基于改进 Bow-Tie 模型的民航重着陆事件分析

为深入分析我国民航重着陆事件信息,为重着陆事故预防提供实际参考,提出改进的 Bow-Tie 模型。在原因辨识环节将原因归纳为人、机、环、管四个方面,并通过数量统计对所有原因和后果进行量化。利用该模型分析了262起重着陆事件的原因、后果,并制定相应的预防控制措施和减少控制措施,建立重着陆事件改进 Bow-Tie 图。以2016年河北航空发生的重着陆及尾撬擦地事件为例进行实证分析。结果表明,重着陆事件改进 Bow-Tie 图内容涵盖了一般重着陆事件可能涉及的原因及后果信息,并包含针对性较强的预防和管控措施,能够为重着陆事件的预防和风险控制提供参考。

An Analysis of Hard Landing Events in Civil Aviation Based on an Improved Bow-Tie Model

In order to thoroughly analyze hard landing events of civil flights in China,and provide practical preven-tion measures,an improved Bow-Tie model is proposed.This model classifies all causes of hard landing events into the following four aspects:human,machine,environment,and management and statistically quantifies them.The causes and consequences of 262 hard landing events are analyzed,with which preventive and reducing measures are developed.An improved Bow-Tie diagram of hard landing events is established.A hard landing and tail-skid collision of Hebei Airlines in 201 6 is selected as a case study.The results show that the improved Bow-Tie diagram covers all possible causes and con-sequences of hard landing events,and can provide targeted measures for prevention and control.Therefore,it can serve as a reference for prevention and risk management of hard landing events.