<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">报告随后提到规章具有一个严重缺陷一形<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">式上的符合一其叙述如下：<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">“……如果当局不能评估航空公司的真实运<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">行条件，或者不具有充分的权力这样去<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">做，监督和针对结果采取措施就只能走形<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">式。这种方法取代了广泛的评估，只能导<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">致对个人违规的判断，而不可能把握住组<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">织和运行环境中危及安全的基本因素……”<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">“……在调查过程中， 总体上没有特殊的<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">理由对飞行员或其他运行人员提出质疑。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">最主要的问题是公司的安全文化差……正<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">因为如此，国家航空委员会在飞行员的个<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">人执照和等级方面采取的措施几乎不会影<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">响公司的飞行运行安全，除非同时能确保<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">公司的管理人员采取了适当的态度，并具<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">有足够的能力履行他们的职能。”<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">四、资源的分配<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">社会技术系统中的组织按照两个不同的目<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">标分配资源：生产与安全。从长远观点来<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">看，这两个目标是一致的；但假定资源是<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">有限的，很可能在许多情况下会出现短期<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的利益冲突。为促进生产，就会减少安全<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">方面的可用资源，反之亦然（见下图）。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">机制不完善的组织可能强调生产管理而不<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">是安全或风险管理。例如在拖飞机过程<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">中，相关人员没有通讯设备（或设备故<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">障），环境噪声大，发生紧急情况时不能<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">有效沟通，造成飞机与拖车、机库、飞机<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">和其它障碍物相碰而损伤。不配备通讯设<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">备可以节省一些资金，然而，由于缺少保<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">证安全的必要设备，所造成损失可能更<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">大。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">第三节复杂技术系统中的事故<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">为了理解决策者的行为或未采取任何行安<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">全的影响，有必要介绍目前对事故原因<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的看法。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">一、如何认识事故原因<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 航空系统作为复杂的社会技术系统，要<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">正常运作，需要大量人机间的密切合<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">作，它还应具有精心设立的安全防线。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 航空系统中的事故是大量主动因素相结<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">合的产物，其中每一因素是必需的但各<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">自不足以突破系统防线。由于技术的不<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">断进步，主要设备故障或操作人员差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">很少成为系统安全防线崩溃的根本原<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">因。相反，安全防线崩溃主要是由发生<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在管理阶层的人的决策失误造成的。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 根据故障后果的直接性，故障可分为主<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">动故障或潜在故障（隐患）。主动故障<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">是指具有直接不良影响的差错和违规，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">通常与运行人员（飞行员、管制员、维<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">修人员等）相关；隐患是指决策或行<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">为，其后果可能保持一个较长的潜伏<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">期。在主动故障、技术问题或不良系统<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">状态触发下，隐患变得明显并突破系统<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 隐患只在事故发生前显现出来，它很可<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">能是决策者、规章管理人员和在时间和<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">空间上远离事件的其它人员孕育的。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">137<o:p></o:p></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 那些处于人一机界面中的运行人员承袭<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">了系统缺陷（例如，设计差、目标冲<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">突、组织缺陷和管理决策失误），他们<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">只不过创造了使隐患明显化的条件。要<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">促进安全，努力的方向应为发现和解决<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">这些隐患，而不是尽量将主动故障减少<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">到最小。主动故障只是众所周知的表面<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">部分。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 人在事故中的影响如下图所示。大多数<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">隐患的主要根源都可追溯到决策者所犯<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的差错上。甚至在运作很好的组织上，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">大量的重要决策也会具有消极的一面，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">因此必须采取步骤查找这些不安全决<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">策，并缓解它们的不良后果。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">• 航空公司管理中的错误决策可能具有下<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">列形式：程序不充分、安排不合理或缺<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">乏危险意识等。它们可能导致技能不充<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">分、规则不适当或知识缺乏，或者它们<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">表现出计划或技艺较差。错误的决策还<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">可能是由资源缺乏引起的。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
