臺灣博碩士論文加值系統

航空公司位於飛航安全的第一線，飛航安全亦是航空業經營成功與否的重要關鍵，而飛安管理的主要核心便是預防事件的發生。然而，航空運輸為一複雜系統，其涉及個人、機器、設備、組織與環境等諸多因素，而且其交互間之影響關係相當密切，欲確切發掘問題之核心，以杜絕事件之發生，實非易事。因此，必須建立完善之飛安風險分析系統，協助飛安管理者系統性地深入剖析複雜之飛安體系，探索所有潛在飛安危險因子，發掘一切導致問題發生之可能環節，以改善根本缺失並提升飛安系統運作之績效。基於上述原因，本研究由失事肇因、系統組成、事件形成與系統運作等觀點之釐清，以及飛安管理理念與機制之探討著手，掌握飛航安全系統之內涵與本質，進而構建完整性與層級性的航空公司飛安系統架構。本研究以結構化方程模式作為方法論之基礎，為能確實反應飛安系統之架構且有效發掘系統問題之根本，進而研擬模式構建、系統解析與問題改善之方式。接著，依據本研究所研提之模式構建方式，一一探討各系統層級之飛安影響因素，研擬對應之績效品質評量指標，以確立飛安系統之衡量模式；透過系統各層級與各活動關係之釐清，系統性串連各飛安系統環節，以確立飛安系統之結構模式。最後，基於完整之系統模式架構與給定之假設性線性參數，進一步透過數值案例，應用與呈現本研究所研提之系統解析與問題改善方式；結果顯示，本研究所研提之系統安全分析模式確能運作，而且可作為診斷航空公司安全品質與健康之有效工具。

Airlines are on the forefront to deal with the aviation safety which is crucial for success. The core of the aviation safety management is to prevent the occurrence of accidents. However, air transportation is a complex system involving closely related factors such as humans, machines, facilities, organizations and environments, and it is hard to discover the causes to prevent accidents from the system. Therefore, it is necessary to develop a system safety analysis model to assist the safety managers dissecting and analyzing the system, exploring the hazard factors and discovering the critical problems with a systemically approach. For this reason, this study begins with clarifying the characteristics of aviation safety system through different viewpoints— accident causes, system components, accident formations and system operations; and then, exploring the concepts and essences of safety management. Thus, a comprehensive and hierarchical framework of airline safety system could be constructed. In order to clearly represent the framework and effectively discover the root cause of the system, the methodology of Structural Equation Model (SEM) is adopted, and the processes of model construction, safety analysis and problem improvement are brought up. According to the proposed model construction process, the study follows with specifying the frameworks of measurement model and structure model of the system. The effecting factors of each system level are explored one by one, and their corresponding indicators and measurements are drawn up respectively. The relationship between levels and activities of the system are identified, and all the system components can be methodically connected. In the final, basis on the constructed model frameworks and given linear parameters, a numerical case is further illustrated by applying the proposed processes of safety analysis and problem improvement. The demonstration reveals that the proposed system safety analysis model works well and can be a useful tool for airlines to diagnose the quality and health of their safety systems.

第一章 緒論 1
1.1 研究緣起 1
1.2 研究背景 2
1.3 研究目的 6
1.4 研究範疇 7
1.5 研究內容 8
1.6 研究架構 10
第二章 飛安系統之本質 11
2.1 失事事件之概況 11
2.2 失事事件之形成 14
2.3 飛安系統之體系 16
2.4 飛安系統之組成 22
2.5 小結 34
第三章 飛安管理之機制 37
3.1 飛安管理之角色 37
3.2 飛安管理之理念 39
3.3 飛安管理之觀點 43
3.4 小結 53
第四章 系統分析之方法 53
4.1 分析模式之概念 53
4.2 分析模式之理論 58
4.3 系統模式之建立 64
4.4 系統模式之分析 67
4.5 系統問題之改善 72
4.6 小結 74
第五章 分析模式之結構 75
5.1 系統解構之方法 75
5.2 線上活動之組成 79
5.3 線上活動之關係 81
5.4 安全計畫之型態 83
5.5 安全計畫之關係 86
5.6 安全架構與分析之整合 87
5.7 結構模式之架構 88
第六章 分析模式之指標 93
6.1 觀測因子之探討 93
6.2 觀測資料之型態 99
6.3 觀測因子之指標 101
6.4 觀測資料之彙整 106
6.5 衡量模式之架構 109
第七章 分析模式之應用 111
7.1 數值模式 111
7.2 案例分析 127
7.3 改善計劃 135
7.4 小結 138
第八章 結論與建議 139
8.1 結論 139
8.2 建議 143
參考文獻 147

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