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使用事故后分类系统探索军事航空飞行安全事件中的人为失误。

Exploring human error in military aviation flight safety events using post-incident classification systems.

作者信息

Hooper Brionny J, O'Hare David P A

机构信息

Department of Psychology, University of Otago, Dunedin 9054, New Zealand.

出版信息

Aviat Space Environ Med. 2013 Aug;84(8):803-13. doi: 10.3357/asem.3176.2013.

DOI:10.3357/asem.3176.2013
PMID:23926655
Abstract

INTRODUCTION

Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations.

METHOD

This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008.

RESULTS

Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors.

DISCUSSION

Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

摘要

引言

人为错误分类系统理论上允许研究人员以客观且一致的方式分析事故后的数据。人因分析与分类系统(HFACS)框架就是这样一种实用的分析工具,已被广泛用于航空领域的人为错误分类。认知错误分类法(CET)是另一种。据推测,关注HFACS中的相互关系有助于识别飞行员错误的潜在原因。CET在不安全行为层面提供了更高的粒度。目的是分析较高组织层面的因素对一线操作人员不安全行为的影响,并比较固定翼和旋翼机操作中的错误。

方法

本研究分析了2001年至2008年间澳大利亚一个军事组织发生的288起涉及人为错误的飞机事故。

结果

与固定翼事故(23%)相比,旋翼机事故中行动错误的比例几乎是其两倍(44%)。两种分类系统均显示,诸如物理环境、心理和生理状态、机组资源管理、训练和个人准备情况等前兆因素与基于技能而非基于决策的行为之间存在显著关系。CET分析显示了基于技能行为不同方面的不同诱发因素。

讨论

军事行动中基于技能的错误在旋翼机事故中更为普遍,且与组织中的高层监督过程有关。认知错误分类法为HFACS对不安全行为的分析提供了更高的粒度。

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