基于HFACS模型的偏离指令高度的分析及建议

Analysis and Suggestion of Deviation from the Instructed AltitudeBased on HFACS Model

2018年初,民航局开展了专项整治行动,其中偏离指令高度的发生率占近一半。看似简单且不太可能发生的事件,其背后往往是由诸多人为差错相互叠加导致的,要找出这类事件的真正诱因较为复杂。本文借助人为因素分析分类系统(HFACS)模型,结合空客飞行机组操作手册中相关内容,对偏离指令高度这一差错的原因从显性差错到隐性差错的思路进行分析,并针对航空公司提出可行的建议。

At the beginning of 2018,the CAAC carried out special rectification actions,of which the incidence of deviation from the instructed altitude accounted for nearly half.Some events which seems simple and impossible are often caused by the superposition of many human errors.It is more complicated to find the real cause of such events.With the help of the HFACS and the relevant contents in Airbus flight crew operating manual,this paper analyzes the causes of deviation from the instructed altitude from explicit error to recessive error,and puts forward feasible suggestions for airlines.