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维修中的人为因素:对飞机事故频率和严重程度的影响。

Human factors in maintenance: impact on aircraft mishap frequency and severity.

作者信息

Krulak David C

机构信息

Naval Aerospace Medical Institute, Pensacola, FL 32508, USA.

出版信息

Aviat Space Environ Med. 2004 May;75(5):429-32.

Abstract

INTRODUCTION

Aviation mishaps caused by maintenance factors vary in severity, but can cost untold sums in lives and equipment lost. This study proposes to demonstrate that certain specific maintenance-related human factors are significantly correlated with both mishap frequency and severity.

METHODS

Using information from the Maintenance Error Information Management System (MEIMS), 1,016 aircraft mishaps caused by human factors in maintenance were examined. These mishaps were previously categorized using the Human Factors Analysis and Classification System-Maintenance Extension (HFACS-ME). Frequency analysis was used to determine the most common HFACS-ME factors seen in aircraft mishaps. Logistic regression techniques were used to describe the relationship between the dichotomized outcome of mishap severity and the human factors found in the HFACS-ME.

RESULTS

Inadequate supervision, attention/memory errors, and judgment/decision errors were the factors found most often in aircraft mishaps. The factors of inadequate design, inadequate adaptability/flexibility, inadequate lighting/light, confining workspace, and attention/memory error increased odds of being associated with a higher severity mishap.

DISCUSSION

Emphasis in training and education placed in the first three factors mentioned may reduce overall number of mishaps. Concentrating resources on the final five factors may decrease the number of severe mishaps.

摘要

引言

由维护因素导致的航空事故严重程度各异,但会造成生命和设备损失方面难以估量的代价。本研究旨在证明某些与维护相关的特定人为因素与事故频率和严重程度均显著相关。

方法

利用维护错误信息管理系统(MEIMS)中的信息,对1016起由维护中的人为因素导致的飞机事故进行了检查。这些事故此前已使用人为因素分析与分类系统 - 维护扩展版(HFACS - ME)进行了分类。频率分析用于确定飞机事故中最常见的HFACS - ME因素。逻辑回归技术用于描述事故严重程度的二分结果与HFACS - ME中发现的人为因素之间的关系。

结果

监督不足、注意力/记忆错误以及判断/决策错误是飞机事故中最常出现的因素。设计不足、适应性/灵活性不足、照明/光线不足、工作空间受限以及注意力/记忆错误等因素增加了与更严重事故相关联的几率。

讨论

对上述前三个因素的培训和教育予以重视可能会减少事故总数。将资源集中于最后五个因素可能会减少严重事故的数量。

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