本研究分析2008~2019年間由中華民國運輸安全調查委員會完成調查並公佈的十件民航機客艙加壓控制系統(cabin pressure control system，CPCS)故障造成艙壓失效的事件。由於這些事故的發生，導致駕駛員必須立即將民航機緊急下降到最近機場來執行維修。運用根本原因分析(Root cause Analysis，RCA)方法來分析這十件事故發生與雙供氣系統，外節流閥門和單向閥門故障有直接關係。依故障來源分為四個主要原因含(1)設計(2)環境(3)維修計劃(4)未依維修作業程序來探討事故發生的主要原因以預防未來再次發生相同的事故。
本研究顯示，將故障零件搭配功能方塊圖和故障模式分析(FMEA)可以找到影響系統操作問題發生的零件和相關性原因，運用根本原因分析也可同時分類出人員、系統設備、文件程序、管理和環境等因素所造成客艙失去壓力的相關連性，這些研究結果都可以提供給航空公司或飛機製造廠家聚焦在重要零件發生事故原因，同時，做為維修計劃或故障零件設計變更的依據，可預防同類型事故再次發生。

This study analyzes ten cases of cabin pressure failure caused by the failure of the Cabin Pressure Control System (CPCS) of civil aviation aircraft that were investigated and announced from the Transportation Safety Investigation Commission of the Republic of China from 2008 to 2019. Due to the occurrence of these accidents, the pilot must immediately descend the civil aircraft to the nearest airport to perform maintenance. Using Root Cause Analysis (RCA) method to analyze the occurrence of these ten accidents is directly relate to the failure of the dual bleed air system, the outflow valve and the one-way valve. According to the source of the failure, there are four main reasons including (1) design, (2) environment, (3) maintenance plan, and (4) failure to follow maintenance procedures to explore the main causes of accidents to prevent the same accident in the future.
This research shows that combining faulty parts with functional block diagrams and failure mode analysis (FMEA) can find parts and related causes that affect system operation problems. The use of root cause analysis can also classify the correlation between the loss of pressure in the cabin caused by factors such as personnel, system equipment, document procedures, management, and environment. These research results provided to airlines or aircraft manufacturers to focus on the causes of accidents in important parts. At the same time, it used as a basis for maintenance plans or design changes of faulty parts to prevent the same type of accident.

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