HFACS應用於失事調查分析- 以監察院報告為例
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| 摘要 無論是空軍、民航公司，飛行安全並降低失事率一直是每個飛航組織最注重的目標。飛航事故調查在確認可能肇因與安全風險有關的安全調查及飛安建議。調查發現，雖然人為因素一直是造成飛機失事的主要可能肇因，但這是因為飛航組員僅是事故發生結果中，最後一位產生不安全行為的人。對調查人員來說，如何確認事故肇因，是一項挑戰。因此，調查員在選擇事故調查的方法上是很重要的。尤其涉及人為疏失，更需專業的理論與新進之調查工具輔助，始能正確、清楚的確認事件肇因。有鑒於此，國際間針對人為疏失調查工作所需之技術相繼的被發展出來。本研究以「人為因素分析與歸類系統(HFACS)」為理論架構，並以監察院報告為例，用HFACS分析其內容，探討案例中的人為因素因子。結果呼應HFACS 理論，亦即「架構中每一較高層級均會直接影響下一層級的子項目」，顯示這些人為因素不論從最高層級的組織管理階層，到最低層級的飛行員操作行為，彼此間的關係更為複雜。
關鍵字：人為因素分析與歸類系統(HFACS)、監察院、失事調查、起司模型。 ABSTRACT Whether it is an Airforce or a civil aviation organization, flight safety in reducing the crash rate has always been the most crucial goal of every aviation organization. The purpose of aircraft accident investigations is to identify probable causes and related risk factors and provide safety recommendations to prevent the accident from happening again. Although human factors have always been the major probable causes of aircraft crashes, the conclusions of those investigations, according to the cheese model, are just because the flight crews were only the last defensive net to produce unsafe behaviors due to the accident. It is always a challenge for investigators to identify the actual causes of an aircraft accident; therefore, selecting a proper investigating method is essential. Professional, theoretical, and updated investigative tools are helpful to confirm the cause of the incident correctly, especially involving human errors. The current study utilizes the "Human Factors Analysis and Classification System (HFACS)" to analyze four Control Yuan's ROC Airforce accidental reports. Results prove that every higher level in the HFACS directly affects the lower level, and the human factors, from the highest level of organizational management to the lowest level of pilots' operational behavior, are closely related to each other. That relationship is far more complicated than just contributing to pilots' errors. KEYWORDS: Human Factors Analysis And Classification System (HFACS); Control Yuan; Aircraft Accident Investigation; Cheese Model |