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


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


Flight Safety 飛航安全


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


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

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U.S. Air ForceU.S. Air Force

Source: U.S. Air Force Safety Center

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50

60

1950

1960

1970

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1990

2000

Acc

iden

ts/1

00,0

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U.S. Navy/Marine CorpsU.S. Navy/Marine Corps

Source: U.S. Naval Safety Center


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


Projected Traffic Growth and Accident Rates

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Year

0

5

10

15

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35

Dep

artu

re (

mil

lion

s) /

Rat

e p

er m

illi

on

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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


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?


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.”


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

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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


Human Factors

“Human factors” means different things to different people.

Pilot Error

Ergonomics

Aeromedical Issues

CRM

Organizational Factors


ErgonomicsAeromedical Issues

Organizational Factors

CRMPilot Error

人為因素 Human Factors


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


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


人類為什麼會犯錯？設計


人類為什麼會犯錯？工作環境


人類為什麼會犯錯？環境演變


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%


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


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


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


UA DC-8UA DC-8

• 28 December 1978• United Airlines• DC-8-61• Portland, Oregon, USA• 10/189 Lives


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


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


Information Management and Display

• Information exchange between people

• Information exchange between people and systems

• Information displays

• Communications processes


Human Information Processing

Perception and Memory


Human Information ProcessingHuman Information Processing

Information Input

Information Storage

Sensing (Information Receiving)

Information Processing and

Decision

Action Functions (Physical Control)

Output


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


Perception


Perceptual Organization

• Apparent motion

• Orientation

• Display or Control Grouping


Orientation

Human visual system is particularly sensitive to the orientation of stimuli


Display or Control Grouping


Depth Perception

• Binocular visual clues

• Monocular visual clues


Monocular Depth Cues


Perception Illusion


Perception Illusion


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.



• Issues in Human Performance Assessment– Human capabilities and limitations– Environmental impacts (external and internal)– Methods for measurement


Human Cognitive LimitationHuman Cognitive Limitation

• Attention

• Working Memory


AttentionAttention

• Bottleneck

• Sequential rather than parallel

• Attention overload– Load shedding– Channelized attention

• Stress and Attention


Stress and AttentionStress and Attention

High

Low

Low High

Attention

Stress Level


Stress and PerformanceStress and Performance

High

Low

Low High

Performance Efficiency

Stress Level


Attention ExerciseAttention Exercise


請仔細觀察所播放的短片請仔細觀察所播放的短片


What happened??


MemoryMemory

Different memory systems adapted to different purposes

• Sensory store

• Short term memory

• Long term memory


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


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


Short term memory practiceShort term memory practice


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


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



• Issues in Human-Centered Automation– Workload– Operational situation awareness and system mode

awareness– Automation dependencies and skill retention– Interface alternatives


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


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



• Issues in Selection and Training– New equipment training strategies– Selection criteria and methods


Human Factors Models


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


SHELL Model

Liveware• Physical size and shape

• Physical needs• Input characteristics• Information processing• Output characteristics• Environmental

tolerances

L


L

L

SHELL Model

Liveware - Liveware• Leadership• Crew cooperation• Teamwork• Personality

interaction• Staff/management

relationship


H

L

SHELL Model

Liveware - Hardware• Design of seats• Design of displays• Design of controls• Equipment locations


S L

SHELL Model

Liveware -Software• Procedures• Manuals• Checklists• Symbology• Computer programs


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


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


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


Flight Safety

And

Human Factors Investigation


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?


Org

aniz

atio

nal F

ailu

res

Unsafe Superv

ision

Preconditions

Unsafe Acts

Where should we look to prevent accidents?

Operating Environment


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


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


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


發生原因WHY?

發生了什麼 ?

WHAT?

如何避免再度發生 ??


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


失事案件討論失事案件討論


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.


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。


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


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


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


機場施工區機場施工區機場施工區機場施工區


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


• 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


• 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


• 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


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


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


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


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


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


PVDPVDPVDPVDPara-Visual Display


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


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


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


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


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。


Not to BlameNot to BlameBut to PreventBut to Prevent

Documents

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行政院飛航安全委員會報告人王興中