基于狮航空难的多层次事故致因分析及预防

Multi-level Accident Cause Analysis and Prevention Based on Lion Air Crash

为探究重大航空事故的致因机理及预防措施,以2018年狮航空难为典型案例,首先从系统视角进行组织安全控制分析,指出控制行为不足、沟通失效以及过程模型缺陷是组织层的安全隐患;然后通过飞机研制的全生命周期分析,指出设计逻辑缺陷、零部件故障以及维修漏洞等积累并影响了系统可靠性;接着基于人机共享控制理论分析了人机协同中的冲突,凸显了自动化透明度及人机功能分配等技术对安全的影响;还通过人因分类分析得到心理因素不良、机组协调以及人员训练不足导致了不安全行为。最后结合航空安全理论分析,提出了有效的组织安全控制回路、全周期的飞机系统可靠性、以人为中心的人机协同设计和动态科学的人员选拔和训练等安全预防措施。

In order to explore the causal mechanisms and preventive measures of major aviation accidents,the Lion Air crash in 2018 as a typical case was analyzed.Firstly,the organizational safety control analysis was conducted from the systematic perspective and points out that inadequate control behaviors,communication failures and process model defects were the potential safety hazards at the organizational level.Then through the whole life cycle analysis of aircraft development,it points out that the design logic defects,component failures and maintenance loopholes accumulate and affect the system reliability.Based on the human-computer shared control theory,the conflict of human-computer cooperation was analyzed,and the influence of automation transparency and human-computer function allocation on safety was highlighted.Through the human factors analysis and classification,it finds that poor psychological factors,crew coordination and inadequate personnel training lead to unsafe behaviors.Finally,combining with the analysis of aviation safety theories,safety prevention measures such as effective organizational safety control loops,full-cycle aircraft system reliability,human-computer collaborative design with human as the center and dynamic and scientific personnel selection and training were proposed.