民航局近期发布了《关于进一步加强和改进新时期客舱安全管理工作的意见》,该文件更新并替代了之前的《关于加强客舱安全管理工作的意见》(民航发〔2012〕96号文)。随着新意见的出台,96号文正式失效,新意见将成为航空公司客舱安全管理的新准则。
根据新意见,各运输航空公司需深入探讨并采取切实措施来贯彻实施,各地区管理局也将加强监管,以保证航空公司严格遵循新意见执行操作。
特别指出的是,新意见强调了加强机组成员的CRM(机组资源管理)训练和联合演练,以及对风险管控措施的有效监督检查,旨在有效预防乘客和机组人员在飞行中因颠簸而受伤。
我们在之前的公众号文章中也曾提及这些要点,看看客舱如何对TEM进行管理。
威胁与差错管理(TEM)是通过识别、避免、捕捉和管理操作威胁与人为差错的持续过程来促进安全运营的。TEM 是 CRM 的一个重要组成部分。
The human error factor is always a possibility in the performance of cabin crew functions, and threats are always a component of their environment. The ultimate goal of TEM is to maximize flight safety by minimizing incidents and accidents caused by human factors. IOSA defines TEM as the actions taken by the flight crew (or cabin crew) to reduce threats or manage errors.
威胁与差错管理(TEM)是通过识别、避免、捕捉和管理操作威胁与人为差错的持续过程来促进安全运营的。TEM 是 CRM 的一个重要组成部分。人为差错因素始终存在于机组成员执行职能的过程中,而威胁始终是其环境的组成部分。TEM 的最终目标是通过最小化人为因素引起的事件来最大限度地提高飞行安全。IOSA 将 TEM 定义为机组人员(或客舱乘务员)为减少威胁或管理差错而采取的行动。
According to the TEM framework developed by the Human Factors Research Project (HFRP) at the University of Texas in Austin, TEM are developed as a conceptual framework to interpret data obtained from both normal and abnormal operations. For many years, IATA has worked closely with the HFRP team, ICAO, member airlines, and manufacturers to apply TEM to its many safety activities. The following are definitions of terms and tables that describe the TEM framework:
根据德克萨斯大学奥斯汀分校的人因研究项目(HFRP)开发的 TEM 框架, TEM 被开发为一个概念框架来解释从正常和非正常运行中获得的数据。多年来,IATA一直与 HFRP 团队、国际民航组织、成员航空公司和制造商密切合作,将 TEM 应用于许多其他安全活动。以下是描述 TEM 框架的术语和表格的定义:
An event or error that occurs outside the influence of the crew, but which requires crew attention and management to properly maintain safety margins.
在乘务人员无法控制的范围内发生的事件或差错,但需要乘务人员注意和管理以正确维持安全裕度。
Type of Threat 威胁类型 | Examples 威胁类型 |
Operational 运行 | • Time pressures 时间压力 • Flight diversion 航班变更 • Unfamiliar cabin/galley configurations 不熟悉的客舱/厨房构型 • Abnormal operations (i.e., rejected takeoff) 非正常运行状态(例如,中断起飞) • Traffic and ground congestion 空中和地面流量大和管制 • Adverse weather/turbulence 恶劣天气/空中颠簸 • Airport construction 机场建设 |
Flight deck events 机上事件 | • Pilot incapacitation 飞行员失能 • Flight crew error/distraction/interruption 飞行机组人员差错/分散注意力/干扰 |
Crew support threats 人员支援类威胁 | • Errors by maintenance, catering, security or ground crew 由维修人员、航食人员、安保人员或地勤人员导致的差错 • Faulty equipment boarded 机上配备错误的设备 • Paperwork errors (e.g., passenger load, cabin defect logbook) 文书差错(例如,舱单、客舱故障记录本) • Crew scheduling errors 人员排班差错 |
Aircraft 飞机 | • Equipment malfunction 设备故障 • Design issues 设计缺陷 • Particular galley/cabin configuration 特殊的厨房/客舱构型 |
Passenger 旅客 | • Abusive or unruly passengers 粗鲁或不守规矩的旅客 • Passengers smoking in the lavatory 旅客在厕所内抽烟 • Passengers standing during turbulence/taxi 旅客在空中颠簸或滑行时站立 • Baggage not stowed 行李未正确存放 • Unlawful entry into the flight deck 非法闯入驾驶舱 |
An observed cabin crew deviation from organizational expectations or crew intentions.
可观察到与组织期望或人员意识发生的偏差。
Type of Error 差错类型 | Description 描述 | Examples 示例 |
Intentional non-compliance 故意违规 | These errors result from the crews deliberate and premeditated deviation from SOPs or regulations. 这些差错是由于机组人员故意和蓄意偏离 SOP 或规章而导致的。 | • Disregarding sterile cockpit rule 无视驾驶舱的规定 • Not performing the safety equipment checklist prior to flight 飞行前不进行安全设备清单的检查 • Omitting required safety briefing to passengers with special needs 遗漏向特殊旅客进行必要的安全简报讲解 • Not reporting missing or defective equipment 不报告设备的缺失或缺陷 • Standing for non-safety related duties during taxi-out 在滑行期间在没有相关安全职责的情况下站立 • Failure to report smoke detector alarm 未能报告烟雾探测器的警报 |
Procedural 程序性 | Unintentional deviation in the execution of operator procedures and/or regulations. The cabin crew has the necessary knowledge and skills. The intention is correct, but the execution is flawed. It may also include situations where cabin crews forget or omit relevant appropriate action. 运营人程序和/或规章执行中的非故意偏差。乘务员需要具有必要的知识和技能。主观意图是正确的,但是执行存在缺陷。它还可能包括机组人员忘记或忽略相关适当行动的情况。 | • Crewmember completes the preflight equipment checklist, but forgets to check one piece of equipment on the list 乘务员完成了飞行前的设备清单检查,但忘记了检查清单中设备的其中一部分 • Crewmember sets the oven to a higher temperature than indicated in the meal preparation instructions 乘务员将烤箱设置了比餐前准备指导中更高的温度 • SCCM boards the checklist for the wrong aircraft type/configuration 客舱经理记载了错误飞机型号/构型的检查单 • When briefing a special needs passenger, the crewmember forgets to mention the location of the life vest 向特殊旅客介绍情况时,乘务员忘记提示救生衣的位置 |
Communication 沟通 | Miscommunication, misinterpretation or failure to communicate pertinent information within the cabin crew or between the cabin crew and an external agent (e.g., flight crew). CRM issues typically fall under this category. 乘务员内部或乘务员与外部人员(例如飞行人员)之间的沟通不正确,误解或未能传达相关信息。CRM问题通常属于此类。 | • Crewmember to crewmember errors 乘务员之间的差错 • Cabin crew to flight crew errors 乘务员与飞行人员之间的差错 • Crewmember to external agent errors (i.e., ground, catering, security) 乘务员与外部人员(例如,地勤人员、航食人员、安保人员)的差错 |
Proficiency 熟练度 | Cabin crew performance failures due to deficient knowledge or skills. This may be exacerbated by lack of experience, knowledge or training. 由于知识或技能不足,乘务员未能正常表现。缺乏经验、知识或缺乏培训可能会加剧这种情况。 | • Crewmember is unable to work the control panel at L1 乘务员在 L1 舱门处无法正确操作控制面板 • Crewmember opens door not realizing that the slide is armed 乘务员在未意识到滑梯已越位的情况下打开舱门 • Crewmember does not know the procedure to contact the flight deck via the interphone in an emergency situation 乘务员不知道在紧急情况下与驾驶舱使用内话进行联系的程序 |
Operational decision 操作决策 | The adoption or continuation by cabin crews of a course of action that unnecessarily increases operational risks. To qualify under this category, the following prerequisites must exist: (1) the cabin crew had an alternative course of action within operational reason; (2) the alternative course of action was contemplated by the operators SOPs, which were clear and unambiguous; (3) the cabin crew had time to select the alternative course of action, but did not use it; (4) the cabin crew did not recognize or ignored the alternative course of action. 乘务员采取或继续采取不必要的动作会增加操作风险。要符合此类别,必须满足以下先 决条件: (1)乘务员在操作的原因内有备用措施方案; (2)运营人的 SOP 考虑了备用措施方案,这些操作明确且不会被误解; (3)乘务员有时间选择备用措施方案,但没有使用; (4)乘务员没有意识到或忽略备用措施方案。 | • Accepting instructions from the flight deck that unnecessarily increase risk 接受来自驾驶舱会增加不必要风险的指示 • Continuation of service during turbulence 在空中颠簸时继续服务 • Failure to secure cabin for landing 着陆时无法确保客舱安全 • Decision to arm doors without the approval of the SCCM or the Pilot-in-Command 未经客舱经理或机长批准进行舱门预位 • Failure to complete a checklist in a timely manner (i.e., the emergency equipment checklist before takeoff) 无法及时完成检查单(例如,起飞前要检查的应急 设备清单) • Failure to cross-verify documentation such as the Minimum Equipment List (MEL) when equipment is unserviceable 当设备无法使用时,未能交叉验证文件,如MEL • Non-essential communications between cabin crew during takeoff 关键阶段乘务员之间不必要的沟通 |
3、非期望客舱/飞机状态
(Undesired Aircraft States)
A cabin crew induced a cabin/aircraft state that clearly reduces safety margins; a safety compromising situation that results from ineffective threat/error management. An undesired aircraft state is recoverable.
乘务员导致客舱/飞机状态明显降低了安全裕度;因无效的威胁/差错管理而导致的损害安全的情况。非期望的飞机状态是可恢复的。
Type of State 状态 类型 | Examples 示例 |
Configuration 构型 | • Cabin systems: electrical, lighting, electronic (control panels, IFE), water and/or communications in wrong mode or configuration 客舱系统:电器、灯光、电子设备(控制面板、IFE)、水系统设备和或通信设备处于错误模式或构型 • Slides in wrong mode 滑梯处于错误模式(滑梯充放) • Slide/door unserviceable 滑梯/舱门不可用 • Galley equipment left switched on 离开时厨房设备保持开启状态 • Safety equipment (fire extinguishers, oxygen bottles, radio beacon) missing, malfunctioning or inaccessible 安全设备(灭火器、氧气瓶、雷达信标)遗失、故障或不可接近 • Flight deck door left unlocked in flight 飞行中驾驶舱门未锁 |
Critical phase /turbulence 关键阶段/空中颠簸 | • Passengers not seated/seatbelt not fastened 旅客未就座/安全带未系紧 • Seats/trays not in upright position 座椅/小桌板未处于收回直立位置 • Items in cabin/galley not secured 客舱/厨房设施处于不安全状态 • Cabin crew not seated/seatbelt not fasten 乘务员未就座/安全带未系紧 • Isles/exits not cleared 通道/安全出口有障碍物 • Crew rest area not vacated 机组休息区未清空 • Portable Electronic Devices (PEDs) in use 使用移动电子设备(PED) |
Cabin/passenger handling 客舱/旅客操作 | • Passengers not complying to fastened seatbelt sign 旅客未系好安全带 • Passengers smoking in cabin or lavatories 旅客在客舱或厕所内抽烟 • Passengers intoxicated or abusive 旅客醉酒或粗鲁行为 • Seating restrictions not respected (i.e., person with reduced mobility seating at an over-wing exit) 不遵守座位限制(例如,行动不便的旅客坐在翼上应急出口处) • Passengers not briefed 旅客未听从安全简报 • Dangerous goods present in the cabin 客舱内出现危险品 |
Ground states 地面状态 | • Passengers smoking during refueling 旅客在加油过程中抽烟 • Incorrect refueling procedures (i.e., designated evacuation doors left unarmed or unmanned, passengers not briefed on SOPs) 不正确的加油程序(例如,应急逃生门处于非预位或非人工控制状态,旅客不按 SOP 的简令行动) • Doors/exits/isles obstructed 舱门/应急出口/通道被堵塞 • Curtains closed 窗帘关闭(部分机型适用) • Oversize/overweight baggage boarded 超大/超重行李登机 • Unclaimed baggage left on board 行李遗忘在客舱内 • Doors left armed during a stopover 过站时舱门处于预位状态 |
在客舱胜任力课程中,民航Safety邀请CRM教员针对TEM威胁与差错管理有专题讲授,有助您更高效地学习本篇内容。
我们也向您提供:
第6版 IATA-Cabin-Operations-Safety-Best-Practices-Guide-Ed6 中的TEM框架原文和民航Safety团队提供的翻译版文件供您学习与CRM 课程开发参考。如需获取文件,请您在民航Safety公众号后台中回复关键词:
客舱TEM