurrences will be valuable. The goal of this research is to analyze human factors resulted in aviation mishaps and developing strategies to prevent accidents. The ASC-HFACS based on HFACS model will be used to analyze human factors to 33 runway safety-related accidents to explore influence routes within flight occurrences from organizational management to individual operation level. The content analysis of the accident reports shows that skill-based errors, decision errors, and physical environment are the most frequently occurring categories influencing flight occurrences. The analysis of associations suggest that physical environment, condition of operators, supervisory competence, and organizational culture/climate issues are deemed the most potent for accident occurrences. To reduce the runway related accidents resulting from skill-base and decision errors in flight operations the “paths to failure” relating to these organizational and human factors issues must be addressed.
期刊論文
1.鄭永安(20140300)。人為因素與飛航安全。科學發展月刊,495,20-24。  延伸查詢new window
2.李文進、陳正中、李倫文、游重山(20110200)。「人為因素分析與歸類系統(HFACS)」應用於飛行決策失誤之路徑分析。空軍學術雙月刊,620,3-17。  延伸查詢new window
3.Li, W. C.、Harris, D.(2005)。HFACS Analysis of ROC Air Force Aviation Accidents: Reliability Analysis and Cross-Cultural Comparison。International Journal of Applied Aviation Studies,5(1),65-81。  new window
4.Li, W. C.、Harris, D.、Yu, C. S.(2008)。Routes to Failure: Analysis of 41 Civil Aviation Accidents from the Republic of China Using the Human Factors Analysis and Classification System。Accident Analysis and Prevention,40(2),426-434。  new window
5.Shappell, Scott、Detwiler, Cristy、Holcomb, Kali、Hackworth, Carla、Boquet, Albert、Wiegmann, Douglas A.(2007)。Human Error and Commercial Aviation Accidents: An Analysis Using the Human Factors Analysis and Classification System。Human Factors,49(2),227-242。  new window
6.Wiegmann, D. A.、Shappell, S. A.(2001)。Human Error Analysis of Commercial Aviation Accidents: Application of the Human Factors Analysis and Classification System (HFACS)。Aviation, Space, and Environmental Medicine,72(11),1006-1016。  new window
7.Akyuz, E.、Celik, M.(2014)。Utilisation of Cognitive Map in Modelling Human Error in Marine Accident Analysis and Prevention。Safety Science,70,19-28。  new window
8.O'Connor, P.(2008)。HFACS with an Additional Layer of Granularity: Validity and Utility in Accident Analysis。Aviation, Space, and Environmental Medicine,79(6),599-606。  new window
9.Li, W. C.、Young, H. T.、Wang, T.、Harris, D.(2007)。International Cooperation and Challenges: Understanding Cross-Cultural Issues in the Processes of Accident Investigation。ISASI Forum--Air Safety Through Investigation,40(4),16-21。  new window
10.Baysari, M. T.、McIntosh, A. S.、Wilson, J. R.(2008)。Understanding the Human Factors Contribution to Railway Accidents and Incidents in Australia。Accident Analysis and Prevention,40,1750-1757。  new window
11.劉耿良、李倫文(20090900)。以「人為失誤分析與歸納模式」探討臺灣海軍海事事件中引發人為失誤之研究。復興崗學報,95,127-150。new window  延伸查詢new window
12.Celik, M.、Cebi, S.(2009)。Analytical HFACS for Investigating Human Errors in Shipping Accidents。Accident Analysis and Prevention,41,66-75。  new window
13.Chen, S. T.、Wall, A.、Davies, P.、Yang, Z.、Wang, J.、Chou, Y. H.(2013)。A Human and Organisational Factors (HOFs) Analysis Method for Marine Casualties Using HFACS-Maritime Accidents (HFACS-MA)。Safety Science,60,105-114。  new window
14.Chauvin, C.、Lardjane, S.、Morel, G.、Clostermann, J. P.、Langard, B.(2013)。Human and Organisational Factors in Maritime Accidents: Analysis of Collisions at Sea Using the HFACS。Accident Analysis and Prevention,59,26-37。  new window
15.Patterson, J. M.、Shappell, S. A.(2010)。Operator Error and System Deficiencies: Analysis of 508 Mining Incidents and Accidents from Queensland, Australia Using HFACS。Accident Analysis and Prevention,42(4),1379-1385。  new window
16.Lenné, M. G.、Salmon, P. M.、Liu, C. C.、Trotter, M.(2012)。A Systems Approach to Accident Causation in Mining: An Application of the HFACS Method。Accident Analysis and Prevention,48,111-117。  new window
17.Reinach, S.、Viale, A.(2006)。Application of a Human Error Framework to Conduct Train Accident/Incident Investigations。Accident Analysis and Prevention,38(2),396-406。  new window
18.Cohen, Jacob(1960)。A Coefficient of Agreement for Nominal Scales。Educational and Psychological Measurement,20(1),37-46。  new window
會議論文
1.Shappell, S. A.、Wiegmann, D. A.(2004)。HFACS Analysis of Military and Civilian Aviation Accidents: A North American Comparison。The 35th Annual International Seminar。ISASI。  new window
2.Wiegmann, D. A.、Shappell, S. A.(2001)。Applying the Human Factors Analysis and Classification System (HFACS) to the Analysis of Commercial Aviation Accident Data。The 11th International Symposium on Aviation Psychology。Columbus:Ohio State University。  new window
研究報告
1.Shappell, S. A.、Wiegmann, D. A.(2000)。The Human Factors Analysis and Classification System--HFACS。Washington, DC:Federal Aviation Administration。  new window
2.Wiegmann, D. A.、Shappell, S. A.(2001)。A Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis and Classification System (HFACS)。Washington, DC:Federal Aviation Administration。  new window
3.飛航安全調查委員會(2016)。臺灣飛安統計2006-2015年。  延伸查詢new window
4.Shappell, S. A.、Wiegmann, D. A.(2003)。A Human Error Analysis of GA CFIT Accidents 1990-1998。Washington, DC:Federal Aviation Administration。  new window
5.ATSB(2007)。Human Factors Analysis of Australian Aviation Accidents and Comparison with the United States。Australia Transport Safety Bureau。  new window
6.王明揚(2011)。以深化之人為因素分析與歸類系統發展人為失誤根本原因分析技術 (計畫編號:NSC99-2221-E-007-087-MY3)。  延伸查詢new window
學位論文
1.王穎駿(2009)。航空安全人為因素模式與風險因子評估--以飛航駕駛員及維修人員為例(博士論文)。國立成功大學。new window  延伸查詢new window
2.劉耿良(2009)。運用「人為因素分析與歸類系統」辨識海事事件之人為失誤(碩士論文)。國防大學政治作戰學院。  延伸查詢new window
圖書
1.林清山(2014)。心理與教育統計學。東華。  延伸查詢new window
2.張有恆(2005)。飛航安全管理。臺北:華泰文化事業股份有限公司。  延伸查詢new window
3.ICAO(2014)。Safety Report。Montreal:International Civil Aviation Organization。  new window
4.Hawkins, F. H.、Orlady, H. W.(1993)。Human Factors in Flight。Ashgate。  new window
5.Reason, J.(1990)。Human Error。Cambridge University Press。  new window
6.Boeing(2015)。Statistical Summary Of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2014。Chicago:Boeing Company。  new window
7.ICAO(2015)。Runway Safety Team Handbook。Montreal:International Civil Aviation Organization。  new window
8.ICAO(2015)。Safety Report。Montreal:International Civil Aviation Organization。  new window
9.ICAO(2013)。Safety Report。Montreal:International Civil Aviation Organization。  new window
10.ICAO(2010)。ADREP 2000 Taxonomy。Montreal:International Civil Aviation Organization。  new window
11.行政院飛航安全委員會(2015)。飛安自願報告系統簡訊。  延伸查詢new window
12.FAA(2008)。Aviation Maintenance Technician Handbook--General。Federal Aviation Administration。  new window
13.林惠玲、陳正倉(2011)。應用統計學。臺北:雙葉書廊有限公司。new window  延伸查詢new window
14.飛航安全調查委員會(2013)。HFACS應用手冊。  延伸查詢new window
15.Wimmer, R. D.、Dominick, J. R.(2010)。Mass Media Research: An Introduction。Belmont, CA:Wadsworth Publishing Company。  new window
16.邱皓政(2010)。量化研究方法。臺北:雙葉書廊有限公司。  延伸查詢new window
17.行政院飛航安全委員會(2013)。飛安自願報告系統簡訊。  延伸查詢new window
18.Wiegmann, D. A.、Shappell, S. A.(2003)。A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System。Ashgate。  new window
19.邱皓政(2002)。量化研究與統計分析。台北市:五南圖書出版公司。  延伸查詢new window
單篇論文
1.U.S. DoD(2005)。DoD HFACS, Department of Defense Human Factors Analysis and Classification System, a Mishap Investigation and Data Analysis Tool,U.S. Department of Defense。  new window
其他
1.飛航安全調查委員會(2015)。已結案事故調查報告,https://www.asc.gov.tw/main_ch/accident_list_end.aspx?uid=221&pid=201。  延伸查詢new window
2.鄭永安(2005)。2004美國南加州安全學院(SCSI)舉辦之『安全管理人為因素』專業訓練。  延伸查詢new window
圖書論文
1.FAA(2017)。Items 50-54 Ophthalmologic Disorder。Guide for Aviation Medical Examiners。  new window
2.AOPA(2001)。Collision Avoidance: Strategies and Tactics。Safety Advisor, Operations and Proficiency。Air Safety Foundation。  new window
 
 
 
 
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