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118 Fei Ao Rd, Pudong International Airport, Shanghai P.R. China 201207 Tel: +86 (21)2021 5000 Fax: +86 (21)6835-8016 FAA Approved Repair Station No.: 3BSY195B CAAC Approved Maintenance Organization No.: D.200093

安全提示 safety reminder 编号No.: BS_SR_2010_001

日期Date: Jun-10-2010




一. 背景

Maintenance reporting




在环境的人为差错评估中,一个明显的推论是理解这些事是如何及为什么会发生,这样类 似的事情就有可能被阻止。分析过程,不关心责任的归属,而是在于分析其基本的错误及 其潜在的因素。这将有助于我们了解人们的行为及让我们有机会在未来管理并矫正人为的 差错,以避免事故的发生。 One of the obvious consequences of assessing human error in the environment is that, in understanding how and why it happened, similar events may be prevented. The analysis process is not concerned therefore with the attribution of blame, but rather the analysis of the error and its underlying factors. It is hoped that this will help our understanding of human performance and therefore give us the opportunity to recover and manage occurrences of human error in the future.

二. 事件经过

Course of incident

我们公司最近发生了一起人为因素造成的飞 机前风挡玻璃更换差错。工作者由于缺乏耐心 及没有进行深入的沟通与汇报,造成飞机前风 挡的一条火线没有被接入,令飞机在运行过程 中发生故障隐患并且返工。

Our company has recently taken place with a Human Factor error of which incomplete replaced front windshield of an aircraft. Workers due to lack of patience and no in-depth communication and reporting, resulting in fire wires can’t be connected to the aircraft windshields, so that aircraft malfunction during operation and reworked.

这件事件提醒我们任何维修工作中小的疏忽 都会造成维修安全的大的隐患。并且在重建客 户信心上造不良影响。我们必须从人为因素上 探究预防及减少人为差错发生的方法和提出 注意事项。

This incident reminds us of the any small negligence of maintenance work will cause big hazards of maintenance safety. And making adverse effects in the rebuilding the confidence of the customers. We must explore the human factors and prevention methods to reduce and mitigates human error occurred, and then proposed the notice item.

三. 人为因素分析

Analysis of Human Factor

加拿大的MRO最近修订其安全方案,侧重于案 例研究和根本原因分析,分为四个均等的模 块:1)自满,疲劳和缺乏认识; 2)沟通,过

The Canadian MRO recently revised its program from a rehash of the initial course to focus on case studies and root cause analysis Page 1 of 2

118 Fei Ao Rd, Pudong International Airport, Shanghai P.R. China 201207 Tel: +86 (21)2021 5000 Fax: +86 (21)6835-8016 FAA Approved Repair Station No.: 3BSY195B CAAC Approved Maintenance Organization No.: D.200093

分自信及团队意识; 3 )缺乏资源,知识和规 范,以及 4)外界压力,自身压力和干扰.

in the context of four homogeneous modules: 1) complacency, fatigue and lack of awareness; 2) communications, assertiveness and teamwork; 3) lack of resources, knowledge and norms; and 4) stress, pressure and distraction.


Safety reminder in some similar incident:



known, recent work experience will affect the decision


虽然工作中有不清晰的地方,或者不能确 证工作依据的时候,缺少深入研究的自信 及勇气。

Although there is no clear about the ongoing work, or when can not confirm the basis of work we lack of courage/confident to perform in-depth analysis of the uncertainty.


工作中发现问题没有及时沟通及报告,并 确证反馈的结果。

Haven’t practice to promptly reporting and communication the questions when work. And confirmed the results of feedback.

事故的发生似乎是非常复杂的结果, 这些巧合可以预见到的很少...人们总认 为意外不会发生,因为人们有 赌博意识, 但不幸通常都赌输了,事故发生的原因在 于人们不 相信事故发生是在任何可能的 情况下都会产生的!

Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by those involved … accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur, is at all possible.

波音上海 质量安全部 Boeing Shanghai Department



2010 年 6 月 10 日

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BS_Safety_reminder_communication and reporting due to windshield replace (3)  

在环境的人为差错评估中,一个明显的推论是理解这些事是如何及为什么会发生,这样类 似的事情就有可能被阻止。分析过程,不关心责任的归属,而是在于分析其基本的错误及 其潜在的因素。这将有助于我们了解人们的行为及让我们有机会在未来管理并矫正人为的 差错,以避免事故的发生。 Page 1...