1990～2003年中国民航152起小于间隔飞行事件的分类统计研究

小于间隔飞行事件是双机空中相撞事故的潜在威胁 ,对此类事件进行人的因素的分类统计分析有助于寻找错误原因和规律。笔者以 15 2起小于间隔飞行事件为数据源 ,根据Reason模型和HFACS系统进行分类 ,统计了各个因素所占的百分比和部分因素的相关程度。结果表明 ,小于间隔事件与生物节律的关系并不明显而与交通流量密切相关 ;机组不安全行为与管制员未能有效实施监控职能密切相关 ;决策错误、操作错误和知觉错误的主要表现形式分别为 :混淆指令、调错高度窗、听错指令和记错 /忘记管制员指令以及未理解管制员指令 ;不良的机组资源管理是导致小于间隔最主要的机组因素 ,主要表现形式为机组成员之间的配合不好、未有效实施交互监视和交互检查 ;“高度指令”和“相对活动高度”提示的语序问题是一个值得进一步研究的课题。

Study on Categorized Statistics of 152 Cases of Insufficient Separation Event of China Civil Aviation in 1990-2003

Insufficient separation is a potential threat of collision between two airplanes. Study on its categorized statistics to analyze the human factors is helpful to find out the causes of errors as well as their occurrence regularity. 152 insufficient separation cases were taken as the data source, and the percentage of various factors and the correlation among some actors were analyzed according to Reason's model and the HFACS system. The result showed that the cases have no obvious correlation with biorhythm; however, they are closely related to traffic capacity. The unsafe behaviors of aircrew are closely related to the failure of air controllers to exercise effective supervision and control. The main manifestation of decision-making, operational and perceptional errors includes instruction confusion, mishandling of the altitude window, instruction misunderstanding, and incorrect memory/forgetting of ATC instructions. The incompetent management of crew resources is the major cause, such as insufficient coordination between crew members, failure in adopting effective cross supervision and examination etc. The word order of "altitude command" and "relative altitude" indication is a subject worthy of further study.