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飛航安全與人為因素 行政院飛航安全委員會 報告人 王興中

飛航安全與人為因素 行政院飛航安全委員會 報告人 王興中. Flight Safety 飛航安全. U.S. General Aviation. Scheduled Air Carrier. 50. 40. 30. Accidents/100,000 flight hours. 20. 10. 0. 1960. 1970. 1980. 1990. Source: Boeing. Source: NTSB. U.S. Navy/Marine Corps. U.S. Air Force. Accidents/100,000 flight hours.

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飛航安全與人為因素 行政院飛航安全委員會 報告人 王興中

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  1. 飛航安全與人為因素行政院飛航安全委員會報告人 王興中

  2. Flight Safety 飛航安全

  3. U.S. General Aviation Scheduled Air Carrier 50 40 30 Accidents/100,000 flight hours 20 10 0 1960 1970 1980 1990 Source: Boeing Source: NTSB U.S. Navy/Marine Corps U.S. Air Force Accidents/100,000 flight hours Accidents/100,000 flight hours Source: U.S. Naval Safety Center Source: U.S. Air Force Safety Center

  4. 在一次飛航中死亡的機率 • 搭乘全世界飛安紀錄最好的前25名航空公司 • 七百七十一萬分之一 • 搭乘全世界飛安紀錄最差的25名航空公司 • 五十五萬八千分之一

  5. Number of Commercial Jet Accidents, Accident Rate and Traffic Growth - Past, Present and Future 35 70 30 60 25 50 20 40 1 Departure (millions) / Rate per million Accidents Accidents 15 30 2 Traffic Growth 1 Based on current accident rate 10 20 2 Based on industry estimates 3 Based on current accident rate 3 5 10 Accident Rate 0 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year 飛航架次與失事率

  6. 2002年全世界失事紀錄 01/14 Ibertrans Aerea Embraer 120RT Zaldivar, Spain (3/3)-(0/0)-(3/3) 01/15 Procuraduria General De Havilland DHC-6 Chilpancingo, Mexico (0/4)-(0/0)-(3/15) 01/16 Garuda Indonesia Boeing 737-3Q8 Klaten, Indonesia (1/0)-(0/0)-(6/54) 01/17 Petroproduccion Fairchild FH-227E El Tigre, Colombia (5/21)-(0/0)-(5/21) 01/28 TAME Ecuador Boeing 727-134 Cumbal Volcano, (9/83)-(0/0)-(9/83) 02/07 Volare Aviation Antonov AN-12BP Agadir, Morocco (8/0)-(0/0)-(8/0) 02/12 Iran Air Tours Tupolev TU-145M Khorramabad, Iran (12/107)-(0/0)-(12/107) 02/15 Tiramavia Antonov 12BP Monrovia-Roberts (1/0)-(0/0)-(8/0) 03/15 Aerotaxi (Cuba) Antonov AN-2 Baez, Cuba (2/14)-(0/0)-(2/14) 03/17 Djibouti Airlines Let 410 Djibouti, Africa (4/0)-(0/0)-(4/0) 04/12 Tadair Swearingen 226 Palma de Mallorca, Spain (2/0)-(0/0)-(2/0) 04/15 Air China Boeing 767-2J6ER Pusan, South Korea (11/117)-(0/0)-(11/166) 04/19 SELVA Colombia Antonov AN-32A Popayan, Colombia (0/3)-(0/0)-(3/5) 05/04 EAS Airlines BAC One-Eleven Kanos, Nigeria (7/64)-(0/0)-(8/69) 05/07 EgyptAir Boeing 737-566 Tunis, Tunisia (3/11)-(0/0)-(6/56) 05/07 China Northern McDonnell Doulgas Yellow Sea – Dalian, China (9/103)-(0/0)-(9/103) 05/21 Sky Executive Airlines Let 410UVP Calabar, Nigeria (5/0)-(0/0)-(5/0) 05/25 Trigana Air Service De Havilland Nabire, Indonesia (6/0)-(0/0)-(6/0)

  7. 2002年全世界失事紀錄 05/25 China Airlines Boeing 747-209B Taiwan Strait – Penghu, (19/206)-(0/0)-(19/206) 06/01 Airquarius Aviation Hawker George, South Africa (2/1)-(0/0)-(2/1) 06/17 Hawkins and Powers Lockheed Walker, California – U.S.A. (3/0)-(0/0)-(3/0) 07/01 DHL Express Boeing 757 Freighter Ueberlingen, Germany (2/0)-(0/0)-(2/0) 07/04 New Gomair Boeing 707 Bangui, Central African (16/7)-(1/1)-(17/8) 07/16 Britten-Norman BN-2B Borneo Jungles, (2/7)-(0/1)-(2/8) 07/17 Skyline Airways DeHavilland Surkhet, Nepal (2/2)-(0/0)-(2/2) 07/26 FedEx Boeing 727 Tallahassee, Florida, (0/0)-(3/0)-(3/0) 07/27 Ukraine Air Force Sukhoi SU-27 Lviv, Ukraine (0/0)-(2/0)-(2/0) 07/28 Pulkovo Airlines IL-86 Moscow, Russia (14/0)-(2/0)-(16/0) 08/22 Shangri La Air DHC-6-300 Pokhara, Nepal (3/15)-(0/0)-(3/15) 08/29 Vostok Aviakompania Antonov AN-28 Ayan, Russia (2/14)-(0/0)-(2/14) 08/30 Rico Linhas Aereas Embraer 120ER Rico Branco, Brazil (3/20)-(0/0)-(3/28) 09/14 TOTAL Linhas Aereas ATR-42-312 Paranapanema, Brazil (2/0)-(0/0)-(2/0) 10/01 India Military - Navy Ilyushin IL-38/ Vasco, India (12/0)-(0/0)-(12/0) 10/23 Tretyakovo Air Ilyushin IL-62M Bishkek, Kyrgyzstan (0/0)-(0/0)-(11/0) 10/25 Private Charter Beech King Air A100 Eveleth, Minnesota (2/6)-(0/0)-(2/6) 11/06 Lux Air Fokker 50 Luxembourgh (2/18)-(2/0)-(3/19)

  8. 2002年全世界失事紀錄 11/07 Dirgantara Air Service Britten-Norman - 2A Tarakan Indonesia (1/6)-(0/0)-(1/9) 11/08 Nepal Airways Harbin Yunshuji Y-12 Jomsom, Nepal (0/0)-(?)-(3/16) 11/09 Tymen Antonov AN-26 Antalya, Turkey (0/0)-(8)-(9/19) 11/11 Laoag International Fokker F27 Manila, Philippines (1/18)-(?)-(5/29) 11/28 Eagle Aviation Let 410 Masai Mara, Kenya (1/7)-(0/0)-(2/17) 12/03 C F F Air Learjet 36A Astoria, OR (0/0)-(0/0)-(2/2) 12/09 Raytheon Aircraft Beechcraft 1900C Eagleton, AR (2/1)-(0/0)-(2/1) 12/21 Transasia Airways ATR-72-202 Penghu Islands (2/0)-(0/0)-(2/0) 12/23 Aeromist Kharkiv Antonov 140 Baghrabad, Iran (6/38)-(0/0)-(6/38) 12/24 North Flying SA.227AC Metro III Aberdeen-Dyce Airport, UK (0/0)-(2/0)-(2/0)

  9. What is the solution??

  10. 第一次世界大戰時 英國皇家空軍飛行員陣亡的原因 敵人打落 飛機機械或結構失效 人員失誤 早期數據

  11. Accidents by Primary Cause Hull Loss Accidents – Worldwide Commercial Jet Fleet – 1992 Through 2001 失事統計

  12. Aeromedical Issues Ergonomics Organizational Factors CRM Pilot Error 人為因素 Human Factors

  13. Definition of Human Factors Human Factors discovers and applies information about human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe comfortable, and effective human use

  14. 人，與其所生活、工作、活動的環境間之互動，以及環境中各項事物對人類的影響人，與其所生活、工作、活動的環境間之互動，以及環境中各項事物對人類的影響 人為因素

  15. 人類為什麼會犯錯？設計

  16. 人類為什麼會犯錯？工作環境

  17. 人類為什麼會犯錯？環境演變

  18. 為什麼會犯前面的錯誤？ 生理與心理的極限

  19. 人類對資訊的處理 認知與記憶

  20. 資訊儲存 資訊處理 與 決心下達 結果 訊息 動作反應 資訊的接收 資訊的處理

  21. 視覺特性

  22. 錯覺

  23. 人類視覺系統對方向性非常敏感 方向性

  24. Display or Control Grouping

  25. 注意力 記憶力 腦部活動的限制

  26. 串聯而非並行 瓶頸 注意力超負荷 Load shedding Channelized attention 壓力與注意力 注意力

  27. 壓力與注意力 High Attention Low Low High Stress Level

  28. High Performance Efficiency Low Low High Stress Level 壓力與表現

  29. 請仔細觀察所播放的短片

  30. 發生了什麼事 ??

  31. 不同之目的而有不同的記憶力系統 知覺的貯存（Sensory store） 短期記憶力（ Short term memory ） 長期記憶力（ Long term memory ） 記憶力

  32. 訊息最初是被暫存於知覺上的貯存（ sensory store ） 兩種知覺上的貯存 影像的（ Iconic ）-- 眼睛所見 視覺上的訊息可被暫存約 0.5 至 1 秒 回聲的（ Echoic ）-- 耳朵所聽 聽覺上的訊息可被暫存約 2 至 8 秒 知覺的貯存

  33. 特性 未不斷複習，很快就會忘記 記憶容量非常的小 Miller number 短期記憶力

  34. Short term memory practice

  35. ASCNIKEVHSBMWIBMEVA ASC NIKE VHS BMW IBM EVA

  36. 特性 容量沒有限制 訊息可被永久貯存 不需控制腦部的活動來存取訊息 三種貯存於長期記憶中的資訊 一般常識，對環境的瞭解 過去發生的事件 處理事物的知識 長期記憶力

  37. 根據經驗建立自我的心像模組（ mental models ） 預測事物未來走向 以心像模組中之相似情境來達到狀況警覺（ Pattern matched to elements in the mental model to achieve situation awareness ） 情境的認知可達到自動化（ Pattern-recognition sequence can become automaticity ） 有效的運用有限的注意力資源 自動化的情境認知可能對狀況警覺造成負面的影響 長期記憶力

  38. Human Factors Models

  39. SHELL Model L : Liveware S : Software H : Hardware E : Environment H S L E L 人為因素模組

  40. Liveware Physicalsize and shape Physical needs Input characteristics Information processing Output characteristics Environmental tolerances L SHELL Model

  41. Liveware - Liveware Leadership Crew cooperation Teamwork Personality interaction Staff/management relationship L L SHELL Model

  42. Liveware - Hardware Design of seats Design of displays Design of controls Equipment locations H L SHELL Model

  43. Liveware -Software Procedures Manuals Checklists Symbology Computer programs S L SHELL Model

  44. Liveware - Environment Adapting the human to the environment Helmets Flying suits Oxygen masks Anti-G suits Adapting the environment to match human requirements Pressurization Air-conditioning systems Soundproofing Everything affect human performance in the environment L E SHELL Model

  45. H S L E L 人為因素模組

  46. Reason Model Defenses Unsafe Acts Contributing Factors Organizational Factors Active Failures Latent Failures Latent Failures

  47. 飛航安全與人為因素調查

  48. 根據中華民國 飛航事故調查法 第五條 飛安會對於飛航事故之調查，旨在避免類似飛航事故之再發生，不以處分或追究責任為目的。 事故調查之目的

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