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目的用中国民航人的失误分析系统(CN-HFACS)研究人的失误各类别在运输飞行事故致因因素中的重要程度。方法分析35起运输飞行事故调查报告,从个人的不安全行为、不安全行为的前提条件、不安全的管理、组织影响、政府监管因素5个层面进行分析。结果个人的不安全行为及其前提条件在运输飞行事故人的失误类别中占76%;个人的不安全行为主要是基本技能差、违规操作和应急处置错误,不安全行为的前提条件主要是心理状态差、分工及配合不好和智力经验局限。中层不安全的管理主要是管理不到位,企业(组织)影响主要是人力资源管理不善和安全文化氛围差;政府监管因素主要是监督监察不到位;民航从业人员的技能水平显著提高,而违规行为却连续攀升。结论 CN-HFACS可以有效地对运输飞行事故进行人的失误定量分析。
Objective To study the importance of each category of human errors in the causal factors of transporting flight accidents by using the failure analysis system of China Civil Aviation (CN-HFACS). Methods The 35 cases of flight accident investigation were analyzed and analyzed from five aspects: the unsafe behavior of individuals, the preconditions of unsafe behavior, unsafe management, organizational influence and government supervision. Results The personal unsafe behavior and its preconditions accounted for 76% of the categories of mistakes in the transport of flight accidents. The unsafe behaviors of individuals were mainly those with poor basic skills, irregular operation and emergency disposal. The prerequisites for unsafe behavior were mainly psychological Poor condition, division of labor and poor cooperation, and limitation of intelligence experience. Middle-level unsafe management is mainly management is not in place, the impact of business (organization) is mainly poor human resources management and safety culture is poor; the main regulatory factor is the supervision and inspection is not in place; civil aviation practitioners skill level increased significantly, and irregularities But continuous rise. Conclusions CN-HFACS can effectively quantitatively analyze human error in transportation flight accidents.