基于系统理论的因果分析与网络建模的整合,以加强事故分析
Gulsum Kubra Kaya1, Mark Humphreys1, Fanny Camelia2
1Faculty of Engineering and Applied Science, Safety and Accident Investigation Centre, Cranfield University, Cranfield, UK.
Ergonomics
|June 18, 2025
概括
这项研究将基于系统理论 (CAST) 的因果分析与网络建模相结合,以提高航空地面操作安全. 它确定了乘客登机台阶事件中的关键因素,增强了风险管理策略.
科学领域:
- 航空安全与人类因素
- 系统工程和风险管理系统工程和风险管理
- 事故调查方法 事故调查方法
背景情况:
- 航空地面处理操作是复杂的,涉及许多关键任务.
- 接地服务中的事故,特别是涉及乘客登机阶段 (PBS) 的事故,构成重大安全风险.
- 现有的事故分析方法可能无法完全捕捉到这些事件的系统性和交互性.
研究的目的:
- 基于系统理论 (CAST) 的因果分析与网络建模进行整合,以进行增强的航空事故分析.
- 确定与乘客登机阶段 (PBS) 相关的事件中的关键控制行动和促成因素.
- 提高对事故原因的理解,并为航空地面处理中的风险管理策略提供信息.
主要方法:
- 通过基于系统理论 (CAST) 的因果分析,分析了117个与乘客登机阶段 (PBS) 相关的事件报告.
- 将网络建模技术与CAST集成,以可视化因果路径和相互作用.
- 确定关键的控制行动,损失类型和有助于的因素.
主要成果:
- 在40个控制行动中,CAST分析发现了74个缺陷,导致了四种类型的损失.
- 接近,检查,调整和重新定位PBS被确定为最关键的控制行动.
- 关键的贡献因素包括培训,工作量,情境意识,组织文化,程序和设备维护.
结论:
- 通过将CAST与网络建模相结合,通过可视化复杂的相互作用,可以更深入地了解航空事故的原因.
- 综合方法提高了对航空地面服务安全风险的理解.
- 该研究支持航空安全专业人员基于证据的决策,并改善地面操作风险管理.
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