基于功能共振事故模型的航空事故分析-甘旭升

23720137ChinaSafetyScienceJournalVol．23No．7Jul．2013*甘旭升1崔浩林2教授吴亚荣2171012327100516203070X913.4A【】、。5191。。。【】AnalysisofAviationAccidentBasedonFunctionalResonanceAccidentModelGANXu-sheng1CUIHao-lin2WUYa-rong21DepartmentofBasicCoursesXijingCollegeXi'anShaanxi710123China2CollegeofAirTrafficControlandNavigationAirForceEngineeringUniversityXi'anShaanxi710051ChinaAbstractTheaviationaccidentsresultmostlyfromclosecouplingandcomplexinteractionsbetweenmanyinducingfactors．Howeverthetraditionalaccidentanalysismethodsareonlysuitablefortheacci-dentsthatthepurecomponentfailureleadstoandtherelativelysimplesystems．Toovercometheshort-comingofthetraditionalaccidentanalysismethodsanaviationaccidentanalysismethodbasedonfunc-tionalresonanceaccidentmodelwasworkedout．ThemethodwasusedtoanalyzetheaccidentthatAmeri-caflight5191overshottherunway．Theprocessincludesidentificationoffunctionmodulesevaluationofperformancevariabilityforfunctionmodulesdeterminationoffunctionalresonancesandestablishmentofbarriersforperformancevariability．Theanalysisresultsshowthatthemethodcannotonlyidentifythefunctionalresonancesleadingtotheaccidentandtheirinfluencefactorsandexplainthereasonsandprocessesthattheaccidenthappenedbutalsoprovidethecontrolmeasuretoreduceaccidentrisk．Keywordsfunctionalresonancefunctionmoduleaviationaccidentaccidentanalysismethodcommonperformancecondition0。、1、、2、、3*1003－3033201307－0067－062013－05－192013－06－214、5－6。。。、、。FRAMFunctionalResonanceAccidentModelHollnagel78。FRAMFRAM。1、。7“”。。Benzi91。。、、。1Fig．1Principleofstochasticresonance。。“”2。2Fig．2Principleoffunctionalresonance2FRAM。FRAM410－11。2．1、。FRAM、Petri。。FRAM3。。·86·ChinaSafetyScienceJournal232013IOR、、、、C、、PT、。3Fig．3Hexagonalfunctionmodule、、、。。2．2。。。。M、T'O'1。①②③。④②③。、、8。4。1MT'O'Table1RelationshipbetweencommonperformanceconditionandMT'O'MT'O'O'T'O'T'MMO'MMMMMT'MT'2．3。1。。。1。2。。3。、。2．4。FRAM41。21。3·96·7。4。22。、。33．12006827ComairCL－600－2B195191247。12。4Fig．4Schematicdiagramofairportrunway05494951915191ATIS2240s264。26。2622、。3．2FRAM1。F1F2F3∶ATISF4F5F6F7F8F9∶FAAF10∶ATCF11。11111。F62。2F6Table2FunctionmoduleF6IO22RNACO、T136sCATCP2。1。F63。3F6Table3EvaluationofperformancevariabilityforfunctionmoduleF6·07·ChinaSafetyScienceJournal23201322。37“”3“”F6F6。4。4Table4EvaluationresultofperformancevariabilityofeachfunctionF1F2F3ATISF4F5F6F7F8F9FAAF10ATCF11F6F102。3。115FRAM。。F6F102。、5。5、Table5FunctionalresonancemoduleinfluencefactorandfailureconnnectionF6F6CF6OF7IF7F6CF7OF11IF10OF6CF10F6R、F10OF6PF10OF7PF11F10CF10TF10P4。F6F10267。5Fig．5Systemfunctionnetworkdiagram·17·76F6Table6ControlofperformancevariabilityforfunctionmoduleF6ATCATIS、7F11Table7ControlofperformancevariabilityforfunctionmoduleF1145191FRAM1FRAM。。2FRAM。3FRAMFRAM。4FRAM、。1AnderssonORollenhagenC．TheMTOconceptandorganizationallearningatForsmarkNPPC．IAEAInternationalConferenceonSafetyCultureinNuclearInstallations20021－4．2KimJN．ThedevelopmentofK-HPESaKorean-versionhumanperformanceenhancementsystemfornuclearpowerplantcontrolC．Proceedingsofthe1997IEEE6thConferenceonHumanFactorandPowerPlants199716－20．3HendrickKBennerL．InvestigatingAccidentswithSTEPM．NewYorkMarcelDekkerIncorporated19877－35．4SvensonO．TheaccidentevolutionandbarrierfunctionAEBmodelappliedtoincidentanalysisintheprocessingindus-triesJ．RiskAnalysis1991113499－507．5ReasonJ．HumanErrorM．NewYorkCambridgeUniversityPress19901－19．6．J．2011215119－125．GANXu-shengDUANMUJing-shunCONGWeietal．InducementpatternanalysisandpredictionstudyonmechanicalcausationflightaccidentJ．ChinaSafetyScienceJournal2011215119－125．7HollnagelE．BarriersandAccidentPreventionM．AldershotUKAshgatePubLtd2004167－176．8．J．20117465－70．ZHANGXiao-quanWUGui-feng．ApplicationofFRAMmodelinCFITaccidentanalysisJ．JournalofSafetyScienceandTechnology20117465－70．9BenziRParisiGSuteraAetal．AtheoryofstochasticresonanceinclimaticchangeJ．SIAMJournalonAppliedMathematics1983433565－578．10DeCarvalhoPVR．TheuseoffunctionalresonanceanalysismethodFRAMinamid-aircollisiontounderstandsomecharacteristicsoftheairtrafficmanagementsystemresilienceJ．ReliabilityEngineer-ingandSystemSafety201196111482－1498．11BelmonteFSchnWHeurleyLetal．Interdisciplinarysafetyanalysisofcomplexsocio-technologicalsystemsbasedonthefunctionalresonanceaccidentmodelanapplicationtorailwaytrafficsupervisionJ．ReliabilityEngineeringandSys-temSafety2011962237－249．12HollnagelEPruchnickiSwoltjerRetal．AnalysisofComairflight5191withthefunctionalresonanceaccidentmodelC．The8thInternationalSymposiumoftheAustralianAviationPsychologyAssociation200878－85．甘旭升1971－。[e-mail]．·27·ChinaSafetyScienceJournal232013