摘 要

隨著世界經濟的擴展與世界地球村的商旅需求，全球航空市場蓬勃發展，飛機的數量與飛航機場快速增加，零事故的安全飛行，是航空業從業人員努力的目標。探討事故發生的原因，往往是一連串的失誤。但若只檢討直接明顯的失誤而未全面追究隱藏的間接潛在失誤，類似的事故仍可能再度發生，即便這樣的潛在人為失誤不易被發現，仍必須設法探討以防患於未然。
本研究引用國科會潛在人為失誤模式分析計畫之結果，並應用在民航機維修作業失誤檢討，藉由分析航空器航線維護過夜檢查工作流程，檢討失誤因子的關聯性，並進行問卷調查，得到重要顯性因子及潛在因子排序關係。進一步在四項個案探討中，蒐集與分析工作情境，嘗試套用失誤因子，並藉由失效模式歸納出四個探討案例所共通的潛在失誤因子：工作手冊不合時宜，而其中共同的內涵因素為「認知」。
於管理策略的探討，著重公司制度對員工心緒的影響，在安全為基礎的架構之下，強調以溝通及凝聚員工共識來建立員工向心力，員工的表現需要公司正面企業文化的支持，管理作為應該留意是那些因素造成事故的發生，而非僅著眼於對工作人員的究責，其目標是建立安全文化，預先察覺工作風險，事先規劃防範作為，以團隊合作的正確決策確保零失誤完成工作。
關鍵字：潛在失誤，航機維修，根本原因分析法，人因分析與分類系統法

Abstract
Following the development of global economics and strong worldwide travel demand, the fast growing aviation market has resulted in more and more of aircraft deliver into service and increasing flight routes connection. It is a major challenge for airlines carrier to meet the target of “zero event” safety operations. The causes of an accident are usually due to a sequence of errors. If only the direct active error was reviewed without further investigating indirect latent errors, the similar accident may happen again. The latent human errors are not easy to be identified. However, it is necessary to try setting up solution in advance for accident prevention.
This search was a follow up study of human errors analytical model study under NSC project, and further applied on aircraft line maintenance task error evaluation. Initially, the working steps of aircraft line maintenance Daily Check tasks were analyzed to find out the relationship between each error factor. Then retrieving from the questionnaire result analysis, the ranking list of significant active and latent error factors was settled and adopted in case studies by analyzing case study background information. Finally by the method of failure mode and effect analysis (FMEA), the common latent error factor was found as “Manual need to be revised”, and the core issue of this common factor was “Acknowledgement”.
For the study of management strategy, it focus on the emotion impact of company regulations to employee. Based on the safety basis structure, it was suggested to establish employee centripetal force by well communication and staff consensus. The target is creating working risk awareness behavior, taking necessary risk prevention action in advance, and cooperating with support of team work right commanding decision to finish job with error free.
Keywords: Latent Error, Aviation Maintenance Task, Root Cause Analysis, HFACS

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