基于Bow-tie模型的民机擦机尾事件致因研究

Study on the Cause of Tail-scraping Event of Civil Aircraft Based on Bow-tie Model

通过对导致擦机尾事件的原因进行分析,总结出主要有4大类原因,分别是飞行员操作失误、天气因素、设备故障和管理因素,其中最重要的是飞行员操作失误,起飞阶段(含复飞)有8类原因,着陆阶段有10类原因。应用Bow-tie模型形成以擦机尾事件为中心事件的擦机尾Bow-tie模型图,并对擦机尾事件危险源和后果提出相应的管控措施。

Through the analysis of the reasons leading to the tail-scraping event,it is concluded that there are four main types of reasons,namely,flight operation reasons,equipment failures,weather factors and management factors,among which the most important one is the pilot’s operation error.There are eight kinds of reasons in the take-off stage(including re-flight)and ten kinds of reasons in the landing stage.By using the Bow-tie model,the Bow-tie model diagram of the tail scraping event is formed,and the corresponding control measures are put forward for the hazard source and consequence event of the tail scraping event.