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

Presentation on theme: "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"— Presentation transcript:

1 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

2 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

3 Flight Safety 飛航安全

4 Scheduled Air Carrier Accidents (1959-1997)
Source: Boeing 10 20 30 40 50 1960 1970 1980 1990 ___ - - - U.S. and Canadian Operators Rest of World This graph shows the total scheduled carrier accidents, worldwide, that occurred between 1959 and As shown in the graph, the rate of accidents for all types of aircraft has dropped dramatically since their introduction into the fleet. By the late 1970s and early 1980s, accident rates had dropped to approximately 3 accidents per 1 million departures worldwide. Note: The data exclude occurrences associated with sabotage, military operations, turbulence, and injuries sustained during evacuation. Second generation aircraft referred to in the figure include the 727, 737, DC-9, BAC 111, Trident, F-28, and VC-10 aircraft. Wide- body aircraft include the 747, DC-10, L-1011, and A300 aircraft. The graph was previously published in a book chapter by Nagel (1988); the source of the data comes from Boeing Commercial Airplane Company (1985).

5 U.S. General Aviation U.S. Navy/Marine Corps U.S. Air Force
Source: Boeing 10 20 30 40 50 1960 1970 1980 1990 Scheduled Air Carrier Accidents/100,000 flight hours U.S. General Aviation Source: NTSB Improvements in aviation safety, however, are not unique to commercial carriers. General aviation deaths and fatal accident rates in the U.S. declined to a 15-year low in 1996, with only 1.51 accidents occurring per 100,000 flight hours (NTSB, 1997). Aviation accidents within the U.S. military (i.e., Army1, Navy, Air Force, and Marine Corps) have also decreased steadily over the past 2 decades. The rate of major accidents in the U.S. military, calculated as the number of accidents per 100,000 flying hours, declined from about 4.3 in 1975 to 1.5 in 1995. In fact, if one were to examine any Service organization or even the civilian sector they would all look essentially the same (USN/USMC - upper right; USAF - upper left; commercial airlines - bottom). Specifically, they all reveal the same downward trend throughout the 50s, 60s and into the early 70s. Many have attributed this stark decline in the overall mishap rate to improved design, materials, training, and the implementation of standardized training programs. Notably, however, all the graphs show the same “flattening” of that positive downward trend in the mishap rate over the last couple decades. 1 The U.S. Army rates between 1950 and 1972 were unavailable at the time of publication. Accidents/100,000 flight hours U.S. Navy/Marine Corps Source: U.S. Naval Safety Center Accidents/100,000 flight hours U.S. Air Force Source: U.S. Air Force Safety Center

6 REASONS FOR CONCERN 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. Although the overall accident rate in civil and military aviation is very low, certain aspects of the data are unsettling. Specifically, the rate of improvement has slowed “significantly” and “substantially” during the last 10 years (Nagel, 1988). This plateau has led some to conclude that further reductions in the accident rate are improbable if not impossible. Still, worldwide air traffic is expected to double during the next 10 to 15 years (FSF, 1997). Therefore, even if the current level of safety is maintained, the number of aviation accidents will likely increase due to the increasing number aircraft and hours flown. Clearly, “accident-prevention steps must be taken now to stop the accident rate from exceeding its current level, and even greater effort must be taken to further reduce the current accident rate.” (FSF, 1997).

7 Projected Traffic Growth and Accident Rates
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year 5 10 15 20 25 30 35 Departure (millions) / Rate per million 40 50 60 70 Accidents Traffic Growth Accident Rate 1 2 3 1 Based on current accident rate 2 Based on industry estimates 3 Based on current accident rate Number of Commercial Jet Accidents, Accident Rate and Traffic Growth - Past, Present and Future The red (bottom) line in this graph shows worldwide trends in aviation accident rates, as well as projected accident rates through the year The green (middle) line depicts the traffic growth which is expected to increase dramatically over the next 10 years. The blue (top) line shows the predicted increase in accident frequency due to the rapid industry expansion. Note that this predicted increase is based on the current accident rate; therefore, even if the accident rate stays the same over the next decade, the raw number of accidents will increase markedly. Furthermore, as can be seen from the graph, there may be as many as 52 accidents a year worldwide during the first decade of the new century. This translates into an astonishing one accident a week. Note. Graph adapted from Flight Safety Foundation (1997). Values plotted in the graph are estimates based on industry statistics.

8 WHAT MUST WE DO? 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 “Although the global aviation safety record is admirable when compared with any other means of mass transportation, continuous effort must be exerted to maintain commercial aviation’s current level of safety” (Flight Safety Foundation, 1997). In order to maintain the current level of safety, we must reduce the accident rates still further. In order to accomplish this goal, however, accident prevention measures must address the primary cause of accidents, which in most cases, is the human.

9 “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” 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 error has been implicated in 60-80% of accidents in complex, high technology systems. These systems include aviation, nuclear power, oil, medical, rail, and marine transport industries. Although the overall rate of many industrial and transportation accidents has declined steadily during the past 20 years, reductions in human error-related accidents have not paralleled those related to mechanical/environmental factors. Indeed, humans have played a progressively more important causal role in both civil and military aviation accidents as aircraft equipment has become more reliable (Nagel, 1988).

10 Class A, B,& C Mishaps/100,000 Flight Hours
All US NAVY/MARINE Mishaps Class A, B,& C Mishaps/100,000 Flight Hours 2 4 6 8 10 12 14 16 1977 1979 1981 1983 1985 1987 1989 1991 Year Mechanical Human This figure depicts the annual frequency of U.S. Navy/Marine Corps Class A, B, and C mishaps attributable, at least in part, to human error (top circles) and those solely attributed to mechanical/ catastrophic failures (bottom circles) between 1977 and While it is true that several mishaps attributed to human error in this figure were preceded by mechanical failure, in the opinion of the mishap board, the mishap might not have occurred, or been as severe, if the aircrew had not made an error. Main Points: - Aviation accidents attributable to human and mechanical/environmental factors were nearly equal in Yet by 1992, accidents solely attributable to mechanical/environmental factors had been virtually eliminated while those attributable to human error had been reduced by only 50%. - If aviation accidents are to be reduced further, more needs to be done to prevent the occurrence of human error and/or to design more error-tolerant systems. Note: This is a figure from our 1996 publication in Aviation, Space, and Environmental Medicine entitled “U.S. Naval Aviation Mishaps, : Differences Between Single- and Dual-Piloted Aircraft.”

11 Human Factors “Human factors” means different things to different people. Pilot Error Ergonomics Aeromedical Issues CRM Organizational Factors Adding to the problem is the fact that “human factors” means different things to different people. These multiple definitions have led to confusion among safety professionals and, in some cases, have lead to extreme single-minded views of accident causation. There are at least 5 different terms frequently used synonymously with the term “human factors.” These include: Pilot error - refers to the actions or inactions of pilots that are thought to directly cause the accident. Viewed from this perspective, the pilot is the “major cause of aircraft accidents” (Murray, 1997), and “the pilot and aircrew are the weak link in the aviation safety chain.” (Feggetter, 1985). As a result, pilots are more dangerous than the aircraft they fly (Mason, 1993). Ergonomics - refers to errors caused by the design of knobs, dials and displays, or a mismatch between the anthropometric requirements of the task and that of the human. From this perspective, all accidents are design-induced and all errors can be engineered out of the system. Aeromedical - refers to the physiological and psychological condition of aviators that cause accidents. From this perspective, accidents occur because aviators were not physically qualified or aeronautically adaptable. CRM - refers to crew resource management (CRM), also known as aircrew coordination training (ACT), as well as other names. From this perspective, accidents are due to a breakdown in teamwork or the failure of the crew to work together properly. Organizational factors -refers to errors committed by officials within the management hierarchy, such as line managers and supervisors, that initiate the sequence of events leading to an accident. From this perspective “Every accident, no matter how minor, is a failure of organization.” (Andrews, 1953). Furthermore, “...an accident is a reflection on management’s ability to manage...Even minor incidents are symptoms of management incompetence that may result in a major loss” (Ferry, 1988). How can all these pieces be put together into a coherent accident investigation and prevention program?

12 Organizational Factors
人為因素 Human Factors Ergonomics Aeromedical Issues Organizational Factors CRM Pilot Error A comprehensive Human Factors Analysis and Classification System (HFACS) has recently been developed to meet these needs. This system, which is based upon Reason’s (1990) model of latent and active failures (Shappell & Wiegmann, 1997a), encompasses all aspects of human error, including the conditions of operators and organizational failure.

13 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

14 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

15 人類為什麼會犯錯？ 設計

16 人類為什麼會犯錯？ 工作環境

17 人類為什麼會犯錯？ 環境演變

18 飛航安全 與 人為因素

19 失事統計 Accidents by Primary Cause
Flight crew Airplane Weather Maintenance Misc./Other Airport/ATC 91 15 10 8 6 5 11% 67% 7% 6% 5% 4% Accidents by Primary Cause Hull Loss Accidents – Worldwide Commercial Jet Fleet – 1990 Through 1999 10% % % % % % % %

20 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

21 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

22 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

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

24 世界人為因素發展 歐洲 美國 澳洲 – KLM’s Human Factors Awareness Course
– Command, Leadership, Resource Management Course 澳洲 – Airlines’ Aircrew Team Management Program

25 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

26 Information Management and Display
Information exchange between people Information exchange between people and systems Information displays Communications processes

27 Human Information Processing
Perception and Memory

28 Human Information Processing
Information Input Information Storage Sensing (Information Receiving) Information Processing and Decision Action Functions (Physical Control) Output

29 Human 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

30 Perception

31 Perceptual Organization
Apparent motion Orientation Display or Control Grouping

32 Orientation Human visual system is particularly sensitive to the orientation of stimuli

33 Display or Control Grouping

34 Depth Perception Binocular visual clues Monocular visual clues

35 Monocular Depth Cues

36 Perception Illusion

37 Perception Illusion

38 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.

39 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

40 Human Cognitive Limitation
Attention Working Memory

41 Attention Bottleneck Sequential rather than parallel
Attention overload Load shedding Channelized attention Stress and Attention

42 Stress and Attention High Attention Low Low High Stress Level

43 Stress and Performance
High Low Performance Efficiency Stress Level

44 Attention Exercise

45 請仔細觀察所播放的短片

46 What happened??

47 Memory Different memory systems adapted to different purposes
Sensory store Short term memory Long term memory

48 Sensory 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

49 Short Term Memory Also called working memory
Properties of short term memory Information is forgotten in seconds without rehearsal Extremely limited capacity Miller number

50 Short term memory practice

51 Long 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

52 Long 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

53 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

54 Evolution of Transport Aircraft Automation
Pilot Controls Autopilot Controller CDU Control System Aircraft FMS NavAids INS Increasing peripheralization of the pilot

55 Boeing Flight Deck Design Committee Examples 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

56 目前人為因素發展重點 Issues in Selection and Training
New equipment training strategies Selection criteria and methods

57 Human Factors Models

58 H S E L 人為因素模組 SHELL Model L : Liveware S : Software H : Hardware
E : Environment

59 L SHELL Model Liveware Physical size and shape Physical needs
Input characteristics Information processing Output characteristics Environmental tolerances

60 L SHELL Model Liveware - Liveware Leadership Crew cooperation Teamwork
Personality interaction Staff/management relationship L

61 H L SHELL Model Liveware - Hardware Design of seats Design of displays
Design of controls Equipment locations H L

62 S L SHELL Model Liveware -Software Procedures Manuals Checklists
Symbology Computer programs S L

63 E L SHELL Model Liveware - 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 E L

64 資料蒐集、分析模組 The Reason Model Defenses Productive activities
Inadequate Defenses Unsafe acts Productive activities Preconditions Precursors of unsafe acts Deficiencies Line management Decision- makers Fallible decisions The Reason Model

65 Breakdown of a Productive System
Inputs Economic inflation Few qualified pilots Organizational Factors Latent Conditions Excessive cost cutting Inadequate promotion policies Unsafe Supervision Latent Conditions Deficient training program Improper crew pairing Preconditions for Unsafe Acts Active and Latent Conditions Poor CRM Loss of situational awareness As mentioned earlier, we have incorporated Reason’s (1990) model of how humans contribute to the breakdown of safe flight operations into our HFACS model. In this model, system failures are classified as either active or latent conditions. However, the exact nature of these failures or “holes” in the cheese have yet to identified and described. In this section, we provide a framework or taxonomy for identifying, classifying, and organizing active and latent failures with in the system. As previously stated, the framework is based upon the “The Taxonomy of Unsafe Operations” (Shappell & Wiegmann, 1997) which was developed for, and has recently been adopted by, the U.S. Navy/Marine Corps and U.S. Coast Guard for use in aviation accident investigation and analysis. The taxonomy describes four levels of failure within the system which include: (a) organizational factors, (b) unsafe supervisory practices, (c) unsafe conditions of operators, and (d) the unsafe acts operators commit. Each level is described in detail, beginning with the level most closely tied to the accident itself, unsafe acts. Unsafe Acts Active Conditions Failed to scan instruments Penetrated IMC when VMC only Failed or Absent Defenses Accident & Injury Crashed into side of mountain Adapted from Reason (1990)

66 Human Factors Investigation
Flight Safety And Human Factors Investigation

67 Where do we usually look to prevent accidents?
Organizational Factors Unsafe Supervision Preconditions System failures are like dominos, with the failure of one “domino” effecting the toppling of the next. The end result is the accident or injury. When this happens, however, we often forget that the accident itself is the last “domino” in this sequence, and that many dominos fell well before the accident occurred. As a result, we tend to focus almost exclusively on the people responsible for front line operations (i.e., the aircrew). Unfortunately, this has lead accident pilots (if they survive the accident) to feel severely scrutinized, as if they are being placed under a microscope or interrogated for a crime. Unsafe Acts

68 Where should we look to prevent accidents?
Organizational Failures Unsafe Supervision Preconditions Unsafe Acts Rather than scrutinizing the failure of a single system component, we must take a step back and look at the entire sequence of events that lead to the accident. A systems perspective requires that we examine blemishes or faults throughout the entire system. After all, it is often the failure of multiple components that combined together to produce an accident. Some people may raise the question, “Why stop at the organizational or even industry level?” Does the system’s boundary really end there? Presumably everything has a prior cause. Therefore, we could potentially trace the cause of an accident all the way back to the Big Bang. Stopping at the organizational level is just arbitrary. Theoretically this may be true. But we need to be practical. In seeking the reasons for an accident, we should search far enough back to identify factors that, if corrected, would render the system more tolerant to, or even prevent, subsequent encounters with conditions that produced the original accident. The people most concerned and best equipped to do this are those within the organization (Reason, 1990). Operating Environment

69 人為因素調查 發覺人類行為上的失誤對事件可能造成的影響 找出人類生理及心理方面的極限和事故原因間的關聯
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

70 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

71 失事原因 飛行員於五邊進場時飛入雷雨造成飛機失控

72 發生了什麼? WHAT? 發生原因 WHY? 如何避免再度發生??

73 調查重點演變 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+ 操作者與操作環境+ 操作者與機器介面+ 組織與管理

74 失事案件討論

75 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.

76 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。

77 事件背景 89年10月31日晚上11時17分 新加坡航空SQ006, B 中正國際機場飛往洛杉磯

78 事件背景 起飛時誤入施工中跑道 飛機全毀、83人死亡

79 當時天氣 象神颱風 機場的天氣 中正機場南方360公里 最大風速75浬，陣風90浬 風向020，風速30浬，最大陣風61浬 能見度600公尺
雲高200呎 大雨

80 機場施工區

81 駕駛員 正駕駛 CM-1 Male, age 41 副駕駛 CM-2 Male, age 36 加強組員 CM-3 Male, age 38
Total Flying Hours ,235 hrs Total Command Hours on B ,017 hrs 副駕駛 CM Male, age 36 Total Flying Hours ,442 hrs Total Command Hours on B hrs  加強組員 CM Male, age 38 Total Flying Hours ,508 hrs Total Hours on B ,518 hrs

82 跑道選擇 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

83 正駕駛的考量 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

84 滑行 正駕駛跟 隨著綠色 的滑行道中心線燈 滑入05右跑道

85 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

86 轉入跑道時 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

87 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 不記得看見跑道邊燈 沒看見任何跑道標誌及指示牌

88 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

89 儀表顯示 駕駛艙內可供飛航組員參考的資訊 PVD PFD

90 PVD Para-Visual Display

91 PFD Indications Associated With Tuning the ILS
Primary Flight Display PFD Indications Associated With Tuning the ILS Aligned with centerline Not Aligned with centerline Rising runway Localizer pointer and scale

92 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

93 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

94 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

95 調查結果 與可能肇因有關之調查結果 與風險有關之調查結果 其它調查結果
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。

96 Not to Blame But to Prevent