近12年中国民航人因事故与事故征候的分类研究

目的：对中国民航1990～2001年期间发生的人因事故征候和飞行事故进行分类研究。方法：运用Reason事故链模型，结合中国民航的传统分类方法，制订人因事故与事故征候分类标准，在此基础上按分类标准进行分类统计和分析。结果：1)在飞行的各个阶段中，滑行和巡航阶段小于间隔飞行的事故征候发生的百分比高于起飞、爬升、下降以及进近阶段。2)事故征候的主要类型为偏出、冲出跑道，危险接近，擦机尾或翼尖、发动机以及地面撞障碍物。3)飞行事故的主要表现形式是机组原因造成飞机失控、撞山以及冲出跑道。4)基本驾驶术有所下降，主要表现为修正偏差的能力不足。5)机组错误的主要表现是操纵不当、违反规章程序飞行、迷航及飞错高度。结论：不良的驾驶舱资源管理技能是影响我国民航飞行安全的主要因素，这与国际上的研究相符。但事故征候高发阶段、机组错误的类型和表现形式等，与国际上航空发达国家相比差异较大，具有明显的特点。要进一步改善我国民航的航空安全水平，必须针对我国民航的特点，加强对机组人员驾驶舱资源管理技能的训练。

A Classification on Human Factor Accident/Incident of China Civil Aviation in Recent Twelve Years

Objective: To study human factor accident/incident occurred during 1990-2001 using new classification standard. Method: The human factor accident/incident classification standard is developed on the basis of Reason's Model, combining with CAAC's traditional classifying method, and applied to the classified statistical analysis for 361 flying incidents and 35 flight accidents of China civil aviation, which is induced by human factors and occurred from 1990 to 2001. Result: 1) the incident percentage of taxi and cruise is higher than that of takeoff, climb and descent. 2) The dominating type of flight incidents is diverging of runway, overrunning, near-miss, tail/wingtip/engine strike and ground obstacle impacting. 3) The top three accidents are out of control caused by crew, mountain collision and over runway. 4) Crew's basic operating skill is lower than what we imagined, the mostly representation is poor correcting ability when flight error happened. 5) Crew errors can be represented by incorrect control, regulation and procedure violation, disorientation and diverging percentage of correct flight level. Conclusion: The poor CRM skill is the dominant factor impacting China civil aviation safety, this result has a coincidence with previous study, but there is much difference and distinct characteristic in top incident phase, the type of crew error and behavior performance compared with that of advanced countries. We should strengthen CRM training for all of pilots aiming at the Chinese pilot behavior characteristic in order to improve the safety level of China civil aviation.