空中交通管制团队人误的分类及致因研究

Analysis of Team Errors in Air Traffic Control

复杂社会技术系统通常以团队方式运行,认识与预防团队人误是控制安全风险的重要途径。研究采用威胁与差错管理(TEM)的研究框架,以某空管运行自愿报告系统2004年全年数据为样本源,分析团队人误的流程与致因,统计发现团队人误占总体空管人误的31%。团队发现和指出错误后仍不能有效纠正错误的比例达到8%。根据样本统计并结合典型团队人误的案例,确认了空管团队人误的主要类型和分布情况以及团队行为促成因素(PSF)的框架及重要性排序,其中缺乏交流是团队人误的最常见PSF,报告样本量出现率达47.1%。最后,从组织文化建设、团队管理、标准操作程序、培训等方面提出了减少团队人误的建议。

Identifying and preventing team errors is one of the important means to control safety risk in complex social-technical system. This paper, using the research framework of Threat and Error Management （TEM）, statistically analyzes the team errors and causes in air traffic control （ATC） with the data from certain air control voluntary report system in 2004 as the sample. The result shows that team errors account for 31 percent of the total reporting ATC errors, the rate of not being able to correct the errors after being recognized is up to 8 percent. Based on the statistical result and some typical cases of team errors, main types of team errors and their distribution are pointed out, the Performance Shaping Factors （PSF） for team errors are listed in sequence of importance. Statistical analysis on the sample shows that the lack of communication in teams is the common PSF, which accounts for 47.1 percent. Finally, suggestions about how to reduce the tem errors are presented from the aspects of organizational culture, team management, SOP （Standard Operation Procedure） and training etc.