摘 要
飛航管制系統中，主要的工作人員是管制員，工作的內容經常必須面臨時間的緊迫性。飛航管制與核子工業、化學工業及飛行一樣，是屬於高危險的工作。人為失誤幾乎是意外發生的主要因素，而且主要是發生在第一線管制員身上。有些學者認為，飛航管制的人為失誤佔了所有意外原因的百分之九十或以上。
高比例的人為失誤所帶來的問題是：人為失誤發生的原因、來源為何？如何預防人為失誤發生或減少發生的頻率？本研究之目的在於發掘飛航管制人為因素，減少飛航管制員人為失誤之發生。構建及發展以人為因素理論為基礎的飛航管制員風險因子架構，發掘潛在的風險因子，作為增進飛航安全策略之參考。
本研究所要建立之模式，是以SHELL模式為基礎，結合Reason教授的組織事故理論、Issac金字塔模式。也就是SHELL模式加上與組織(Organization)互動的介面，以找出飛航管制員工作必須面臨與組織間溝通協調的獨特性，同時也修正SHELL模式成適合在飛航管制業務上應用之架構，最後提出一個新的理論架構HELLOS模式，由原始Liveware的核心能力及五個互動構面（Liveware與Software、Hardware、Environment、Liveware、Organization）五者互動結合而成。
本研究的首要步驟是援引飛安理論之研究模式，經適當修改後，做為本研究的人為失誤研究模式。第一次問卷主要調查專家意見篩選準則，並藉模糊德菲法挑選適當之飛航安全風險因素。第二次問卷以篩選後飛航安全風險因素調查專家意見，藉由模糊層級分析法，以分析風險因素之相對權重，探討國內飛航管制專家對飛航管制風險因素的評估與建議。根據第一、二次問卷，本研究取得專家對於風險因素的重要性看法之後，進行第三次問卷，對象是民航局行政主管及行政幕僚，探討其對風險因子改善的看法，並建構一整合模式，提出進行改善之優先順序之建議。
HELLOS模式調查結果，管制專家們認為最重要的前五項風險因素是「管制員個人知識技能」、「管制員人力資源運用」、「對緊急狀況應變之訓練不足」、「備援系統是否易於使用」、「空域結構劃分不當」；政府官員對風險因素改善可行性的高低調查前五項為「管制員交接不完整確實」、「相關支援設備供應不足」、「飛航管制員與飛行員之溝通不良」、「管制員人力資源運用」、「欠缺正確之流量管理措施」。
本研究另調查民航局相關行政官員對於風險因素的改善意見，並將之與HELLOS模式之歸納結果整合，依其重要性與可行性整合得出四個群組，第一群之優先執行組，第二群為重點規劃組，第三群為彈性整合組，第四群為長期策略組，供主管機關評估參考。

Abstract

Air traffic control specialists are the primary operators in the air traffic control system. And they are decision makers in a dynamic environment involving strict time pressure. Controllers collaborate with pilots, technical staff, management and other controllers to assure the safe, orderly, and expeditious flow of air traffic. Investigations often reveal that human factor plays a leading role in air traffic control related incidents and accidents.

Accidents prevention is critically linked the adequacy of the investigation of human factors. Yet human error is under-served by traditional event investigation methods. the prevailing means of investigating human error in air traffic control accidents remains the analysis of accidents and incidents data. As a result, these means are relatively ineffective in finding human errors.

The study focused on the risk factors often contributed to the occurrence of human errors in the air traffic control system in Taiwan. With the application of theories of human factor engineering, the study has developed a framework to evaluate the safety of air traffic control system . On top of that, the study adopted the SHELL model, which is developed earlier to describe the interactions of liveware with the other four dimensions such as liveware, hardware, software, environment in a dynamic system, to construct a new model called HELLOS model. The statistical analysis methods used in the study to be combined with the HELLOS model are Fuzzy Delphi and Fuzzy Analytic Hierarchical Process. In Addition, Linguistic Variable is also applied to evaluate the feasibility and priority of the improving strategies.

The study is the first attempt to give a comprehensive analysis of risk factors existed in the local air traffic control system and has met with encouraging result. The outcome and findings of the study will help the management and the aviation authority understand the significant factors in the decision process of defending the air traffic control system against human error.

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