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研究生: 林語婕
Yu-Chieh Lin
論文名稱: 固定翼飛機的事故致災因素分析
Classification of Causal Factors for Fixed-wing Aircraft Accidents
指導教授: 紀佳芬
Chia-Fen Chi
口試委員: 張琬喻
Woan-Yuh Jang
張庭彰
Tin-Chang Chang
學位類別: 碩士
Master
系所名稱: 管理學院 - 工業管理系
Department of Industrial Management
論文出版年: 2020
畢業學年度: 108
語文別: 中文
論文頁數: 89
中文關鍵詞: 意外事故分析致災原因飛航安全
外文關鍵詞: accident analysis, causal factors, flight safety
相關次數: 點閱:350下載:0
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  • 每天天空中有數萬架飛機,連接著各地區的人民、經濟、貿易。面對現今航空軟硬體設施的快速發展及因應人們的需求,不可預期之經濟、社會環境及能源需求之變動與挑戰,政府、航空相關工業與從業人應致力持續改善及提升整體飛航環境,以現有的飛航安全績效為基礎持續精進。快速成長的航空運量,使得飛航安全成為重要的課題。為了提升飛航安全,並能獨立、客觀、公正的執行專業事故調查,我國行政院於 1998 年成立飛航安全委員會我國專責調查台灣境內飛安事故的飛航安全委員會,在2019 年擴大改制為運輸安全調查委員會,調查台灣境內陸、海、空等重大運輸事故,以建立更安全完善的運輸環境。而近幾年台灣飛安史上重大的飛安事故,不僅奪走數條人命,且帶來不可抹滅的傷害,透過分析先前事故原因,能夠幫助了解當前的飛航安全疏失,避免重複的事故再次發生。
    本研究將從國家運輸安全調查委員會已結案(1999~2018 年)並公告的事故調查報告中,其中 78 件與民航機相關事故,利用 IATA、Safety Factors、HFACS 三種意外事故編碼模型進行統計分析。探討台灣民航機飛安事故的致災原因,統計不同事故類別的發生次數,探討致災因素與模式分析。


    Facing the rapid development of aviation hardware and software facilities and the unpredictable changes in economic, social environment and energy demand in response to people's needs. The government, aviation-related industries should strive to continuously improve and enhance the overall aviation environment, continue to improve based on the existing flight safety performance. The rapid growth of air traffic makes flight safety an important issue.
    To improve flight safety, and be able to independently, objectively, and fairly perform accident investigations. Taiwan Executive Yuan established the Flight Safety Committee in 1998 to specialize in investigating flight safety accidents in Taiwan, and restructuring in 2019 become Transportation Safety Board. It is a transportation safety investigation committee to investigate major transportation accidents in Taiwan, such as land, sea and air, in order to establish a safer and better transportation environment.
    In recent years, the major flight accident in Taiwan has claimed several lives and brought indelible injuries. By analyzing the causes of previous accidents, it can help to understand the latest flight safety failures and avoid the accident happened again.
    In this study, the National Transportation Safety Investigation Committee has closed the case (1999~2018) and announced the accident investigation report. Among them, 78 accidents related to civil aircraft were statistically analyzed using IATA, safety factors, and HFACS accident coding models. This research will analyze the accident cause, count coding number, and Pattern Analysis for different categories.

    中文摘要................................................................................................................................I ABSTRACT..........................................................................................................................II 致謝..................................................................................................................................... III 圖目錄...................................................................................................................................V 表目錄................................................................................................................................. VI 第一章 緒論......................................................................................................................... 1 第一節 研究背景..........................................................................................................1 第二節 研究目的與方法..............................................................................................3 第三節 研究架構..........................................................................................................4 第二章 文獻探討................................................................................................................. 5 第一節 台灣飛安事故調查..........................................................................................5 第二節 意外事故理論..................................................................................................8 第三章 研究方法............................................................................................................... 12 第一節 台灣飛安事故報告........................................................................................12 第二節 飛安事故原因................................................................................................13 第三節 事故原因編碼................................................................................................20 第四章 研究結果............................................................................................................... 37 第一節 總事故原因統計結果....................................................................................42 第二節 維修相關事故之模式分析............................................................................51 第三節 環境相關事故之模式分析............................................................................56 第四節 飛航操作相關事故之模式分析....................................................................60 第五節 其他人員相關事故之模式分析....................................................................65 第五章 結論與建議........................................................................................................... 70 第一節 三種編碼模型特色........................................................................................70 第二節 各事故類型模式分析....................................................................................72 第三節 研究限制與未來方向....................................................................................75 參考文獻............................................................................................................................. 76 附錄一 ICAO occurrence category.............................................................................80

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