本研究以國內某航空公司飛航操作品質保證系統內之飛行資料為研究母體，對金門機場各種進場程序進行風險評估，定義金門尚義機場風險較高的進場程序。論文研究2004至2006年進場降落階段觸發偏離標準操作事項的2598筆航班資料，結果顯示使用目視進場降落24跑道是金門機場風險較高的進場程序，平均航班觸發標準高度偏離標準操作事項之機率是使用儀降06跑道的4.17倍；平均航班觸發高風險層級的複合高度偏離操作事項之機率更是使用儀降06跑道的65.44倍。針對24跑道目視進場程序進行風險成因分析，結果顯示造成風險過高係由『地形』、『心理因素』、『飛航組員操作』、『進場航路』、『地面助導航設施燈號』、『航機總重』等多種原因綜合導致。對操作偏離事項進行相關性分析，顯示發生複合偏離標準操作事項『終端進場過程中持續過高』、『終端進場過程中持續下降過快』及『短五邊進場時改正過晚』後，飛行員發生誤失而觸發『平飄時間過短』、『觸地時仰角過大』、『彈跳落地』…等標準偏離標準操作事項的機率較高，同時降落觸地時『平均垂直速度』與『平均垂直加速度』皆較一般正常航班值略高，相對發生重落地事故的機率亦隨之增高；此外，進場期間曾觸發上述複合偏離標準操作事項的航班，於觸地時再觸發『彈跳落地』標準偏離標準操作事項或『未觸發任何標準偏離標準操作事項』時，所使用跑道距離亦較一般正常航班要遠，意味衝出跑道事故發生的機率亦隨之提高。金門機場24跑道目視進場風險較高主要乃受限於地形因素，本研究建議航空公司派遣對24跑道目視進場程序較熟悉的組員執行任務、並在標準操作程序中增加24跑道進場標準操作程序章節且在文中加註可能遭遇之風險，同時加強飛航組員進場程序、遭遇風切時應變程序訓練，在簽派24跑道任務時不攜帶回程油料以降低飛機總重。此外，也建議民航局增設24跑道助導航燈號並對24跑道進場航路進行適度修改或重新規劃，以提升飛航安全。

This thesis research collaborated with a domestic airline to investigate the flight data of 2,598 flights to Kimen Airport logged in the Flight Operation Quality Assurance data bank of the airline. The triggered non-standard events were studied and used to precede risk assessment. The statistical results showed that the risk level of Visual Approach on Runway 24 is higher than that of both ILS Approach and Visual Approach on Runway 06. The probability of triggering a standard “red event” of Visual Approach on Runway 24 is 4.12 folds of those selecting ILS Approach on Runway 06, while the probability of triggering a composite “red event” of Visual Approach on Runway 24 is 65.44 times higher than those selecting ILS Approach Procedure of Runway 06. The cause analysis indicated that the facts which make Visual Approach on Runway 24 riskier are composed by the factors of “terrain”, “psychological factor”, “operation skill”, “route of approach”, “ground navigation aids”, and “gross weight of aircraft.” The correlation analysis of Visual Approach on Runway 24 validated that the probability of triggering standard events such as “short flare”, “pitch high at touchdown”, “bounced landing” at touch down become higher when the flight had triggered composite events such as “continuously high during final”, “continuously steep during final”, “late offset in short final.” A scenario was made that late correction after triggered composite events during final would affect the accuracy of aircraft maneuvering and cause the potential risk of hard landing and runway overrun. Since Kimen Airport is difficult in nature (landform and weather), this study suggested that airlines should dispatch highly experienced flight crews in executing operations to Kimen Airport. In order to lower the risk of flights, the airlines should also put addition chapter of Kimen NDB/DME D Approach on Runway 24 in their Standard Operation Procedures, enhance wind-shear-encountered training, and try not to carry extra return leg tanked fuel. The conclusions also suggested that the authority should set up new navigation aids lamps or redesign the approach route of Visual Approach on Runway 24 in order to promote the progress of flight safety.

【1】Boeing Commercial Airplanes Group Aviation Safety, Statistical Summary of Commercial Jet Airplane Accidents Worldwide Operations 1959-2005, 2005
【2】Boeing Commercial Airplanes Group Market Analysis, Current Market Outlook 2006, 2006
【3】Boeing Commercial Airplane Group Airplane Safety Engineering, Accident Prevention Strategies, Commercial Jet Aircraft Accidents, World Wide Operations 1982-1991, 1993
【4】Brown, Norman M. & Moren, Charles R., Background Emotional Dynamics of Crew Resource Management: Shame Emotions and Coping Responses, The International Journal of Aviation Psychology, Vol.13, no.3, pp.269-286, 2003
【5】張有恆, 成功大學交通管理科學系所教授,飛航安全管理, 2005
【6】McFadden, K. L., Comparing Pilot-error Accident Rates of Male and Female Airline Pilots, Omega, Vol. 24, No.4, 1996, pp.443-450.
【7】陳啟昭, 從機師族群探討組織氣候、安全氣候與組員資源管理及航務滿意度之關聯性, 國立成功大學交通管理科學研究所碩士論文, 民90
【8】Yee, Y.N. & Liu, B.S., Inflight Workload Assessment: Comparison of Subjective and Physiological Measurements, Aviation, Space, and Environmental Medicine, Vol.47, no.10, pp.1078-1084, 2003
【9】廖瑋晟, 以航務操作監控系統（LOMS）飛航資料之飛航風險因素分析, 國立成功大學航空太空工程研究所碩士論文, 民94.
【10】姚雋偉, 尾風超限進場之風險分析, 國立成功大學航空太空工程研究所碩士論文, 民95.
【11】U.S. General Accounting Office, Aviation Safety: U.S. Efforts to Implement Flight Operational Quality Assurance Programs, Flight Safety Digest, Vol.17, no.7-9, pp.1-36, 1998
【12】Jacques Verrière, FOQA Contribution to Flight Safety Management, 12th annual European Aviation Safety Seminar, pp.7-12, 2000
【13】官文霖, 行政院飛航安全調查委員會調查實驗室, 飛航記錄器之發展歷程與特性.ppt, 2004
【14】R. Curtis Graeber and Mike M. Moodi, Boeing Commercial Airplane Group, Understanding Flight Crew Adherence to Procedures: The Procedural Event Analysis Tool (PEAT), 1993
【15】行政院飛航安全委員會, 航空器失事調查報告ASC-AAR-02-04-002中華民國89年 10月31日新加坡航空公司006班機BOEING 747-400型機國籍登記號碼9V-SPK於中正國際機場起飛時撞毀在部分關閉跑道上, 2002
【16】蔡聿珮, 飛航操作品保系統成功因素之探討, 國立成功大學交通管理科學研究所碩士論文, 民93
【17】Flight Safety Foundation Editorial Staff, Pilot Union Encourage Use of FOQA Programs, Flight Safety Digest, Vol.17, no.7-9, pp.8-10, 1998
【18】Robert L. Helmerich, The University of Texas at Austin, Crew Performance Monitoring Programme Continued to Evolve as Database Grows, ICAO Journal, May 2002, p6-7
【19】Flight Safety Foundation-Taiwan, FOQA - A Proven Safety Enhancer, Touchdown Vol.3 Issue I.
【20】Holtom, Mike, FOQA：Aviation’s Most Important Safety Tool, 52nd annual FSF International Air Safety Seminar, pp.209-222, 1999
【21】Xie Zinan, Shu Ping, Yu Liling and Xu Xiangsong, The FOQA Project in China, 57th annual International Air Safety Seminar, 2004, pp73-79.
【22】Airbus, FOM, Flight Operation Monitoring Handbook, April 2002, p42-45.
【23】行政院飛航安全委員會, 航空器失事調查報告ASC-AAR-02-02-001 立榮航空公司B7 695 DASH-8-300 B-15235 重落地失事, 2002
【24】行政院飛航安全委員會, 航空器失事調查報告ASC-AOR-04-10-002 中華民國92年8月21日遠東航空EF055班機 MD-82型機 國籍標誌及登記號碼B-28011於金門尚義機場偏出跑道, 2004
【25】Airbus, Flight Profile Manual V2.6.3 Line Operation Monitoring System Rev.01, 2002
【26】交通部民用航空局, 金門尚義機場整體規劃, 民95年
【27】Department of Army, TM 5-811-5, Army Aviation Lighting, 13 December 1991.
【28】Airports Authority of India, Runway Lead-in Lighting Approach System First Of Its Kind Installed At Calicut Airport, Website of Airports Authority of India,
【29】民航局, 飛安自願報告系統簡訊 TACARE-11, 2005 June.
【30】Yue Xu, Antonio A. Trani, and Hojog Baik, Preliminary Assessment of Lower Landing Minima Capabilities in the Small Aircraft Transportation System Program, Transportation Research Board Monograph.

【31】Paul Miller, Independent Pilot Association Safety Committee, Safety: Beginning at the Bottom, A Response-based, Pilot-oriented Safety Program. Toward Safer Flight Operation and a Joint IPA-UPS Flight Safety Program, 53nd annual FSF International Air Safety Seminar, pp.217-224, 2000
【32】Thackray. R.I, Performance Recovery Following Startle: A Laboratory Approach to The Study of Behavioral Response to Sudden Aircraft Emergencies, FAA AM-88-04, 1998
【33】Gurevich. A, Pull up Pull up – The when and how GPWS pull ups, British Airways Flight Deck – Issue 1, Autumn 1991
【34】Flight Safety Foundation, Simulator-based Study of Emergencies Yield Insights into Pilots’ Reaction Times, 1999