民用航空運輸業評議事件之分析探討

Abstract

運輸安全為運輸系統中首要的條件。在系統運作中的小錯誤往往都會被忽略，而當一連串的錯誤發生後，則有可能釀成重大災難。有很多因素都會影響事故的發生，例如工程設計、運具設計、人為因素及環璄因素等等。因此，不論是以工程面、管理面抑或是政策面來提升旅客的安全，都是值得檢視、探討的研究課題。 隨著航空科技、技術的不斷進步，以及在航空體系的努力之下，飛機系統的運作已有較高之可靠度。相對而言，人為疏失所造成的影響卻有逐步提升的現象，許多失事或意外事件往往肇因於人為疏失。根據行政院飛航安全委員會(2009)的統計資料顯示，我國近十年民用航空運輸業飛機飛航事故原因分類，與人相關之飛航事故所佔比率最高，佔96.3%（其中74.1%與駕駛員有關，22.2%與其他人員如維修及空中管制人員有關）。因此，在可預見的未來，人為因素領域的提升與應用在飛安管理中所占比重與扮演角色將越顯重要。 目前已發展建立並廣為各界所熟知及使用之人為因素理論模式，包括「SHELL 模式」、「Reason 模式」，以及美國「人為因素分析及分類系統(Human Factors Analysis and Classification System, HFACS)」等。其中，HFACS理論發展迄今，已證實是飛安事故調查的有效工具，亦是當前研究飛安事件之原因分析與失事預防策略之主流(Wiegmann & Shappell,2003；Li & Harris,2005)。 民航局依民用航空法(以下簡稱民航法)對航空公司及航空人員之違規缺失採取強制執行措施。為審慎辦理違反民航法有關飛航安全之行政處分，民航局自民國87年9月9日訂定「民用航空局飛航安全評議委員會設置要點」後正式運作，成為飛安監理工作之重要行政處分機制。飛航安全評議會(以下簡稱飛安評議會)迄今已運行近12年之久，民航局依據飛安評議會設置要點第八點將飛安評議相關資料歸檔存查，亦保留許多寶貴的資料。惟此一寶貴資料目前卻鮮少進行分析及探討，而其中民用航空運輸業資料量所佔比例最高。 因此，本研究依據Wiegmann & Shappell(2003)提出的「人為因素分析及分類系統(Human Factors Analysis and Classification System, HFACS)」為理論架構，並以我國民用航空運輸業評議事件資料為分析題材，期能以此分析方法瞭解評議事件之人為疏失情形，並進一步探討業者潛在問題與風險管理決策，以作為民航飛安管理單位之重要參考。

Transportation safety has served as the top concern in appraising the performance of transportation system. One got to concur that minor misbehavior is ignored oftentimes during the operation of transportation system whereas its consecutive accumulation may raise the likelihood to severe catastrophe. Some factors contributing to the occurrence of accident/incident have also been identified, including engineering design, transport vehicle design, human factor and environment factor, etc. As the consequence, it is concluded that adequate investigation, either from engineering, administration, or policy perspective, will be imperative for enhancing transportation safety. Thanks to the speedy progress in aviation technology and also the diligent effort dedicated by professionals in aviation industry, in general aircraft system has revealed increasingly high reliability in system operation. Contrarily, odds of safety concerns suffered from human error increase constantly, as evidenced by momentous accident history wherein human error involved. According to the statistical data fostered by Aviation Safety Council (short for ASC), Executive Yuan(2009), human error stands as the top factor (96.3%) contributing to the local aircraft accident for the past ten years, in which about 74.1% can be classified as pilot related whereas the others (22.3%) be attributed to poor maintenance and inadequate airborne control. Therefore, at least in the future we may foresee, promotion and implementation of human factor study will play a progressively more crucial role in the flight safety management. Nowadays some renowned and widely adopted human factor models are available worldwide, for instance, the SHELL and HFACS model. Among them, the HFACS model, which was developed in the States, has been confirmed as a functional tool in the investigation of flight safety events and serves as the most popular in uncovering root cause of accident and locating the relevant prevention strategy. (Wiegmann & Shappell, 2003; Li & Harris, 2005). The Civil Aeronautics Administration (short for CAA) is authorized by the Civil Aviation Act to implement enforcement measure on the illegal findings that identified via conducting surveillance on airlines as well as their personnel. To ensure prudent and scrupulous judgment thereof, CAA has promulgated the “Principles for establishing CAA Flight safety assessment committee”, effective September 9, 1998, to serve as principal mechanism to carry out surveillance activity over the airlines. Since then the Flight Safety Assessment Committee was established and has operated over 12 years. CAA, as abide by the Article 8 of the said Principles, has continuously maintained the files relating to operation of flight safety assessment committee. Nevertheless, this precious material, mostly concerning the Civil Air transport enterprise, hitherto has seldom been surveyed. Therefore, upon the filed records enclosing flight safety assessment events for civil transportation enterprises, in this study the HFACS model (Wiegmann & Shappell, 2003) will be implemented. This research will endeavor the evaluation for the impact of human error and, if possible, the analysis of its cause-consequence relationship to flight safety events. Furthering, effort for data-mining potential problems within airlines as well as the adequacy of their strategy for risk management will be conducted. The final outcome can afford CAA as the good reference for its discretion in flight safety surveillance.