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摘要: 为了提高空中交通安全, 将业务流程管理与人为因素分析分类系统相结合, 提出了多维事故原因分析模型, 确定了模型的使用步骤, 并使用此模型对实际案例进行了原因分析。分析结果表明: 利用此模型能够引导调查分析人员利用“瑞士奶酪”模型全面查清各工作环节存在的漏洞; 工作流程的细致程度和完整性与分析结果的详细程度和全面性成正比; 原因分类的层次越深, 分析结果越详细; 该模型应用在工作流程相对固定的领域可优化工作流程, 提高系统可靠性; 将工作流程及各原因之间的关系存储在数据库中, 可便于事件重现, 为风险评价与安全预警提供有用数据。Abstract: In order to improve air traffic safety, a multidimensional analysis model of accident causes(MAMAC)was put forward by integrating business process management(BPM), human factors analysis and classification system(HFACS), its using steps were proposed, and the accident causes of an actual case were analyzed by using the model.The result indicates that the model can lead investigators to find all holes of processes by using Swiss Cheese Model; the detailed level and completeness of business process are proportional to the detailed level and completeness of cause analysis; the degree of cause analysis hierarchy is proportional to the detailed level of analysis result; when the model is applied to the fields where business process is relatively stable, business process can be optimized, and the reliability of system can be increased; when the relationships of the causes are stored into a database, it is easy to realize event recurrence, and the data can be used in risk evaluation, safety forecast and alert.
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Key words:
- air traffic safety /
- accident /
- human factor /
- cause analysis /
- BPM
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表 2 各子系统漏洞分析
Table 2. Failure analysis of subsystems
序号 子系统 组织因素(D) 不安全的监督(E) 不安全行为的前提条件(F) 不安全行为(G) A 机务起飞前试车检查系统 试车工作单不完善(AD2) 指派经验不足的机务排故(AE2) 试车时没有检查油料平衡(AG3) B 机组起飞前检查系统 机组操纵程序不完善(BD2) 疲劳(BF3) 起飞前未检查油料平衡(BG3) C 飞机油料平衡指示系统 飞机油料平衡指示未设计告警(CF6) 
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