为预防失控类事故引发的灾难性后果,选取航空安全网(Aviation Safety Network,ASN)2015-2022 年 102 起失控类事故为样本,以2018年"10·29"印尼客机坠毁事故为例,采用基于系统理论的因果分析(Causal Analysis based on System Theory,CAST)方法从系统角度梳理并识别失控类事故发生过程中涉及的安全控制缺陷.在此基础上,采用故障树分析(Fault Tree Analysis,FTA)法绘制失控类事故故障树模型,并对其进行定性、定量分析,得出失控类事故的主要致因.结果表明:基于CAST模型分析识别出25个系统缺陷;通过故障树定性分析得出16个最小割集;通过定量分析计算出失控类事故在所有事故中发生的概率为0.400 86;确定机组操作不当、机组沟通不足、飞机系统缺陷及飞机制造商假设不全、制造商未提供相关文件为失控类事故的主要影响因素.
Cause analysis of loss of control accidents based on CAST-FTA
In order to prevent the catastrophic consequences caused by loss of control accidents,102 loss of control accidents from 2015 to 2022 were selected as samples by the Aviation Safety Network(ASN),and the Indonesian passenger plane crash on October 29,2018 was taken as an example.The Causal Analysis based on System Theory(CAST)method was adopted to sort out and identify the safety control defects involved in the occurrence of loss of control accidents from a systematic perspective.Taking the identified control defects as the basic events,the fault tree model of loss of control accidents is drawn by using Fault Tree Analysis(FTA).The CAST-FTA model is qualitatively analyzed by using Boolean algebra method,and the minimum cut set of fault number is obtained.The CAST-FTA model is quantitatively analyzed by using the disinter section algorithm,and the probability of loss of control accidents and the structural importance and probability importance of basic events are calculated.Finally,the main causes of loss of control accidents are obtained.Conclusions:25 system defects are identified based on CAST model analysis,and 16 minimum cut sets are obtained through fault tree qualitative analysis.Among them,the order of X10,X11,X18,X19 and X20 is the lowest(all being 1),indicating that when only one basic event occurs,and a loss of control accident will occur;By quantitative analysis,the probability of loss of control accidents occurring in all accidents is 0.400 86,and the structural importance and probability importance of the fault tree are calculated.The structure importance of X10,X11,X18,X19 and X20(all above are 0.021 7)is the highest.The probability importance of X10(0.844 7)is the highest,followed by X11(0.636 1),X18 and X20(both 0.628 4).According to the above calculation results,it is determined that X10,X11,X18,X19 and X20 are the main influencing factors of runaway accidents,and the corresponding basic events respectively are improper crew control,insufficient crew communication,Maneuvering Characteristics Augmentation System(MCAS)function defects and incomplete assumptions,and Boeing did not provide relevant documents.
safety engineeringloss of control accidentsCausal Analysis based on System Theory(CAST)Fault Tree Analysis(FTA)causation analysis
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