国际民航组织安全管理系统课程讲义.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,国际民航组织安全管理系统（,SMS,）课程讲义,N2 Anyfield,机场事故,国际民航组织安全管理系统课程讲义,第1页,Contents,一、事件经过,二,、原因分析,2.1,调查结果,2.2,小组讨论,2.3,提议,逻辑,结构,三、表格填写,国际民航组织安全管理系统课程讲义,第2页,序言,阅读事故,相关文本,小组讨论,文字编辑,PPT,制作,工作流程,国际民航组织安全管理系统课程讲义,第3页,调查分析,+,合理提议,+,整改,=,安全,国际民航组织安全管理系统课程讲义,第4页,一、事件经过,国际民航组织安全管理系统课程讲义,第5页,一、事件经过,In the early hours of an autumn Monday-morning,a twin-engined jet transport with 5 crew-members and 63 passengers on board while in its take-off run at Anyfield Airport collided with a small twin-engined propeller-driven aircraft,with only a single crew-member that had intruded the departure-runway.Both aircraft were severely damaged as a result of the collision.The subsequent fire destroyed both aircraft and was the death-cause for most of the passengers.,在秋季周一早上凌晨，在,Anyfield,机场,1,一架双引擎喷气运输机,5,名机组组员和,63,名乘客，在其起飞运行时与一个侵入离场跑道只有一个机组组员双引擎螺旋桨小飞机相撞。这两架飞机因为碰撞遭到严重破坏。随即大火烧毁了飞机，同时造成大部分乘客死亡。,国际民航组织安全管理系统课程讲义,第6页,一、事件经过,Anyfield Airport is a medium-sized airport,with a single runway which can be accessed(or vacated)by a number of intersections.It is a controlled aerodrome;the control-tower is located 400 meters north of the middle of the runway.Traffic-numbers are on the rise as quite a few commuter-type airlines have started operating to and from Anyfield.,Anyfield,机场是一个中型机场，一条跑道连接着一些十字路口（或腾空）。这是一个管制机场，控制塔位于距北跑道中间,400,米位置。因为不少通勤型航空企业已开始来往于,Anyfield,，,Anyfield,交通流量逐步上升。,Although the airport is in a region in which several foggy days a year are common,it is not equipped with a Surface Movement Radar(SMR),nor does it have special taxiway-lighting facilities for use under low visibility-conditions.,即使机场处于一年中雾天很常见一个地域，不过它并没有配置地面活动雷达（,SMR,），也没有特殊滑行道照明设施供低能见度条件下使用。,国际民航组织安全管理系统课程讲义,第7页,一、事件经过,Air Traffic Control at Anyfield is slightly understaffed,but so far it was not thought necessary to impose restrictions on operations to and from Anyfield.There is a discrete frequency(Ground Control)to handle taxiing aircraft.,空中交通管制在,Anyfield,是略有不足，但到当前为止，并不认为需要加强对于在,Anyfield,运行限制。有一个离散频率（地面管制）处理滑行航空器。,At the time of the collision,the average visibility was around 700 meters with fog-banks,which is just sufficient to allow the tower-controller to see the middle part of the runway.The controllers view at the intersection where the intruding aircraft entered the runway however was obstructed by the newly constructed extension to the terminal building at Anyfield Airport.,在碰撞时，伴随雾坡度，平均能见度约,700,米，这是恰好足以让塔控制员看到跑道中间部分。新建成,Anyfield,机场候机楼扩展出来部分在阻挡了控制员视野，恰好是侵入跑道飞机进入跑道位置。,国际民航组织安全管理系统课程讲义,第8页,一、事件经过,The Air Traffic Controller(ATCO)was a very experienced controller.He had been working in ATC for many years,at several major facilities,and had been transferred to Anyfield to act as an OJT-instructor only eight months before the date of the accident.,空中交通管制（管制员）是一个非常有经验控制员。他曾在,ATC,工作多年，在几个主要管制中心，在意外发生日期仅,8,个月前被转移到,Anyfield,作为,OJT-,指导员。,At the time of the collision,the ATCO1 was alone in the control-tower,as his Assistant/Ground Controller ATCO2 of far less experiencehad briefly left the TWR to answer a call of nature.They were both completing their third consecutive nightshift,had come on duty at 22:00 hours the previous evening and were due to be relieved within thirty minutes when the accident occurred.,碰撞时，,ATCO1,独自一人在塔台，作为他助理,/,地面管制员,ATCO2-,远不如,ATCO1,经验丰富,-,曾短暂离开塔台上厕所。他们都完成他们第三个连续夜班，因为已经从前一天晚上,22:00,值班到现在，在事故发生时,30,分钟内就能够换班。,国际民航组织安全管理系统课程讲义,第9页,一、事件经过,The crew of the jet-aircraft was experienced operators to and from Anyfield.From their point of view,on the morning of the accident there was nothing unusual in the way their flight was handled by ATC.They taxied to the runway with the extra caution required by the fog-conditions,and after being cleared for take-off they made certain they were lined up correctly on the runway-centerline before applying take-off power.,喷气飞机机组来往于,Anyfield,经验丰富。从他们角度来看，事故发生在早晨，在,ATC,航路上没有不什么正常。他们在雾条件下格外小心地滑行到跑道，取得起飞许可后，在提出申请前起飞推力之前，确认他们在跑道中心线列队正确。,The pilot of the twin-engined piston-driven aircraft was unfamiliar with Anyfield Airport,having been sent there at short notice to collect an aircraft that had to divert into Anyfield two days earlier for weather-reasons.,双引擎活塞式飞机飞行员不熟悉,Anyfield,机场，被送到那里去短时间内接收两天前因为天气原因不得不转飞到,Anyfield,一架飞机。,国际民航组织安全管理系统课程讲义,第10页,上厕所回来发觉联络不上小飞机,双引擎螺旋桨小飞机,（误入跑到）,一架双引擎喷气运输机,（正起飞）,管制员,1,管制员,2,同时进行管制和地面两席位工作,在预计移交时间发觉运输机一直无应答。,上厕所前给小飞机公布滑行指令,消防队救援车辆因为不清楚事发准确地点，和雾天通行困难赶到现场时面正确是几乎烧毁完全飞机残骸,。,一、事件经过,跑道相撞,他没有从他能看到那部分跑道观察到离场喷气飞机,国际民航组织安全管理系统课程讲义,第11页,二、原因分析,国际民航组织安全管理系统课程讲义,第12页,2.,1,调查结果,国际民航组织安全管理系统课程讲义,第13页,2.1,调查结果,Although ATCO1 was very experienced,he had only worked a limited number of solo-shifts in Anyfield TWR.Having validated his TWR-rating in early summer,he had been involved in giving on-the-job-training(OJT)instruction on most of his shifts after that.As a consequence of the staff-shortage he was required to work his share of nightshifts like all other controllers.The shift in which the accident occurred was only his second where he had worked at Anyfield TWR under foggy/low visibility conditions;the first had been the previous night,when there was hardly any traffic as it was the night from Saturday to Sunday.,即使,ATCO1,是非常有经验，不过他在,Anyfield,塔台独自工作次数很有限。在初夏他才验证塔台管制评级，在那之后，他在大部分换班后参加到在职培训（,OJT,）指导工作因为人员短缺，他被要求必须像全部其它管制员一样值参加夜班工作。在该事故发生时仅仅是他在,Anyfield-TWR,班次中，第二次碰到雾,/,低能见度条件。第一次是在前一天晚上，当初几乎没有任何交通，因为那是在周六到周日晚上。,国际民航组织安全管理系统课程讲义,第14页,2.1,调查结果,A number of years ago there had been an incident at Anyfield involving runway-intrusion by a vehicle,under similar meteorological conditions as in this case.One of the recommendations at that time was the installation of a SMR,together with stop-bars at all runway-intersections.The authorities decided that in view of the limited number of days(with fog)that would warrant the use of a SMR,the benefit of having a SMR didnt match the costs of having one installed.The same applied for the installation of stop-bars,but in lieu of those,painted signs had been put in the grass next to the runway-intersections,informing those who noticed them there was a runway ahead.,Anyfield,在许多年前曾出现过车辆入侵跑道情况，也是在这种类似该事件气象条件情况下。当初提议之一是安装一个,SMR,，同时在全部跑道交叉口设置停顿阻挡。当局决定，鉴于需要使用,SMR,有限天数（雾天），安装,SMR,收益和支出并不匹配。安装停顿阻挡也是如此。不过我们能够用画在跑道十字路口旁边草地上图标代替,SMR,和停顿阻挡，提醒看到图标人，他们前面有“跑道”。,国际民航组织安全管理系统课程讲义,第15页,2.1,调查结果,As the early morning-traffic began to come alive,ATCO1 and ATCO2 were each working an independent R/T-frequency.When ATCO2 announced he had to visit the mens room for a second,ATCO1 told him to go ahead,intending to work both frequencies by himself.In order to do so,ATCO1 had to physically move between two control-positions in the TWR that are about three meters apart,for Anyfield TWR isnt equipped with a frequency-coupling installation.Transmissions on one frequency cant be heard by stations on the other frequency.,当清晨交通开始繁忙起来时，,ATCO1 ATCO2,分别在独立,R/T,频率上工作。,ATCO2,说他不得不再次去洗手间，,ATCO1,同意，打算自己在两个工作频率上工作。为了做到这一点，因为,Anyfield,塔台没有配置频率耦合装置，声音在一个频率上传输不能被其它频率听到，,ATCO1,不得不在在两个相距约三米管制席位间往返走动。,国际民航组织安全管理系统课程讲义,第16页,2.1,调查结果,The piston-engined aircrafts pilot had arrived in Anyfield late the night before.After a short sleep he went to the airport quickly in order to waste as little time as possible,for his company wanted the aircraft back at its home base a.s.a.p.After the minimum of preparation needed,he went to his aircraft and called ATC for approval to taxi to the runway.He obtained the clearance and began taxiing,but soon found himself lost at the foggy,unfamiliar airport.The fact that there were no signs denominating the various taxiway-intersections didnt help much either.,活塞式引擎飞机飞行员在前一天晚深夜才抵达,Anyfield,。经过短暂睡眠，他以尽可能少时间赶到机场，他企业希望飞机尽可能快速地回到其大本营。在最快地完成所需准备后，他去到他飞机，并向管制员申请滑行到跑道滑行许可。他取得许可，开始在跑道上滑行，但很快就发觉自己迷失在笼罩在云里雾里不熟悉机场。实际上，没有任何标志命名各种滑行道交叉，这也并没有多大帮助。,国际民航组织安全管理系统课程讲义,第17页,2.1,调查结果,The R/T-tapes showed that the piston-pilot then called G/C(by R/T)and asked for progressive taxi-instructions.ATCO2 replied by asking his position.The pilot said:I believe Im approaching Foxtrot-intersection,to which ATCO2 answered:At Foxtrot taxi straight ahead.In fact the pilot had already passed Foxtrot,and should have turned onto the parallel taxiway.The instruction from ATCO2,though technically correct,caused the pilot to taxi onto the runway where the jet was in its take-off roll.Since the communications to both aircraft took place on different frequencies,neither pilot was aware of what was happening.,R/T,磁带表明，活塞飞机飞行员呼叫叫地面管制员（经过,R/T,）并提出“渐进式滑行指令”要求。,ATCO2,回答，问询他位置。飞行员说：“我相信我靠近,F,交叉口”，,ATCO2,回答：“在,F,交叉口向前滑行”。实际上，飞行员已经通,F,交叉口，应该滑行到平行滑行道。,ATCO2,发出指令，即使在技术上是正确，不过造成活塞飞机飞行员滑行进入了喷气机正在进行起飞滑跑跑道。因为两飞机通信发生在不一样频率上，两飞行员都不知道发生了什么事。,国际民航组织安全管理系统课程讲义,第18页,After the collision,it took ATCO1 several minutes to realize something was wrong.Of course he hadnt observed the departing jet passing on the section of the runway that was visible to him,but he initially blamed that on the fog patches and/or being distracted by traffic on the G/C frequency.,撞机事件发生后，,ATCO1,花了好几分钟才明白出现了情况。当然，他没有从他能看到那部分跑道观察到离场喷气飞机，不过他最初将其（没观察到喷气飞机起飞）归因于雾和,/,或地面管制频率交通使他分心。,And apart from the fog,ATCO1 was unable to see the part of the runway where the collision had taken place because of the newly built extension of the terminal building blocking his view.So it was not until he wanted to transfer the departing jet to the next controller(Departure Control)that he became aware things werent as they should be,when his transmissions to the jet remained unanswered.,因为除了雾，新建成航站楼延伸部分，挡住了他视线，,ATCO1,无法看到跑道发生了碰撞。所以，直到他想起将飞喷气转移到下一个管制员（离场管制员）时一直没有得到喷气飞机回复，他才意识到事情发展偏离了预定情况。,国际民航组织安全管理系统课程讲义,第19页,ATCO2,who returned shortly after the accident,at the same time reported having no contact with the taxiing twin-prop.ATCO1 then decided to alert the fire-brigade,but as he had no idea where to send them,more precious time was lost as the rescue-vehicles tried to make their way across the foggy airport.When they finally arrived at the accident-site,they found there was little they could do as the wreckage of the aircraft had almost burnt-out completely already.,ATCO2,在事故发生后很快返回，在同一时间汇报没有同在滑行双螺旋桨取得任何联络。,ATCO1,然后决定提醒消防队，但因为他不知道指派消防队去哪儿，同时救援车辆艰难地经过被雾笼罩机场，更是使得宝贵救援时间损失掉了。当他们终于赶到事故现场时，面对几乎烧毁完全飞机残骸，他们发觉他们能做不多了。,国际民航组织安全管理系统课程讲义,第20页,2.1,调查结果,Had a SMR been installed following the recommendation after the other incident,this would have provided the following lines-of-defense(in declining order):,假如遵照其它事件发生后提议安装一个,SMR,，这将提供以下线防御（降序）：,Proper taxi-instructions could have been given to the lost aircraft.,正确滑行指令可能已经发给了“迷路”飞机。,The ATCOs would have observed the runway-intrusion.,空管人员将已经观察到跑道入侵。,The collision-site would have been easily identified.,碰撞现场将被轻易识别。,Adequate instructions could have been given to the rescue-vehicles.,适当指令，可能已经发给了救援车辆。,This goes for the stop-bars as well.Had they been installed,the twin-prop more likely than not wouldnt have entered the runway.,这一样适合用于停顿阻挡装置。假如他们已经被安装，双螺旋桨较可能不会已经进入跑道。,国际民航组织安全管理系统课程讲义,第21页,2.1,调查结果,At the very least,special procedures for Low Visibility Operations(LVO)at Anyfield should have been developed and in force,limiting the number of movements at the field.The ATCOs should have been trained in working with these special procedures,ideally on a simulator,to help them cope with the unusual situation once it occurred.,最起码，在,Anyfield,，经过限制在机场活动区运行航空器数量特殊低能见度运行程序（,LVO,）应该已经被开发并投入使用。管制员应该已经完成这些尤其程序工作训练。最好经过模拟器训练，以帮助他们应付可能发生异常情况。,In their talks with the airport-authorities,ATC management should have firmly opposed the plans for extension of the terminal-building.But,as a result of not having any input from the operational ATCOs(who were not available to attend the meetings due to staff-shortage),management wasnt even aware it would constitute a line-of-vision problem from the TWR.,在与机场当局谈话中，空管管理层应果断反对候机楼扩建计划。不过，因为没有任何业务管制员（没有出席会议因为人员短缺）反应，空管管理层甚至不知道它会组成对塔台视线影响。,国际民航组织安全管理系统课程讲义,第22页,2.1,调查结果,ATCO1 shouldnt find himself in a position where he was forced to work two positions by himself.At all times ATC-positions should be sufficiently staffed to allow the traffic to be handled in a safe manner.,ATCO1,不应该找不到自己位置，他不应该迫使自己在两个工作位置工作。管制席位应该在任何时候都有足够工作人员，使得交通流量以安全方式运行。,The installation of a frequency-coupler might have helped prevent the collision from occurring.As it is,these systems are considered optional by the aviation-authorities,so only few ATC-facilities have them.,频率耦合器安装可能有利于预防碰撞发生。因为它是，这些系统被航空当局认为是“可选”，所以只有少数管制单位安装了它。,国际民航组织安全管理系统课程讲义,第23页,2.1,调查结果,Management should ensure that OJT-instructors are given the opportunity to stay current at the positions where they are supposed to teach,by scheduling the instructor for duties without trainees at regular intervals.Such duties should be sufficiently challenging of nature to allow the instructor to practice his skills(in other words:shifts without traffic may look good in a roster,but are of no value for currency-maintaining purposes),管理层应确保，,OJT-,指导员有机会保持在教学岗位上，安排没有不用指导学员定时值班。这些班次应含有足够挑战性，让教练来实践他技能（换句话说：没有交通流量班次可能会在名册看起来好看，但对于保持交通流量没有价值）,Had there been a well-devised training-curriculum that was correlated with the duty-roster,management would have recognized that ATCO1,although qualified,hadnt been able to acquaint himself with working at Anyfield TWR under low visibility-conditions.Ideally,they wouldnt have scheduled him for unsupervised duty when low visibility was forecast.,假如当初有一个精心设计与责任名册相关培训课程，管理层将意识到，,ATCO1,即使合格，不过不能够单独在低能见度条件下在,Anyfield,塔台工作。在理想情况下，他们不会已经安排他在预测到低能见度那天在不受监督情况下值班。,国际民航组织安全管理系统课程讲义,第24页,2.1,调查结果,Dedicated LVO-training would have made ATCO2 aware of the dangers involved,alerting him to be more positive in guiding the lost taxiing pilot.At the very least he probably wouldnt have given the pilot irrelevant information.,专用,LVO,培训会将 使,ATCO2,意识到所包括危险，提醒他要愈加主动去引导“迷路”正在滑行飞行员。最起码，他不会给飞行员无关信息。,It is a scientific fact that when consecutive nightshifts are worked,the performance of persons engaged in cognitive tasks(such as ATC)decreases dramatically in the second and later nights,especially between 03:00 hrs and 07:00 hrs.ATCO1 at Anyfield was on his third nightshift in a row,which could explain why he failed to recognize a potentially dangerous situation that he wouldnt have missed under other circumstances.When designing shift-rosters for ATCOs it is advisable to keep the number of consecutive nightshifts to an absolute minimum.,连续夜班工作时，从事认知任务（如管制工作）人，在第二次及以后夜晚，他表现会急剧下降，尤其是凌晨,03:00,点至早,07:00,点之间，这是一个科学事实。,ATCO1,在进行他在,Anyfield,第三个连续夜班，这能够解释为何他没有认识到有潜在危险情况，在其它情况下，他将不会错过。当设计管制员排班名册时，最好能使连续夜班数量保持在绝对最低水平。,国际民航组织安全管理系统课程讲义,第25页,2.1,调查结果,Based on the meteorological forecast,and taking into account the propeller-aircrafts pilot was unfamiliar with Anyfield,it may be argued that the air operator would have done better to send two pilots to collect the aircraft.Even with limited knowledge of CRM-principles,a second pilot could have prevented the other pilot from acting the way he did.,依据气象预测，并考虑到螺旋桨飞机飞行员是不熟悉,Anyfield,，可能会认为