國際民航組織安全管理

系統(tǒng)（SMS）課程

講義No2–

Anyfield機場事故

第1頁Contents一、事件經(jīng)過二、原因分析2.1調(diào)查結(jié)果2.2小組討論2.3提議邏輯結(jié)構(gòu)三、表格填寫第2頁序言閱讀事故相關(guān)文本小組討論文字編輯PPT制作工作流程第3頁調(diào)查分析+合理提議+整改=安全第4頁一、事件經(jīng)過第5頁一、事件經(jīng)過IntheearlyhoursofanautumnMonday-morning,atwin-enginedjettransportwith5crew-membersand63passengersonboardwhileinitstake-offrunatAnyfieldAirportcollidedwithasmalltwin-enginedpropeller-drivenaircraft,withonlyasinglecrew-memberthathadintrudedthedeparture-runway.Bothaircraftwereseverelydamagedasaresultofthecollision.Thesubsequentfiredestroyedbothaircraftandwasthedeath-causeformostofthepassengers.在秋季周一早上凌晨，在Anyfield機場1一架雙引擎噴氣運輸機5名機組組員和63名乘客，在其起飛運行時與一個侵入離場跑道只有一個機組組員雙引擎螺旋槳小飛機相撞。這兩架飛機因為碰撞遭到嚴(yán)重破壞。隨即大火燒毀了飛機，同時造成大部分乘客死亡。第6頁一、事件經(jīng)過AnyfieldAirportisamedium-sizedairport,withasinglerunwaywhichcanbeaccessed(orvacated)byanumberofintersections.Itisacontrolledaerodrome;thecontrol-towerislocated400metersnorthofthemiddleoftherunway.Traffic-numbersareontheriseasquiteafewcommuter-typeairlineshavestartedoperatingtoandfromAnyfield.Anyfield機場是一個中型機場，一條跑道連接著一些十字路口（或騰空）。這是一個管制機場，控制塔位于距北跑道中間400米位置。因為不少通勤型航空企業(yè)已開始來往于Anyfield，Anyfield交通流量逐步上升。Althoughtheairportisinaregioninwhichseveralfoggydaysayeararecommon,itisnotequippedwithaSurfaceMovementRadar(SMR),nordoesithavespecialtaxiway-lightingfacilitiesforuseunderlowvisibility-conditions.即使機場處于一年中霧天很常見一個地域，不過它并沒有配置地面活動雷達(dá)（SMR），也沒有特殊滑行道照明設(shè)施供低能見度條件下使用。第7頁一、事件經(jīng)過AirTrafficControlatAnyfieldisslightlyunderstaffed,butsofaritwasnotthoughtnecessarytoimposerestrictionsonoperationstoandfromAnyfield.Thereisadiscretefrequency(GroundControl)tohandletaxiingaircraft.空中交通管制在Anyfield是略有不足，但到當(dāng)前為止，并不認(rèn)為需要加強對于在Anyfield運行限制。有一個離散頻率（地面管制）處理滑行航空器。Atthetimeofthecollision,theaveragevisibilitywasaround700meterswithfog-banks,whichisjustsufficienttoallowthetower-controllertoseethemiddlepartoftherunway.Thecontrollers'viewattheintersectionwheretheintrudingaircraftenteredtherunwayhoweverwasobstructedbythenewlyconstructedextensiontotheterminalbuildingatAnyfieldAirport.在碰撞時，伴隨霧坡度，平均能見度約700米，這是恰好足以讓塔控制員看到跑道中間部分。新建成Anyfield機場候機樓擴展出來部分在阻擋了控制員視野，恰好是侵入跑道飛機進入跑道位置。第8頁一、事件經(jīng)過TheAirTrafficController(ATCO)wasaveryexperiencedcontroller.HehadbeenworkinginATCformanyyears,atseveralmajorfacilities,andhadbeentransferredtoAnyfieldtoactasanOJT-instructoronlyeightmonthsbeforethedateoftheaccident.空中交通管制（管制員）是一個非常有經(jīng)驗控制員。他曾在ATC工作多年，在幾個主要管制中心，在意外發(fā)生日期僅8個月前被轉(zhuǎn)移到Anyfield作為OJT-指導(dǎo)員。Atthetimeofthecollision,theATCO1wasaloneinthecontrol-tower,ashisAssistant/GroundControllerATCO2–offarlessexperience–hadbrieflylefttheTWRtoansweracallofnature.Theywerebothcompletingtheirthirdconsecutivenightshift,hadcomeondutyat22:00hoursthepreviouseveningandwereduetoberelievedwithinthirtyminuteswhentheaccidentoccurred.

碰撞時，ATCO1獨自一人在塔臺，作為他助理/地面管制員ATCO2-遠(yuǎn)不如ATCO1經(jīng)驗豐富-曾短暫離開塔臺上廁所。他們都完成他們第三個連續(xù)夜班，因為已經(jīng)從前一天晚上22:00值班到現(xiàn)在，在事故發(fā)生時30分鐘內(nèi)就能夠換班。第9頁一、事件經(jīng)過Thecrewofthejet-aircraftwasexperiencedoperatorstoandfromAnyfield.Fromtheirpointofview,onthemorningoftheaccidenttherewasnothingunusualinthewaytheirflightwashandledbyATC.Theytaxiedtotherunwaywiththeextracautionrequiredbythefog-conditions,andafterbeingclearedfortake-offtheymadecertaintheywerelinedupcorrectlyontherunway-centerlinebeforeapplyingtake-offpower.噴氣飛機機組來往于Anyfield經(jīng)驗豐富。從他們角度來看，事故發(fā)生在早晨，在ATC航路上沒有不什么正常。他們在霧條件下格外小心地滑行到跑道，取得起飛許可后，在提出申請前起飛推力之前，確認(rèn)他們在跑道中心線列隊正確。Thepilotofthetwin-enginedpiston-drivenaircraftwasunfamiliarwithAnyfieldAirport,havingbeensentthereatshortnoticetocollectanaircraftthathadtodivertintoAnyfieldtwodaysearlierforweather-reasons.雙引擎活塞式飛機飛行員不熟悉Anyfield機場，被送到那里去短時間內(nèi)接收兩天前因為天氣原因不得不轉(zhuǎn)飛到Anyfield一架飛機。第10頁上廁所回來發(fā)覺聯(lián)絡(luò)不上小飛機雙引擎螺旋槳小飛機（誤入跑到）

一架雙引擎噴氣運輸機

（正起飛）管制員1管制員2同時進行管制和地面兩席位工作在預(yù)計移交時間發(fā)覺運輸機一直無應(yīng)答。上廁所前給小飛機公布滑行指令消防隊救援車輛因為不清楚事發(fā)準(zhǔn)確地點，和霧天通行困難趕到現(xiàn)場時面正確是幾乎燒毀完全飛機殘骸

。一、事件經(jīng)過跑道相撞他沒有從他能看到那部分跑道觀察到離場噴氣飛機

第11頁二、原因分析第12頁2.1調(diào)查結(jié)果第13頁2.1調(diào)查結(jié)果AlthoughATCO1wasveryexperienced,hehadonlyworkedalimitednumberofsolo-shiftsinAnyfieldTWR.HavingvalidatedhisTWR-ratinginearlysummer,hehadbeeninvolvedingivingon-the-job-training(OJT)instructiononmostofhisshiftsafterthat.Asaconsequenceofthestaff-shortagehewasrequiredtoworkhisshareofnightshiftslikeallothercontrollers.TheshiftinwhichtheaccidentoccurredwasonlyhissecondwherehehadworkedatAnyfieldTWRunderfoggy/lowvisibilityconditions;thefirsthadbeenthepreviousnight,whentherewashardlyanytrafficasitwasthenightfromSaturdaytoSunday.即使ATCO1是非常有經(jīng)驗，不過他在Anyfield塔臺獨自工作次數(shù)很有限。在初夏他才驗證塔臺管制評級，在那之后，他在大部分換班后參加到在職培訓(xùn)（OJT）指導(dǎo)工作因為人員短缺，他被要求必須像全部其它管制員一樣值參加夜班工作。在該事故發(fā)生時僅僅是他在Anyfield-TWR班次中，第二次碰到霧/低能見度條件。第一次是在前一天晚上，當(dāng)初幾乎沒有任何交通，因為那是在周六到周日晚上。第14頁2.1調(diào)查結(jié)果AnumberofyearsagotherehadbeenanincidentatAnyfieldinvolvingrunway-intrusionbyavehicle,undersimilarmeteorologicalconditionsasinthiscase.OneoftherecommendationsatthattimewastheinstallationofaSMR,togetherwithstop-barsatallrunway-intersections.Theauthoritiesdecidedthatinviewofthelimitednumberofdays(withfog)thatwouldwarranttheuseofaSMR,thebenefitofhavingaSMRdidn'tmatchthecostsofhavingoneinstalled.Thesameappliedfortheinstallationofstop-bars,butinlieuofthose,paintedsignshadbeenputinthegrassnexttotherunway-intersections,informingthosewhonoticedthemtherewasa"runwayahead".Anyfield在許多年前曾出現(xiàn)過車輛入侵跑道情況，也是在這種類似該事件氣象條件情況下。當(dāng)初提議之一是安裝一個SMR，同時在全部跑道交叉口設(shè)置停頓阻擋。當(dāng)局決定，鑒于需要使用SMR有限天數(shù)（霧天），安裝SMR收益和支出并不匹配。安裝停頓阻擋也是如此。不過我們能夠用畫在跑道十字路口旁邊草地上圖標(biāo)代替SMR和停頓阻擋，提醒看到圖標(biāo)人，他們前面有“跑道”。第15頁2.1調(diào)查結(jié)果Astheearlymorning-trafficbegantocomealive,ATCO1andATCO2wereeachworkinganindependentR/T-frequency.WhenATCO2announcedhehadtovisitthemen'sroomforasecond,ATCO1toldhimtogoahead,intendingtoworkbothfrequenciesbyhimself.Inordertodoso,ATCO1hadtophysicallymovebetweentwocontrol-positionsintheTWRthatareaboutthreemetersapart,forAnyfieldTWRisn'tequippedwithafrequency-couplinginstallation.Transmissionsononefrequencycan'tbeheardbystationsontheotherfrequency.當(dāng)清晨交通開始繁忙起來時，ATCO1ATCO2分別在獨立R/T頻率上工作。ATCO2說他不得不再次去洗手間，ATCO1同意，打算自己在兩個工作頻率上工作。為了做到這一點，因為Anyfield塔臺沒有配置頻率耦合裝置，聲音在一個頻率上傳輸不能被其它頻率聽到，ATCO1不得不在在兩個相距約三米管制席位間往返走動。第16頁2.1調(diào)查結(jié)果Thepiston-enginedaircraft'spilothadarrivedinAnyfieldlatethenightbefore.Afterashortsleephewenttotheairportquicklyinordertowasteaslittletimeaspossible,forhiscompanywantedtheaircraftbackatitshomebasea.s.a.p.Aftertheminimumofpreparationneeded,hewenttohisaircraftandcalledATCforapprovaltotaxitotherunway.Heobtainedtheclearanceandbegantaxiing,butsoonfoundhimselflostatthefoggy,unfamiliarairport.Thefactthattherewerenosignsdenominatingthevarioustaxiway-intersectionsdidn'thelpmucheither.活塞式引擎飛機飛行員在前一天晚深夜才抵達(dá)Anyfield。經(jīng)過短暫睡眠，他以盡可能少時間趕到機場，他企業(yè)希望飛機盡可能快速地回到其大本營。在最快地完成所需準(zhǔn)備后，他去到他飛機，并向管制員申請滑行到跑道滑行許可。他取得許可，開始在跑道上滑行，但很快就發(fā)覺自己迷失在籠罩在云里霧里不熟悉機場。實際上，沒有任何標(biāo)志命名各種滑行道交叉，這也并沒有多大幫助。第17頁2.1調(diào)查結(jié)果TheR/T-tapesshowedthatthepiston-pilotthencalledG/C(byR/T)andaskedfor"progressivetaxi-instructions".ATCO2repliedbyaskinghisposition.Thepilotsaid:"IbelieveI'mapproachingFoxtrot-intersection",towhichATCO2answered:"AtFoxtrottaxistraightahead".InfactthepilothadalreadypassedFoxtrot,andshouldhaveturnedontotheparalleltaxiway.TheinstructionfromATCO2,thoughtechnicallycorrect,causedthepilottotaxiontotherunwaywherethejetwasinitstake-offroll.Sincethecommunicationstobothaircrafttookplaceondifferentfrequencies,neitherpilotwasawareofwhatwashappening.R/T磁帶表明，活塞飛機飛行員呼叫叫地面管制員（經(jīng)過R/T）并提出“漸進式滑行指令”要求。ATCO2回答，問詢他位置。飛行員說：“我相信我靠近F交叉口”，ATCO2回答：“在F交叉口向前滑行”。實際上，飛行員已經(jīng)通F交叉口，應(yīng)該滑行到平行滑行道。ATCO2發(fā)出指令，即使在技術(shù)上是正確，不過造成活塞飛機飛行員滑行進入了噴氣機正在進行起飛滑跑跑道。因為兩飛機通信發(fā)生在不一樣頻率上，兩飛行員都不知道發(fā)生了什么事。第18頁Afterthecollision,ittookATCO1severalminutestorealizesomethingwaswrong.Ofcoursehehadn'tobservedthedepartingjetpassingonthesectionoftherunwaythatwasvisibletohim,butheinitiallyblamedthatonthefogpatchesand/orbeingdistractedbytrafficontheG/Cfrequency.撞機事件發(fā)生后，ATCO1花了好幾分鐘才明白出現(xiàn)了情況。當(dāng)然，他沒有從他能看到那部分跑道觀察到離場噴氣飛機，不過他最初將其（沒觀察到噴氣飛機起飛）歸因于霧和/或地面管制頻率交通使他分心。Andapartfromthefog,ATCO1wasunabletoseethepartoftherunwaywherethecollisionhadtakenplacebecauseofthenewlybuiltextensionoftheterminalbuildingblockinghisview.Soitwasnotuntilhewantedtotransferthedepartingjettothenextcontroller(DepartureControl)thathebecameawarethingsweren'tastheyshouldbe,whenhistransmissionstothejetremainedunanswered.因為除了霧，新建成航站樓延伸部分，擋住了他視線，ATCO1無法看到跑道發(fā)生了碰撞。所以，直到他想起將飛噴氣轉(zhuǎn)移到下一個管制員（離場管制員）??時一直沒有得到噴氣飛機回復(fù)，他才意識到事情發(fā)展偏離了預(yù)定情況。第19頁ATCO2,whoreturnedshortlyaftertheaccident,atthesametimereportedhavingnocontactwiththetaxiingtwin-prop.ATCO1thendecidedtoalertthefire-brigade,butashehadnoideawheretosendthem,moreprecioustimewaslostastherescue-vehiclestriedtomaketheirwayacrossthefoggyairport.Whentheyfinallyarrivedattheaccident-site,theyfoundtherewaslittletheycoulddoasthewreckageoftheaircrafthadalmostburnt-outcompletelyalready.ATCO2在事故發(fā)生后很快返回，在同一時間匯報沒有同在滑行雙螺旋槳取得任何聯(lián)絡(luò)。ATCO1然后決定提醒消防隊，但因為他不知道指派消防隊去哪兒，同時救援車輛艱難地經(jīng)過被霧籠罩機場，更是使得寶貴救援時間損失掉了。當(dāng)他們終于趕到事故現(xiàn)場時，面對幾乎燒毀完全飛機殘骸，他們發(fā)覺他們能做不多了。第20頁2.1調(diào)查結(jié)果HadaSMRbeeninstalledfollowingtherecommendationaftertheotherincident,thiswouldhaveprovidedthefollowinglines-of-defense(indecliningorder):假如遵照其它事件發(fā)生后提議安裝一個SMR，這將提供以下線防御（降序）：Propertaxi-instructionscouldhavebeengiventothe"lost"aircraft.?正確滑行指令可能已經(jīng)發(fā)給了“迷路”飛機。TheATCOswouldhaveobservedtherunway-intrusion.空管人員將已經(jīng)觀察到跑道入侵。Thecollision-sitewouldhavebeeneasilyidentified.?碰撞現(xiàn)場將被輕易識別。Adequateinstructionscouldhavebeengiventotherescue-vehicles.?適當(dāng)指令，可能已經(jīng)發(fā)給了救援車輛。Thisgoesforthestop-barsaswell.Hadtheybeeninstalled,thetwin-propmorelikelythannotwouldn'thaveenteredtherunway.這一樣適合用于停頓阻擋裝置。假如他們已經(jīng)被安裝，雙螺旋槳較可能不會已經(jīng)進入跑道。第21頁2.1調(diào)查結(jié)果Attheveryleast,specialproceduresforLowVisibilityOperations(LVO)atAnyfieldshouldhavebeendevelopedandinforce,limitingthenumberofmovementsatthefield.TheATCOsshouldhavebeentrainedinworkingwiththesespecialprocedures,ideallyonasimulator,tohelpthemcopewiththeunusualsituationonceitoccurred.最起碼，在Anyfield，經(jīng)過限制在機場活動區(qū)運行航空器數(shù)量特殊低能見度運行程序（LVO）應(yīng)該已經(jīng)被開發(fā)并投入使用。管制員應(yīng)該已經(jīng)完成這些尤其程序工作訓(xùn)練。最好經(jīng)過模擬器訓(xùn)練，以幫助他們應(yīng)付可能發(fā)生異常情況。Intheirtalkswiththeairport-authorities,ATCmanagementshouldhavefirmlyopposedtheplansforextensionoftheterminal-building.But,asaresultofnothavinganyinputfromtheoperationalATCOs(whowerenotavailabletoattendthemeetingsduetostaff-shortage),managementwasn'tevenawareitwouldconstitutealine-of-visionproblemfromtheTWR.在與機場當(dāng)局談話中，空管管理層應(yīng)果斷反對候機樓擴建計劃。不過，因為沒有任何業(yè)務(wù)管制員（沒有出席會議因為人員短缺）反應(yīng)，空管管理層甚至不知道它會組成對塔臺視線影響。第22頁2.1調(diào)查結(jié)果ATCO1shouldn'tfindhimselfinapositionwherehewasforcedtoworktwopositionsbyhimself.AtalltimesATC-positionsshouldbesufficientlystaffedtoallowthetraffictobehandledinasafemanner.ATCO1不應(yīng)該找不到自己位置，他不應(yīng)該迫使自己在兩個工作位置工作。管制席位應(yīng)該在任何時候都有足夠工作人員，使得交通流量以安全方式運行。Theinstallationofafrequency-couplermighthavehelpedpreventthecollisionfromoccurring.Asitis,thesesystemsareconsidered"optional"bytheaviation-authorities,soonlyfewATC-facilitieshavethem.頻率耦合器安裝可能有利于預(yù)防碰撞發(fā)生。因為它是，這些系統(tǒng)被航空當(dāng)局認(rèn)為是“可選”，所以只有少數(shù)管制單位安裝了它。第23頁2.1調(diào)查結(jié)果ManagementshouldensurethatOJT-instructorsaregiventheopportunitytostaycurrentatthepositionswheretheyaresupposedtoteach,byschedulingtheinstructorfordutieswithouttraineesatregularintervals.Suchdutiesshouldbesufficientlychallengingofnaturetoallowtheinstructortopracticehisskills(inotherwords:shiftswithouttrafficmaylookgoodinaroster,butareofnovalueforcurrency-maintainingpurposes)管理層應(yīng)確保，OJT-指??導(dǎo)員有機會保持在教學(xué)崗位上，安排沒有不用指導(dǎo)學(xué)員定時值班。這些班次應(yīng)含有足夠挑戰(zhàn)性，讓教練來實踐他技能（換句話說：沒有交通流量班次可能會在名冊看起來好看，但對于保持交通流量沒有價值）Hadtherebeenawell-devisedtraining-curriculumthatwascorrelatedwiththeduty-roster,managementwouldhaverecognizedthatATCO1,althoughqualified,hadn'tbeenabletoacquainthimselfwithworkingatAnyfieldTWRunderlowvisibility-conditions.Ideally,theywouldn'thavescheduledhimforunsuperviseddutywhenlowvisibilitywasforecast.假如當(dāng)初有一個精心設(shè)計與責(zé)任名冊相關(guān)培訓(xùn)課程，管理層將意識到，ATCO1即使合格，不過不能夠單獨在低能見度條件下在Anyfield塔臺工作。在理想情況下，他們不會已經(jīng)安排他在預(yù)測到低能見度那天在不受監(jiān)督情況下值班。第24頁2.1調(diào)查結(jié)果DedicatedLVO-trainingwouldhavemadeATCO2awareofthedangersinvolved,alertinghimtobemorepositiveinguidingthelosttaxiingpilot.Attheveryleastheprobablywouldn'thavegiventhepilotirrelevantinformation.專用LVO培訓(xùn)會將使ATCO2意識到所包括危險，提醒他要愈加主動去引導(dǎo)“迷路”正在滑行飛行員。最起碼，他不會給飛行員無關(guān)信息。Itisascientificfactthatwhenconsecutivenightshiftsareworked,theperformanceofpersonsengagedincognitivetasks(suchasATC)decreasesdramaticallyinthesecondandlaternights,especiallybetween03:00hrsand07:00hrs.ATCO1atAnyfieldwasonhisthirdnightshiftinarow,whichcouldexplainwhyhefailedtorecognizeapotentiallydangeroussituationthathewouldn'thavemissedunderothercircumstances.Whendesigningshift-rostersforATCOsitisadvisabletokeepthenumberofconsecutivenightshiftstoanabsoluteminimu