อุบัติเหตุของอากาศยานในการบินพาณิชย์ ตอนที่ 2 สาเหตุและรากเหง้าของปัญหา
คำสำคัญ:
อุบัติเหตุของอากาศยาน, มนุษย์ปัจจัย, ความผิดพลาดของมนุษย์, การป้องกันอุบัติเหตุบทคัดย่อ
รายงานอุบัติเหตุในการบินพาณิชย์ส่วนใหญ่ มีข้อสรุปว่า สาเหตุมาจากความผิดพลาดของมนุษย์ อย่างไรก็ตาม เมื่อมีการวิเคราะห์รากเหง้าของปัญหาแล้ว พบว่า ความผิดพลาดของมนุษย์เปรียบเสมือนยอดของภูเขาน้ำแข็ง ซึ่งเป็นส่วนที่สังเกตได้ง่าย ขณะที่มีสาเหตุอื่นอีกจำนวนมากที่สังเกตได้ยากกว่า บทความนี้นำเสนอ สาเหตุของอุบัติเหตุและรากเหง้าของปัญหา ตัวแบบสาเหตุของอุบัติเหตุประกอบด้วย ตัวแบบโดมิโน, ตัวแบบสาเหตุการสูญเสีย, ตัวแบบเนยสวิส, ตัวแบบการแพร่ระบาด, ตัวแบบสแตมป์, ตัวแบบแฟรม และตัวแบบเชลล์ ผลจากการวิเคราะห์ พบว่า รากเหง้าของปัญหาเกิดจาก ความสัมพันธ์เชิงพลวัตของปัจจัยด้านความเปลี่ยนแปลง มนุษย์ และระบบ
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