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基于情景的直升机事故根本原因分析中人-机-环境-程序(HMEP)分类方案的制定。

The development of a scenario-based human-machine-environment-procedure (HMEP) classification scheme for the root cause analysis of helicopter accidents.

机构信息

Department of Industrial Management, National Taiwan University of Science and Technology, Taipei, 106, Taiwan.

Department of Industrial Management, National Taiwan University of Science and Technology, Taipei, 106, Taiwan.

出版信息

Appl Ergon. 2022 Sep;103:103771. doi: 10.1016/j.apergo.2022.103771. Epub 2022 May 3.

Abstract

The current study analyzed the root causes of 22 helicopter accidents/incidents that took place between 1998 and 2019. Each root cause was coded using three commonly used classification models in aviation HFACS, ATSB, and IATA to identify recurring factors for better targeting of future prevention strategies. The frequency analysis revealed that not following procedure (22 observations), training inadequate or unavailable (17), inadequate regulatory oversight (17), inadequate procedure guidance (16), company management absent or deficient (10) and incorrect manuals/charts/checklists (9) were the most frequent contributing factors. Since none of the existing models could summarize the root causes of 22 occurrences effectively, a scenario-based human-machine-environment-procedure (HMEP) classification scheme was proposed to use organizational influences, people management, technical failure, procedure and document, and environment as the first-layer subcategories. The HMEP scheme was additionally applied to the analysis and coding of 4 helicopter accidents in the USA published by the NTSB. The HMEP scheme revealed that NTSB had identified a significantly greater number of root causes in the manufacturer design, manufacturing & documentation. Overall, HMEP can be used to guide the data collection during accident investigation and subsequently to aggregate aviation accidents to derive recurring factors and compare accident patterns in an efficient manner.

摘要

本研究分析了 1998 年至 2019 年间发生的 22 起直升机事故/事件的根本原因。每个根本原因都使用航空 HFACS、ATSB 和 IATA 中常用的三种分类模型进行编码,以确定反复出现的因素,从而更好地针对未来的预防策略。频率分析表明,最常见的因素包括:不遵守程序(22 次观察)、培训不足或无法获得(17 次)、监管监督不足(17 次)、程序指导不足(16 次)、公司管理缺失或不足(10 次)以及不正确的手册/图表/检查表(9 次)。由于现有的模型都无法有效地总结 22 起事件的根本原因,因此提出了基于情景的人机环境程序(HMEP)分类方案,将组织影响、人员管理、技术故障、程序和文件以及环境作为第一层子类别。该 HMEP 方案还应用于对 NTSB 公布的美国 4 起直升机事故的分析和编码。HMEP 方案表明,NTSB 已经在制造商的设计、制造和文件编制方面确定了更多的根本原因。总体而言,HMEP 可用于指导事故调查期间的数据收集,随后以有效的方式汇总航空事故,以得出反复出现的因素并比较事故模式。

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