基于事故树分析法的发动机空中停车人为差错研究  

Research of human errors in in-flight shutdown based on the fault tree analysis

作　　者：曹蓓[1] 于航[2] 孙佳[2] 蒋仲安[1] 

机构地区：[1]北京科技大学土木与环境工程学院,北京100083 [2]中国民航管理干部学院航空安全管理系,北京100102

出　　处：《安全与环境学报》2014年第6期15-18,共4页Journal of Safety and Environment

摘　　要：统计了2001—2011年间国内发动机空中停车的数据,研究了运输航空发动机空中停车的失效模式和主要原因,并重点研究了人为差错这一致因。将机务人员和机组人员作为主要研究对象,采用事故树分析法,根据机务人员和机组人员工作性质的不同,分别绘制了"机务事故树"和"机组事故树"。经过布尔代数运算,得到了相应的4个最小割集和3个最小割集,找到了空中停车发生的途径。通过对事故树的定性分析,计算各基本事件的结构重要度,得出管理和监察不到位是机务人员人为差错的主要表现,而主观判断错误、受到假信息干扰和违章操作则是机组人员人为差错的主要表现形式。Based on the statistics analysis of the collected data during 2001 - 2011, this paper aims to discover the failure modes of IFSD that took place to the air engine, trying to find the main causes, including the mechanics failure, human errors, the unexpected poor weather influential factors. Of all the likely causes, we would like to put our main stress on the analysis of human errors ： The maintenance personnel are to take the charge of the safety and reliability of the aeroengine, whereas the crew members of the aircraft have the direct responsibility to guarantee the flight safety. The research method we have adopted is the fault tree analysis （FFA） for its advantages in the air accident study in looking for the failure modes of IFSD. With re- spect to the maintenance personnel fault tree, the bad safety training, insufficient inspection, insufficient management and rule violation errors serve as the branches of the faulty tree. The crew fault tree is composed of the subjective judgment error, the fake information interference, the careless team operation manners and rule violation errors. With the help of the Boolean algebra calculation, it would be possible to obtain the corresponding 4 and 3 minimum cut sets and in turn work out the associated cause-and-effect chains. In so doing, it can be expected to prevent IFSD by controlling the basic events relat- ed to those in the minimum cut set. And, finally, we could evaluate the safety-related influential factors of the aircraft related to the basic accident event properly qualitatively and quantitatively. And, in turn, it can be concluded that insufficient management and inspection can be the main errors in close correspondence with the related errors of the maintenance personnel, whereas the subjective judgment er- rors, the fake information interference and the rule violation errors can be categorized into the main crew errors. It can thus obviously be proved that the rule violation errors could result in IFSD either as the important human error of the m

关 键 词：安全工程 发动机空中停车 人为差错 事故树分析法 机务人员 机组人员 

分 类 号：X949[环境科学与工程—安全科学]