| Summary: | 碩士 === 國立清華大學 === 工業工程與工程管理學系 === 102 === Today, although many works can be replaced by machines, the maintenance tasks still rely on people with unexpected mistakes at the same time. Usually the causes of these mistakes are due to a sequence of errors; however, if only reviewed the direct active errors without further investigation of indirect latent errors, the similar accident may happen again.
In this study, an analysis method is developed to find out the most important latent human error factor. By using Root Cause Analysis (RCA) method as the basic logic, Human Factor Analysis and Classification System (HFACS) as the factor source and daily check of aviation maintenance as a case study, this research dismantled the maintenance process and collected the data of each procedure. After designing the questionnaire by the preliminary factors and surveyed 115 experienced maintenance operators to do the analysis, the importance ranking of factors allows the airline to specifically design improvement plans directly, and the reference values have also been set for the use to related researches.
Here comes some sum up of conclusions in this study. First, the most important active factor is “Task execution error”, and the latent factor which has the most influence is “Maintenance capability.” Second, the combination of RCA and HFACS is an easy use method to investigate the causal inference and build the factor connection of collected data. Third, the research outcomes suggested not only the results caused by latent errors and the improvement direction, but the priorities for the improvement and the reference values of each active error factor to each step.
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