A Study Of The Management Of Reducing Human Error By M-SHELL Model

[[abstract]]本論文目的主要在探討人為失誤對空軍戰機維修之影響，並以不使用動力機具之「短程空對空飛彈裝掛作業」為分析及安全觀察對象，以M-SHELL模式之M（管理手法）將誘發人為失誤的原因分類為L-S（人與軟體）、L-H（人與硬體）、L-E（人與環境）、L（人本身的限制）、L-L（人與人）等構面，使用分析層級法(AHP)，針對空軍各單位執行（或曾執行）此項作業5年以上之專業人員實施專家問卷訪談，並將空軍91至96年發生之維修、工作意外事件依此模式分類對照後，發現誘發人為失誤之主要因素，均以L（人本身的限制）高居首位，而其中又以「工作人員是否遵守程序」為主要因素，顯見造成意外之主因並不是人為失誤，而是誘發人為失誤的基本原因。惟囿於過往意外事件調查與記錄之方式，未深入探究人為失誤之基本原因，肇致人為維修失誤層出不窮（如發動機FOD、拖機意外事件等）。 本論文以M（管理）的角度就發現之問題提出改善建議，期能建立戰機維修人為失誤意外事件調查與記錄之模式，將飛機維修人為失誤發生之機率降至最低，期逐步建立虛驚事件與人為失誤資料庫。[[abstract]]The main goal of the study is to find out how human errors influence the maintenance of air force fighter planes and to take “the short-range air-to-air missile loading task” which is no needs of machines and tools as the object of analysis and safety observation Based on the M-SHELL model (management technique) we classify the inducements of human errors as L-S (human and software) L-H (human and hardware) L-E (human and environment) L (person's limit) L-L (human and human) and so on To begin with we apply Analytic Hierarchy Process (AHP) to interview some experts with 5-year experiences or above in this field After contrasting the work accidents in the air force from 2002 to 2007 referring to the AHP result we discover the top primary factors inducing human errors are all the item Ls (human's limit) and amid them “whether staff observe the procedure” is the most which obviously indicates that the main factor of any accident is the root cause rather than human error However in the past due to the flawed method of accident investigation and record the artificial service mistakes emerged one after another formerly (e g engine FOD the towing airplane accident and so on) From the angle of M (management) the study brings up some proposals to some obvious questions We suggest establishing a model of accident investigation and record on human error in fighter maintenance which can hopefully diminish the human-error rate and gradually build up a data bank for near miss events and human error