从一起航空运输严重事故征候看航空领域的威胁与差错管理

不安全事件的发生通常经历了威胁-人的差错-意外状态-不安全事件这样一个发展演变的过程。2010年1月13日,上航B5260号机在虹桥机场进近过程中下降低于安全高度,触发近地告警,构成一起航空运输严重事故征候。威胁与差错管理模型揭示:临时变更进近方式构成了来自外部环境的威胁,而航空器驾驶员和管制员在对威胁、人的差错和意外状态管理方面存在的失误是造成这起严重事故征候的主要原因。通过加强对威胁的识别和对人的差错和意外状态的管理,可以提高系统的容错、防错和纠错能力,有效防止不安全事件的发生。

Study on Threats and Error Management in Aviation through a Serious Incident

Unsafe events normally develop as the following process： threat--human error-- undesired state--unsafe event. In Jan 13th, 2010 an aircraft of Shanghai Airlines descended below safe altitude and caused Aircrait Ground Proximity Warning. Threats and Error Management Model reveals that unexpected changeover of approach method is an external threat.Mismanagement of threat, human error and undesired state of both pilots and controllers are the main causes of this severe incident. We can improve the abilities of tolerance, prevention and error correction of the system by strengthening the identification of threats, management of errors and undesired states to prevent unsafe events from happening again.