Download - 飛航安全與人為因素 行政院飛航安全委員會 報告人 王興中
飛航安全與人為因素飛航安全與人為因素
飛航安全與人為因素
行政院飛航安全委員會報告人 王興中
飛航安全與人為因素飛航安全與人為因素
大綱
• 飛航安全• 人為因素• 飛航安全與人為因素• 人為因素模組• 飛航安全與人為因素調查• 人為因素案件研討
飛航安全與人為因素飛航安全與人為因素
Flight Safety 飛航安全
飛航安全與人為因素飛航安全與人為因素
Scheduled Air Carrier Accidents (1959-1997)Scheduled Air Carrier Accidents (1959-1997)
Source: Boeing
0
10
20
30
40
5019
60
1970
1980
1990
___
- - -U.S. and Canadian OperatorsRest of World
飛航安全與人為因素飛航安全與人為因素
Source: Boeing
0
10
20
30
40
50
1960
1970
1980
1990
Scheduled Air CarrierScheduled Air Carrier
0
10
20
30
40
50
1950
1960
1970
1980
1990
2000
Acc
iden
ts/1
00,0
00 f
light
hou
rs
U.S. General AviationU.S. General Aviation
Source: NTSB
0
10
20
30
40
1950
1960
1970
1980
1990
2000
Acc
iden
ts/1
00,0
00 f
light
hou
rs
U.S. Air ForceU.S. Air Force
Source: U.S. Air Force Safety Center
0
10
20
30
40
50
60
1950
1960
1970
1980
1990
2000
Acc
iden
ts/1
00,0
00 f
light
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U.S. Navy/Marine CorpsU.S. Navy/Marine Corps
Source: U.S. Naval Safety Center
飛航安全與人為因素飛航安全與人為因素
The rate of improvement has slowed significantly and substantially during the last 10 years.
This has led some to conclude that further reductions in accident rates are improbable, if not impossible.
Still, worldwide air traffic is expected to double during the next 10 to 15 years.
Therefore, even if the current level of safety is maintained, the number of accidents will increase due to the increasing number of aircraft and hours flown.
REASONS FOR CONCERN
飛航安全與人為因素飛航安全與人為因素
Projected Traffic Growth and Accident Rates
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Year
0
5
10
15
20
25
30
35
Dep
artu
re (
mil
lion
s) /
Rat
e p
er m
illi
on
0
10
20
30
40
50
60
70
Accid
ents
Accidents
Traffic Growth
Accident Rate
1
2
3
1 Based on current accident rate2 Based on industry estimates3 Based on current accident rate
Number of Commercial Jet Accidents, Accident Rate and Traffic Growth - Past, Present and Future
飛航安全與人為因素飛航安全與人為因素
Even greater efforts must be taken to further reduce the accident rate
In order to achieve this goal
accident prevention measures must address the primary cause of accidents, which in most cases, is the HUMAN
WHAT MUST WE DO?
飛航安全與人為因素飛航安全與人為因素
It is not surprising then, that human error has been implicated in 60-80% of accidents in aviation and other complex systems.
In fact, while accidents solely attributable to environmental and mechanical factors have been greatly reduced over the last several years, those attributable to human error continue to plague organizations.
“Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.”
飛航安全與人為因素飛航安全與人為因素
All US NAVY/MARINE MishapsAll US NAVY/MARINE Mishaps
Cla
ss A
, B,&
C M
isha
ps/1
00,0
00 F
ligh
t Hou
rsC
lass
A, B
,& C
Mis
haps
/100
,000
Fli
ght H
ours
00
22
44
66
88
1010
1212
1414
1616
1977
1977
1979
1979
1981
1981
1983
1983
1985
1985
1987
1987
1989
1989
1991
1991
YearYear
Mechanical
Human
飛航安全與人為因素飛航安全與人為因素
Human Factors
“Human factors” means different things to different people.
Pilot Error
Ergonomics
Aeromedical Issues
CRM
Organizational Factors
飛航安全與人為因素飛航安全與人為因素
ErgonomicsAeromedical Issues
Organizational Factors
CRMPilot Error
人為因素 Human Factors
飛航安全與人為因素飛航安全與人為因素
Definition of Human Factors• Human Factors discovers and applies
information about human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe comfortable, and effective human use
飛航安全與人為因素飛航安全與人為因素
人為因素
人,與其所生活、工作、活動的環境間之互動,以及環境中各項事物對人類的影響
飛航安全與人為因素飛航安全與人為因素
人類為什麼會犯錯?設計
飛航安全與人為因素飛航安全與人為因素
人類為什麼會犯錯?工作環境
飛航安全與人為因素飛航安全與人為因素
人類為什麼會犯錯?環境演變
飛航安全與人為因素飛航安全與人為因素
飛航安全與
人為因素
飛航安全與人為因素飛航安全與人為因素
失事統計失事統計
Flight crew
Airplane
Weather
Maintenance
Misc./Other
Airport/ATC
91
15
10
8
6
5
11%
67%
7%
6%
5%
4%
Accidents by Primary CauseHull Loss Accidents – Worldwide Commercial Jet Fleet – 1990 Through 1999
10% 20% 30% 40% 50% 60% 70% 80%
飛航安全與人為因素飛航安全與人為因素
早期數據早期數據
第一次世界大戰時• 英國皇家空軍飛行員陣亡的原因
– 敵人打落– 飛機機械或結構失效– 人員失誤
飛航安全與人為因素飛航安全與人為因素
人為因素發展轉戾點人為因素發展轉戾點
• 1975 ,第二十屆 IATA 技術會議• 1977 , 兩架 B747 相撞, Tenerife
• 1978 , DC-8 失事, Portland
飛航安全與人為因素飛航安全與人為因素
航空史上最慘重的失事航空史上最慘重的失事
March 27, 1977 Tenerife, Canary Islands KLM 747 collided with a Pan Am 747 583 people
飛航安全與人為因素飛航安全與人為因素
UA DC-8UA DC-8
• 28 December 1978• United Airlines• DC-8-61• Portland, Oregon, USA• 10/189 Lives
飛航安全與人為因素飛航安全與人為因素
世界人為因素發展世界人為因素發展
• 歐洲– KLM’s Human Factors Awareness Course
• 美國 – Command, Leadership, Resource Managem
ent Course
• 澳洲 – Airlines’ Aircrew Team Management Progra
m
飛航安全與人為因素飛航安全與人為因素
目前人為因素發展重點目前人為因素發展重點
• Issues in Information Management and Display• Issues in Human Performance Assessment• Issues in Human-Centered Automation• Issues in Selection and Training
飛航安全與人為因素飛航安全與人為因素
Information Management and Display
• Information exchange between people
• Information exchange between people and systems
• Information displays
• Communications processes
飛航安全與人為因素飛航安全與人為因素
Human Information Processing
Perception and Memory
飛航安全與人為因素飛航安全與人為因素
Human Information ProcessingHuman Information Processing
Information Input
Information Storage
Sensing (Information Receiving)
Information Processing and
Decision
Action Functions (Physical Control)
Output
飛航安全與人為因素飛航安全與人為因素
Human Information ProcessingHuman Information Processing
Human actively process information, we do not just passively receive, store, and retrieve information
• We construct what we see
• We construct what we remember
飛航安全與人為因素飛航安全與人為因素
Perception
飛航安全與人為因素飛航安全與人為因素
Perceptual Organization
• Apparent motion
• Orientation
• Display or Control Grouping
飛航安全與人為因素飛航安全與人為因素
Orientation
Human visual system is particularly sensitive to the orientation of stimuli
飛航安全與人為因素飛航安全與人為因素
Display or Control Grouping
飛航安全與人為因素飛航安全與人為因素
Depth Perception
• Binocular visual clues
• Monocular visual clues
飛航安全與人為因素飛航安全與人為因素
Monocular Depth Cues
飛航安全與人為因素飛航安全與人為因素
Perception Illusion
飛航安全與人為因素飛航安全與人為因素
Perception Illusion
飛航安全與人為因素飛航安全與人為因素
US Civil Aeronautics Board Report
Two commercial aircraft were approaching New York city at 11,000 feet and 10,000 feet respectively. At the time, clouds were protruding above a height of 10,000 feet, forming an upward sloping bar of white against the blue sky.
The crew of the lower aircraft misperceived the planes to be on a collision course and increased altitude quickly. The two aircraft then collided at approximately 11,000 feet.
飛航安全與人為因素飛航安全與人為因素
目前人為因素發展重點目前人為因素發展重點
• Issues in Human Performance Assessment– Human capabilities and limitations– Environmental impacts (external and internal)– Methods for measurement
飛航安全與人為因素飛航安全與人為因素
Human Cognitive LimitationHuman Cognitive Limitation
• Attention
• Working Memory
飛航安全與人為因素飛航安全與人為因素
AttentionAttention
• Bottleneck
• Sequential rather than parallel
• Attention overload– Load shedding– Channelized attention
• Stress and Attention
飛航安全與人為因素飛航安全與人為因素
Stress and AttentionStress and Attention
High
Low
Low High
Attention
Stress Level
飛航安全與人為因素飛航安全與人為因素
Stress and PerformanceStress and Performance
High
Low
Low High
Performance Efficiency
Stress Level
飛航安全與人為因素飛航安全與人為因素
Attention ExerciseAttention Exercise
飛航安全與人為因素飛航安全與人為因素
請仔細觀察所播放的短片請仔細觀察所播放的短片
飛航安全與人為因素飛航安全與人為因素
What happened??
飛航安全與人為因素飛航安全與人為因素
MemoryMemory
Different memory systems adapted to different purposes
• Sensory store
• Short term memory
• Long term memory
飛航安全與人為因素飛航安全與人為因素
Sensory StoreSensory Store
Incoming information is initially held in a sensory store
Here are two main forms of sensory store• Iconic for information we see
– Visual information is held for about 0.5 to 1 second
• Echoic for information we hear– Aural information is held for about 2 to 8 second
飛航安全與人為因素飛航安全與人為因素
Short Term MemoryShort Term Memory
Also called working memory
Properties of short term memory
• Information is forgotten in seconds without rehearsal
• Extremely limited capacity– Miller number
飛航安全與人為因素飛航安全與人為因素
Short term memory practiceShort term memory practice
飛航安全與人為因素飛航安全與人為因素
Long Term MemoryLong Term Memory
Properties of long term memory• Capacity is for all intents limitless• Information can potentially be stored forever• Distributed and associative by nature
Three type of information are stored in LTM• General knowledge, our understanding of the world• Memory of past events• Knowledge about how to do things
飛航安全與人為因素飛航安全與人為因素
Long Term MemoryLong Term Memory
• Develop internal mental models with experience• Generating projection of future system states• Pattern matched to elements in the mental
model to achieve situation awareness• Pattern-recognition sequence can become
automaticity• Direct limited attention in efficient ways• Situation awareness can be negatively
impacted by automaticity
飛航安全與人為因素飛航安全與人為因素
目前人為因素發展重點目前人為因素發展重點
• Issues in Human-Centered Automation– Workload– Operational situation awareness and system mode
awareness– Automation dependencies and skill retention– Interface alternatives
飛航安全與人為因素飛航安全與人為因素
Evolution of Transport Aircraft Automation
Pilot Pilot Pilot Pilot
Controls Autopilot Controller CDU
Control System
Controller
Aircraft
FMS
Autopilot
Aircraft Controls
AutopilotControlsAircraft
Aircraft
NavAids
NavAids
INS
Increasing peripheralization of the pilot
飛航安全與人為因素飛航安全與人為因素
Boeing Flight Deck Design CommitteeExamples of accident data reviewed
Accident-related cause• Crew omitted pitot heat
• Wrong position of standby power switch
• Captain conducted unauthorized troubleshooting
• Electrical power switching not coordinated with pilots
• Faulty fuel management
• No leading edge flaps on takeoff
• Confusion over correct spoiler switch position
Design• Auto on when engine start
• Automated standby of essential power
• Simplified systems delete maintenance functions
• Auto switching and load shedding – no crew action required
• Auto fuel management with alert of low fuel, wrong configuration and imbalance
• Improved takeoff warning with digital computer
• Dual electric spoiler control
飛航安全與人為因素飛航安全與人為因素
目前人為因素發展重點目前人為因素發展重點
• Issues in Selection and Training– New equipment training strategies– Selection criteria and methods
飛航安全與人為因素飛航安全與人為因素
Human Factors Models
飛航安全與人為因素飛航安全與人為因素
人為因素模組人為因素模組
SHELL Model• L : Liveware
• S : Software
• H : Hardware
• E : Environment
E
H
S
L
L
飛航安全與人為因素飛航安全與人為因素
SHELL Model
Liveware• Physical size and shape
• Physical needs• Input characteristics• Information processing• Output characteristics• Environmental
tolerances
L
飛航安全與人為因素飛航安全與人為因素
L
L
SHELL Model
Liveware - Liveware• Leadership• Crew cooperation• Teamwork• Personality
interaction• Staff/management
relationship
飛航安全與人為因素飛航安全與人為因素
H
L
SHELL Model
Liveware - Hardware• Design of seats• Design of displays• Design of controls• Equipment locations
飛航安全與人為因素飛航安全與人為因素
S L
SHELL Model
Liveware -Software• Procedures• Manuals• Checklists• Symbology• Computer programs
飛航安全與人為因素飛航安全與人為因素
EL
SHELL ModelLiveware - Environment• Adapting the human to the
environment– Helmets– Flying suits– Oxygen masks– Anti-G suits
• Adapting the environment to match human requirements– Pressurization– Air-conditioning systems– Soundproofing
• Everything affect human performance in the environment
飛航安全與人為因素飛航安全與人為因素
The Reason Model
InadequateInadequate
DefensesDefenses
Unsafe actsUnsafe acts
ProductiveProductiveactivitiesactivities
PreconditionsPreconditions
Precursors ofPrecursors ofunsafe actsunsafe acts
DeficienciesDeficiencies
LineLinemanagementmanagement
Decision- Decision- makersmakers
Fallible Fallible decisionsdecisions
資料蒐集、分析模組資料蒐集、分析模組
飛航安全與人為因素飛航安全與人為因素
Latent Conditions Excessive cost cutting
Inadequate promotion policies
Latent Conditions Deficient training program
Improper crew pairing
Active and Latent Conditions Poor CRM
Loss of situational awareness
Failed orAbsent Defenses
OrganizationalFactors
InputsEconomic
inflation
Few qualified pilots
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Adapted from Reason (1990)
Accident & InjuryCrashed into side of
mountain
Active Conditions Failed to scan instruments
Penetrated IMC when VMC only
Breakdown of a Productive SystemBreakdown of a Productive System
飛航安全與人為因素飛航安全與人為因素
Flight Safety
And
Human Factors Investigation
飛航安全與人為因素飛航安全與人為因素
Org
aniz
atio
nal F
acto
rsUnsafe
Supervisi
on
Preconditions
Unsafe Acts
Where do we usually look Where do we usually look to prevent accidents?to prevent accidents?
飛航安全與人為因素飛航安全與人為因素
Org
aniz
atio
nal F
ailu
res
Unsafe Superv
ision
Preconditions
Unsafe Acts
Where should we look to prevent accidents?
Operating Environment
飛航安全與人為因素飛航安全與人為因素
人為因素調查人為因素調查
1. 發覺人類行為上的失誤對事件可能造成的影響
2. 找出人類生理及心理方面的極限和事故原因間的關聯
3. 對於事件中發生的不安全行為或決定,提出如何避免或降低的改善建議
飛航安全與人為因素飛航安全與人為因素
失事案件失事案件
• 波音 727 型飛機• 當地時間下午 1735
• 第五邊進場• 強風,雷陣雨• 飛機墜毀於距機場跑道一浬處• 98 死, 14 傷
飛航安全與人為因素飛航安全與人為因素
失事原因失事原因
飛行員於五邊進場時飛入雷雨造成飛機失控
飛航安全與人為因素飛航安全與人為因素
發生原因WHY?
發生了什麼 ?
WHAT?
如何避免再度發生 ??
飛航安全與人為因素飛航安全與人為因素
操作者 操作者 +操作者與機器介面
操作者 +操作者與機器介面 +操作者與操作環境
操作者 +操作者與機器介面 +操作者與操作環境 +
組織與管理
調查重點演變調查重點演變
飛航安全與人為因素飛航安全與人為因素
失事案件討論失事案件討論
飛航安全與人為因素飛航安全與人為因素
According to the International Civil Aviation Organization (ICAO) Annex 13, Chapter 3, Section 3.1;
The sole purpose of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.
飛航安全與人為因素飛航安全與人為因素
根據中華民國民用航空法第八十四條
飛安會對航空器失事及重大意外事件從事之認定、調查及鑑定原因,旨在避免失事之再發生,不以處分或追究責任為目的。
飛航安全與人為因素飛航安全與人為因素
89 年 10 月 31 日晚上 11 時 17 分 新加坡航空 SQ006, B747-400
中正國際機場飛往洛杉磯
事件背景事件背景
飛航安全與人為因素飛航安全與人為因素
事件背景事件背景事件背景事件背景 起飛時誤入施工中跑道 飛機全毀、 83 人死亡
飛航安全與人為因素飛航安全與人為因素
象神颱風• 中正機場南方 360 公里• 最大風速 75 浬,陣風 90 浬
機場的天氣• 風向 020 ,風速 30 浬,最大陣風 6
1 浬• 能見度 600 公尺• 雲高 200 呎• 大雨
當時天氣當時天氣當時天氣當時天氣
飛航安全與人為因素飛航安全與人為因素
機場施工區機場施工區機場施工區機場施工區
飛航安全與人為因素飛航安全與人為因素
正駕駛 CM-1 Male, age 41
Total Flying Hours 11,235 hrsTotal Command Hours on B747-400 2,017 hrs
副駕駛 CM-2 Male, age 36Total Flying Hours 2,442 hrsTotal Command Hours on B747-400 552 hrs
加強組員 CM-3 Male, age 38
Total Flying Hours 5,508 hrsTotal Hours on B747-400 4,518 hrs
駕駛員駕駛員
飛航安全與人為因素飛航安全與人為因素
• 新航通常使用 06 跑道
• 正駕駛選擇 05L 跑道• CAT II 能見度限制較低• 跑道較長
• 駕駛員二至三年未曾使用 05L 跑道
跑道選擇跑道選擇
飛航安全與人為因素飛航安全與人為因素
• 正駕駛的主要考量是在於強烈的陣風和低能見度
• 表示若超過限制就延後起飛
• 告訴自已要比平日更加小心
• 擔心天氣狀況會愈來愈糟
正駕駛的考量正駕駛的考量
飛航安全與人為因素飛航安全與人為因素
• 正駕駛跟 隨著綠色的滑行道中心線燈滑入 05右跑道
滑行滑行
飛航安全與人為因素飛航安全與人為因素
轉入跑道時轉入跑道時轉入跑道時轉入跑道時
當正駕駛轉入跑道時•看到了跑道頭標線•沒注意到 N1滑行道上直行的中心線燈
•不記得看見任何跑道標誌或指示牌
飛航安全與人為因素飛航安全與人為因素
當飛機自 NP滑行道轉入 05R• 正駕駛在滑行• 副駕駛正在執行起飛前檢查表• 第三組員在計算側風量
轉入跑道時轉入跑道時轉入跑道時轉入跑道時
飛航安全與人為因素飛航安全與人為因素
對正跑道時對正跑道時對正跑道時對正跑道時• 正駕駛表示
• 看見跑道中心線燈• 有八成把握看見跑道邊燈
• 副駕駛和第三組員表示• 看見跑道中心線燈• 不記得看見跑道邊燈• 沒看見任何跑道標誌及指示牌
飛航安全與人為因素飛航安全與人為因素
起飛前起飛前起飛前起飛前• 三位飛行員
• 都瞭解 05R 因施工而關閉,但可用於滑行• 未看見任何施工警告標示• 相信他們是在 05L
飛航安全與人為因素飛航安全與人為因素
儀表顯示儀表顯示儀表顯示儀表顯示
• 駕駛艙內可供飛航組員參考的資訊
• PVD
• PFD
飛航安全與人為因素飛航安全與人為因素
PVDPVDPVDPVDPara-Visual Display
飛航安全與人為因素飛航安全與人為因素
Primary Flight DisplayPrimary Flight DisplayPrimary Flight DisplayPrimary Flight Display
PFD Indications Associated With Tuning the ILS
Aligned with centerline Not Aligned with centerline
Rising runway Localizer pointer and scale
飛航安全與人為因素飛航安全與人為因素
航管人員航管人員航管人員航管人員• 當飛機滑行過 West Cross 和 NP 的交叉口後,
航管人員即無法目視飛機
• CKS 目前沒有地面雷達可幫助管制員辨識飛機的位置
飛航安全與人為因素飛航安全與人為因素
機場設施機場設施 跑道關閉標誌 跑道警戒燈 跑道中心線標誌 N1滑行道中心線燈
飛航安全與人為因素飛航安全與人為因素
人為因素分析人為因素分析人為因素分析人為因素分析• 為何三名駕駛員會將航機滑入 05R 跑道?• 為何會自 05R 跑道上起飛?
• 分析• 駕駛員和相關因素間的互動
• 駕駛員 – 駕駛員• 駕駛員 – 航管• 駕駛員 – 天氣• 駕駛員 – 機場環境
• 訓練 – 駕駛員,航管人員• 組織規定之程序及政策• 民航監理單位之督導
飛航安全與人為因素飛航安全與人為因素
調查結果• 與可能肇因有關之調查結果
– 此類調查結果係屬已經顯示或幾乎可以確定為與本次事故發生有關之重要因素。其中包括:不安全作為、不安全狀況或造成本次事故之安全缺失等。
• 與風險有關之調查結果– 此類調查結果係涉及飛航安全之風險因素,包括未直接導致本次事故發生之不安全作為、不安全條件及組織和整體性之安全缺失等,以及雖與本次事故無直接關連但對促進飛安有益之事項。
• 其它調查結果– 此類調查結果係屬具有促進飛航安全、解決爭議或澄清疑慮之作用者。其中部份調查結果為大眾所關切,且見於國際調查報告之標準格式中,以作為資料分享、安全警示、教育及改善飛航安全之用。
飛航安全與人為因素飛航安全與人為因素
Not to BlameNot to BlameBut to PreventBut to Prevent