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民航機航線維護工作人為因素及管理策略探討
Thesis

民航機航線維護工作人為因素及管理策略探討

施輝煌
Masters, 國立清華大學, 工業工程與工程管理學系碩士在職專班
2013

Abstract

潛在失誤 航機維修 根本原因分析法 人因分析與分類系統法 Latent Error Aviation Maintenance Task Root Cause Analysis (RCA) Human Factors Analysis and Classification System ( HFACS)
Abstract Following the development of global economics and strong worldwide travel demand, the fast growing aviation market has resulted in more and more of aircraft deliver into service and increasing flight routes connection. It is a major challenge for airlines carrier to meet the target of “zero event” safety operations. The causes of an accident are usually due to a sequence of errors. If only the direct active error was reviewed without further investigating indirect latent errors, the similar accident may happen again. The latent human errors are not easy to be identified. However, it is necessary to try setting up solution in advance for accident prevention. This search was a follow up study of human errors analytical model study under NSC project, and further applied on aircraft line maintenance task error evaluation. Initially, the working steps of aircraft line maintenance Daily Check tasks were analyzed to find out the relationship between each error factor. Then retrieving from the questionnaire result analysis, the ranking list of significant active and latent error factors was settled and adopted in case studies by analyzing case study background information. Finally by the method of failure mode and effect analysis (FMEA), the common latent error factor was found as “Manual need to be revised”, and the core issue of this common factor was “Acknowledgement”. For the study of management strategy, it focus on the emotion impact of company regulations to employee. Based on the safety basis structure, it was suggested to establish employee centripetal force by well communication and staff consensus. The target is creating working risk awareness behavior, taking necessary risk prevention action in advance, and cooperating with support of team work right commanding decision to finish job with error free. Keywords: Latent Error, Aviation Maintenance Task, Root Cause Analysis, HFACS

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