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研究生:張自安
研究生(外文):Chang Dz-An
論文名稱:大型飛機飛行操作之人為失誤辨識
論文名稱(外文):Human Error Identification for Large Airplanes Flight Operation
指導教授:許悅玲許悅玲引用關係李文進李文進引用關係
指導教授(外文):Hsu, Yueh-LingLi, Wen-Chin
學位類別:碩士
校院名稱:開南大學
系所名稱:空運管理學系
學門:運輸服務學門
學類:航空學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:英文
論文頁數:74
中文關鍵詞:人為因素預測模組飛行安全階層任務分析標準操作程序
外文關鍵詞:Aviation SafetyHierarchical Task AnalysisHuman Error TemplateStandard Operation Aviation SafetyHierarchical Task AnalysiHierarchical Task AnalysisHuman Error TemplateStandard Operation Procedure
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「人為失誤預測模組」( Human Error Template, HET)是特地為預測飛行員駕駛航機時發生操作失誤,而研發出的分析研究方式,以能有效的做出防範措施。人為失誤常肇因於飛行員與駕駛艙內的電腦系統之間非常複雜的互動關係,飛行員駕駛航機時發生操作失誤有時與飛機操控系統的設計不良有關,儘管新一代高度自動化的飛機具備了相當多的安全防護功能,但駕駛艙中所發生的人為失誤卻始終無法完全避免。因此可藉由科學方法預測人為失誤發生之可能性,以有效預防及改善。
「人為失誤預測模組」( Human Error Template, HET)是一種問卷形式其中包含十二項錯誤模組,以調查表的方式分析飛行員駕駛航機時發生操作失誤之潛在可能性。將一任務所需執行的標準作業程序以「階層任務分析」(Hierarchical Task Analysis, HTA)細分成各單一步驟,再將每單一步驟加入「人為失誤預測模組」以問題的方式呈現,分析者須依據個人判斷每單一步驟中,是否有十二項錯誤模中之任一或多項式潛在錯誤模式發生之機率,並提出其對飛行安全影響程度之嚴重性。
本研究是以台灣某航空公司飛行員為受訪對象,使用最新的人為失誤預測方法--「人為失誤預測模組」( Human Error Template, HET)分析B-744機隊在執行重飛任務時的標準作業程序,檢視B-744航機內之儀表設計是否在重飛階段時可能發生誘導飛行員犯錯的潛在失誤,並審視「標準作業程序(SOP)」之流程,分析結果將可作為日後改善之依據,以達到高標準的飛安要求。
以HET來分析研究航機操作標準作業程序(SOP)流程,或航機駕駛艙操作儀表設計缺陷,近程可提供給航空公司標準作業程序制定單位作為改善之依據,或提供航務訓練單位針對操作程序熟練度進行加強訓練,遠程可對航機駕駛艙儀表設計之缺陷向飛機製造公司提出改善意見,可以有效預防人為失誤事件發生,提昇飛行安全。
1. Human Error Template (HET) is a new approach to predict human errors in the cockpit and hence help to develop accident prevention strategies. Human error is often the result of complex interrelationships between humans and computers. Some pilot errors have been proven to be design-induced errors. Despite the development for new technology in the aviation domain, new types of human errors have been provoked in the modern cockpit.
2. Human Error Template (HET) is a checklist style approach to error prediction that comes in the form of an error pro forma containing twelve error modes. HET is applied to each bottom level task step in a hierarchical task analysis (HTA) of the task in question. The technique requires the analyst to indicate which of the HET error modes are credible for each task step, the probability of error and the criticality of error, based upon their judgment.
3. This research applies the latest technique for human error prediction- Human Error Template to evaluate go-around standard operation procedures of B-744 and all the interviewees are pilots from one of the major airlines in Taiwan. The research aims are to predict the potential design-induced human errors in the B-744 during the go-around phase of flight and provide a basis for improving software design and hardware equipment to enhance flight safety.
4. By using of the scientific approach of HET to analyze flight SOPs will effectively provide basis for airliners to modify SOPs and training, furthermore, it can give suggestions to aircraft manufacture for any possible design-induced deficiency to prevent accidents or incidents.
CHAPTER 1 INTRODUCTION 1
1.1 Background and Motive 1
1.2 Purpose 3
1.3 Research Methods 4

CHAPTER 2 LITERATURE REVIEW 6
2.1 Safety Concerns for Air Travel 6
2.2 Efforts on Reducing Human Errors 7
2.3 Human Error-Related Research 8
2.4 The Swiss Cheese Model 10
2.5 Human Error Identification Techniques 11
2.6 Human Error Template 12

CHAPTER 3 METHODOLOGY 14
3.1 Research methods 14
3.2 Stage I - Go-Around Procedure HTA 14
3.3 Stage II - Behavior for Focus Operational Steps 18

CHAPTER 4 RESULTS 20
4.1 Characteristics of Survey Samples 20
4.2 Behavior of Focus Operational Steps 21
4.2.1 Step 1.1 Press TO/GA Switches 22
4.2.2 Step 1.2 Set Flaps Lever to 20 24
4.2.3 Step 1.3 Rotate to Go-around Attitude 25
4.2.4 Step 1.4 Verify Thrust Increase 27
4.2.5 Step 1.5 Gear Up 29
4.2.6 Step 1.6 Select Roll Mode 30
4.2.7 Step 1.7 Select Pitch Mode 33
4.2.8 Step 1.8 Follow Miss Approach Procedures 35
4.2.9 Other Errors 37

CHAPTER 5 DISCUSSIONS 39
5.1 The Basis for Analysis 39
5.2 Step Analysis of B-744 Go-Around Procedures 40
5.2.1 Step 1 – Press TO/GA Switches 41
5.2.2 Step 2 – Set Flaps Lever to 20 43
5.2.3 Step 3 – Rotate to Go-Around Attitude 44
5.2.4 Step 4 - Verify Thrust Increase 45
5.2.5 Step 5 – Gear Up 47
5.2.6 Step 6 – Select Roll Mode 48
5.2.7 Step 7 – Select Pitch Mode 49
5.2.8 Step 8 – Follow Miss Approach Procedure 51
5.2.9 Others Errors During Go-Around 51
5.3 Summary 53

CHAPTER 6 CONCLUSIONS 54

REFERENCE 57

APPENDIX 58
1.Aircraft Operation Manual, (2009). Taipei Taiwan: China airlines

2.Annett, J. (2005). Hierarchical Task Analysis, in, N.A. Stanton, A. Hedge, E. Salas, H. Hendrick, and K. Brookhaus (Eds.) Handbook of Human Factors and Ergonomics Methods. London, Taylor & Francis.

3.Annett, J. (2004). Hierarchical Task Analysis, in, D. Diaper and N.A. Stanton (Eds.), Handbook of Task Analysis in Human-Computer Interaction, Mahwah, NJ: Lawrence Erlbaum Associates.

4.Annett, J., Duncan, K.D., Stammers, R.B. and Gray, M. (1971). Task Analysis, London: HMSO.

5.Beaty, D. (1995), The naked pilot: the human factor in aircraft accidents, Ramsbury, Marlborough Wiltshire SN8 2HR

6.Boeing Commercial Airplanes Group (2000). Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-1999, Boeing, Seattle, WA.

7.Flight crew training manual, Vol.2 (2009). Seattle, WA: Boeing Commercial Airplanes Group

8.Flight Operation Manual, (2009). Taipei Taiwan: China airlines

9.Harris, D., Stanton, N.A., Marshall, A., Young, M.S., Demagalski, J. and Salmon, P.M (2005). Using SHERPA to Predict Design-Induced Error on the Flight Deck. Aerospace Science and Technology, 9, pp. 525-532.

10.Li, W.C. & Harris, D. (2007), 'Eastern Minds in Western Cockpits: Meta-analysis of human factors in mishaps from three nations', Aviation Space and Environmental Medicine, Vol. 78 (4), p.420-425.

11.Li, W.C. and Harris, D. (2006), 'Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents', Aviation Space Environmental Medicine, Vol. 77 (10), p.1056-1061.

12.Li, W.C. & Hsu, Y.L. (2009). Methodology of Human Error Identification: The Application of Hierarchical Task Analysis and Human Error Template. Journal of Crisis Management, Vol. 6 No. 1, p.87-94

13.Standard Manual, (2009). Taipei Taiwan: China airlines

14.US Department Of Transportation (2003). Federal Aviation Regulations, (Part 25 – Airworthiness Standards). Revised January 1, 2003. US Department Of Transportation, Washington, DC.
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