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

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. 飛航安全 人為因素 飛航安全與人為因素 人為因素模組 飛航安全與人為因素調查 人為因素案件研討 大綱

3. Flight Safety 飛航安全

4. Scheduled Air Carrier Accidents (1959-1997) 50 ___ U.S. and Canadian Operators 40 - - - Rest of World 30 20 10 0 1960 1970 1980 1990 Source: Boeing

5. 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

6. REASONS FOR CONCERN • The rate of improvement has slowed significantly and substantially during the last 10 years. • This has led some to conclude that further reductions in accident rates are improbable, if not impossible. • Still, worldwide air traffic is expected to double during the next 10 to 15 years. • Therefore, even if the current level of safety is maintained, the number of accidents will increase due to the increasing number of aircraft and hours flown.

7. 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 Projected Traffic Growth and Accident Rates

8. WHAT MUST WE DO? • Even greater efforts must be taken to further reduce the accident rate • In order to achieve this goal • accident prevention measures must address the primary cause of accidents, which in most cases, is the HUMAN

9. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” • It is not surprising then, that human error has been implicated in 60-80% of accidents in aviation and other complex systems. • In fact, while accidents solely attributable to environmental and mechanical factors have been greatly reduced over the last several years, those attributable to human error continue to plague organizations.

10. All US NAVY/MARINE Mishaps 16 14 12 Human 10 8 Class A, B,& C Mishaps/100,000 Flight Hours 6 4 Mechanical 2 0 1979 1981 1987 1985 1983 1989 1991 1977 Year

11. Human Factors • “Human factors” means different things to different people. • Pilot Error • Ergonomics • Aeromedical Issues • CRM • Organizational Factors

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. 飛航安全 與 人為因素

19. Accidents by Primary Cause Hull Loss Accidents – Worldwide Commercial Jet Fleet – 1990 Through 1999 10% 20% 30% 40% 50% 60% 70% 80% 91 15 10 8 6 5 Flight crew Airplane Weather Maintenance Misc./Other Airport/ATC 67% 11% 7% 6% 5% 4% 失事統計

20. 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

21. 1975，第二十屆 IATA 技術會議 1977， 兩架 B747 相撞， Tenerife 1978， DC-8 失事， Portland 人為因素發展轉戾點

22. 航空史上最慘重的失事 • March 27, 1977 • Tenerife, Canary Islands • KLM 747 collided with a Pan Am 747 • 583 people

23. 28 December 1978 United Airlines DC-8-61 Portland, Oregon, USA 10/189 Lives UA DC-8

24. 歐洲 – KLM’s Human Factors Awareness Course 美國 – Command, Leadership, Resource Management Course 澳洲 – Airlines’ Aircrew Team Management Program 世界人為因素發展

25. Issues in Information Management and Display Issues in Human Performance Assessment Issues in Human-Centered Automation Issues in Selection and Training 目前人為因素發展重點

26. Information exchange between people Information exchange between people and systems Information displays Communications processes Information Management and Display

27. Human Information Processing Perception and Memory

28. Information Storage Action Functions (Physical Control) Sensing (Information Receiving) Information Processing and Decision Information Input Output Human Information Processing

29. Human actively process information, we do not just passively receive, store, and retrieve information We construct what we see We construct what we remember Human Information Processing

30. Perception

31. Apparent motion Orientation Display or Control Grouping Perceptual Organization

32. Human visual system is particularly sensitive to the orientation of stimuli Orientation

33. Display or Control Grouping

34. Binocular visual clues Monocular visual clues Depth Perception

35. Monocular Depth Cues

36. Perception Illusion

37. Perception Illusion

38. Two commercial aircraft were approaching New York city at 11,000 feet and 10,000 feet respectively. At the time, clouds were protruding above a height of 10,000 feet, forming an upward sloping bar of white against the blue sky. The crew of the lower aircraft misperceived the planes to be on a collision course and increased altitude quickly. The two aircraft then collided at approximately 11,000 feet. US Civil Aeronautics Board Report

39. Issues in Human Performance Assessment Human capabilities and limitations Environmental impacts (external and internal) Methods for measurement 目前人為因素發展重點

40. Attention Working Memory Human Cognitive Limitation

41. Bottleneck Sequential rather than parallel Attention overload Load shedding Channelized attention Stress and Attention Attention

42. Stress and Attention High Attention Low Low High Stress Level

43. High Performance Efficiency Low Low High Stress Level Stress and Performance

44. Attention Exercise

45. 請仔細觀察所播放的短片

46. What happened??

47. Different memory systems adapted to different purposes Sensory store Short term memory Long term memory Memory

48. Incoming information is initially held in a sensory store Here are two main forms of sensory store Iconic for information we see Visual information is held for about 0.5 to 1 second Echoic for information we hear Aural information is held for about 2 to 8 second Sensory Store

49. Also called working memory Properties of short term memory Information is forgotten in seconds without rehearsal Extremely limited capacity Miller number Short Term Memory

50. Short term memory practice