建立航空公司維修風險因子

Developing Risk Factors for Airline Maintenance

10.6842/NCTU.2011.00462

吳榮芳

安全管理系統 ； 人為因素分析和分類系統 ； 風險管理 ； 航機維修 ； Safety Management System ； Human Factors Analysis and Classification System (HFACS) ； Risk Management ； Aircraft Maintenance

交通大學管理學院運輸物流學程學位論文

2011年

碩士

汪進財

繁體中文

在所有的交通運輸中，「安全」兩字一直是所有交通運輸產業全體同仁所共同追求之終極目標，在航空產業中更加如此;雖然空中飛航事故的發生率比起地面汽車車禍次數實屬微不足道，但因飛航事故發生之嚴重程度通常都遠遠大於汽車車禍，且飛安事故經常會造成航空公司偌大的內部直接成本和外部間接成本，更一再地影響搭機旅客之生命安全和家庭幸福，這是航空公司極難在短時間可彌補之，故持續維持「飛航安全」之信念和目標，更應深深刻印在所有航空產業人們的心目中。 雖然在航空產業中，很多人高喊著「零事故」的口號，但是大家都深刻了解在真實的環境中，其困難度有多難達成，故航空公司開始致力於座艙資源管理(Crew Resource Management, CRM)、維修資源管理(Maintenance Resource Management, MRM)、風險管理(Risk Management, RM)和安全管理系統(Safety Management System, SMS)等等之研究和推動，其目標就是要透過各種全面性的安全管理制度，有效地控制及面對風險，並系統化地管理安全制度。 雖然目前已建立了許多良好且全盤性之安全管理系統，但許多航空公司在執行過程中，還是無法真正了解組織中存在之風險因子及其根源，故無法經由風險管理之流程，有效的監控、預防和改正風險之措施。本研究則參照人為因素分析和分類系統(Human Factors Analysis and Classification System, HFACS) (Wiegmann and Shappell, 2003 ; Li,W.-C. and Harris, D., 2005)之研究方法，分析並分類個案公司之維修部門，從2004至2010年間的維修事故案例中，逐步且有系統性地分析和分類個案公司之風險因子，並找出人為因素分析和分類系統層級間之相互關係，以提供未來個案公司風險防範與安全管理精進之參考。 關鍵詞：安全管理系統、人為因素分析和分類系統、風險管理、航機維修

"Safety" is the highest goal in Transportation Industry and it has become the common faith we pursue as the ultimate goal, especially in Aviation Industry. Although the occurrence of the accident for flight is lower than vehicle accidents on ground, but the impacts of a flight accident is usually much larger than a car accident. On the other hand, a flight accident will not only cause huge internal direct cost and external indirect cost for an airline company, but also affect the flight safety of the passengers and their families. The airline company will not be able to recover in an extremely short period and that is the reason why the word "flight safety" had always been kept in the root of mind of the people in aviation industry. There is one slogan called "non-accident" in the aviation industry, but everyone knows how difficult it is to reach it in the real world. In order to manage and face the risk, we started to do the research and launch a variety of comprehensive safety management systems, such as Cockpit Resource Management (CRM), Maintenance Resource Management (MRM), Risk Management (RM), and Safety Management System (SMS) projects. The goal we hope is to manage this safety system in a systematic and effective way. Even if there are many well-established and comprehensive safety management systems, but many airlines can not really understand what are their real risk factors and the root cause during implementation process. Therefore they cannot monitor, prevent, and correct the risks effectively by using Risk Management process. This study adopts the research method of Human Factors Analysis and Classification System (HFACS) (Wiegmann and Shappell, 2003; Li, W.-C. and Harris, D., 2005) to analyze and classify the risk factors in maintenance department of the case company from 2004 to 2010 maintenance events systematically. Furthermore, identify the path relationship between the two levels of HFACS. The research result is anticipated the key data for top managers of case company as reference when they implant SMS in the future. Keyword: Safety Management System, Human Factors Analysis and Classification System (HFACS), Risk Management, Aircraft Maintenance

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