運用精實六標準差手法改善人為因素之飛安意外事件

Applying Lean Six Sigma to Improve Human Factors-Induced Incidents

本文旨在導入精實六標準差的概念與程序，加上人為因素的研究方法來進行軍事飛航人為因素的檢驗與改善。本研究先運用精實六標準差手法釐清問題本質與發生流程，再以階層任務分析法（Hierarchical Task Analysis, HTA）與人為因素預測模組(Human Error Template, HET)之系統性的方式循序漸進解決問題；透過資料蒐集與分析，將人為失誤由質化資料轉化成量化資料。研究發現：「系統/設計不佳」、「操作SOP不夠深入」、「飛行員素養(Airmanship)不佳」、「飛行員觀念不正確(知識) 」、「對環境掌握(Situation Awareness, SA)的細膩度不夠」以及「教學標準不一致」等六項，應是造成飛行員在落地減速階段，因人為因素導致意外事件的最主要因素。

關鍵字:精實六標準差(Lean Six Sigma, LSS)、階層任務分析法（Hierarchical Task Analysis, HTA）、人為因素預測模組(Human Error Template, HET)。

This research aims at applying the philosophy and process of Lean Six Sigma, together with Human Research Methods to improve the human factor induced accidents/ incidents in air force. Firstly, Lean Six Sigma approach- Define, Measure, Analyze, Improve and Control is employed to build the research framework and identify the core problem of a particular fleet in air force. By means of the systematic structure, the historical data is quantified and analyzed so that potential problematic procedures can be realized. Then Hierarchical Task Analysis (HTA) is used to probe into the detail procedures and Human Error Template (HET) is applied to each bottom level task step in a hierarchical task analysis. Based on the combined approaches, the results demonstrate that there are six areas with potential threats to human factor induced incident/accidents in landing phase. They are: Aircraft design/system, Operational standard of procedures, Flight crew airmanship, Crew knowledge, Situation awareness and Instructor standard.

KEYWORDS:Lean Six Sigma, Hierarchical Task Analysis, Human Error Template.