国际民航组织安全管理系统课程讲义

LOGO国际民航组织安全管理国际民航组织安全管理国际民航组织安全管理国际民航组织安全管理系统（系统（系统（系统（SMSSMS）课程）课程）课程）课程讲义讲义讲义讲义N2 N2 AnyfieldAnyfield机场事故机场事故机场事故机场事故 Contents一、事件经过二、原因分析2.1调查结果2.2小组讨论2.3建议逻辑逻辑结构结构三、表格填写前言前言阅读事故阅读事故有关文本有关文本小组讨论小组讨论文字编辑文字编辑PPT制作制作工作流程工作流程调查分析调查分析+合理建议合理建议+整改整改=安全安全一、事件经过一、事件经过一、事件经过一、事件经过In the early hours of an autumn Monday-morning,a twin-engined jet transport with 5 crew-members and 63 passengers on board while in its take-off run at Anyfield Airport collided with a small twin-engined propeller-driven aircraft,with only a single crew-member that had intruded the departure-runway.Both aircraft were severely damaged as a result of the collision.The subsequent fire destroyed both aircraft and was the death-cause for most of the passengers.在秋季周一早上凌晨，在在秋季周一早上凌晨，在Anyfield机机场1一架双引擎一架双引擎喷气运气运输机机5名机名机组成成员和和63名乘客，在其起名乘客，在其起飞运行运行时与与一个侵入离一个侵入离场跑道的只有一个机跑道的只有一个机组成成员的双引擎螺旋的双引擎螺旋桨小小飞机相撞。机相撞。这两架两架飞机由于碰撞遭到机由于碰撞遭到严重破坏。随后重破坏。随后的大火的大火烧毁了了飞机，同机，同时造成大部分乘客死亡。造成大部分乘客死亡。一、事件经过一、事件经过Anyfield Airport is a medium-sized airport,with a single runway which can be accessed(or vacated)by a number of intersections.It is a controlled aerodrome;the control-tower is located 400 meters north of the middle of the runway.Traffic-numbers are on the rise as quite a few commuter-type airlines have started operating to and from Anyfield.Anyfield机机场是一个中型机是一个中型机场，一条跑道，一条跑道连接着一些十字路口（或接着一些十字路口（或腾空）。空）。这是一个管制机是一个管制机场，控制塔位于距北跑道中，控制塔位于距北跑道中间400米的位米的位置。由于不少通勤型航空公司已开始来往于置。由于不少通勤型航空公司已开始来往于Anyfield，Anyfield交交通流量逐通流量逐渐上升。上升。Although the airport is in a region in which several foggy days a year are common,it is not equipped with a Surface Movement Radar(SMR),nor does it have special taxiway-lighting facilities for use under low visibility-conditions.虽然机然机场处于一年中于一年中雾天很常天很常见的一个地区，但是它并没有配的一个地区，但是它并没有配备地地面活面活动雷达（雷达（SMR），也没有特殊的滑行道照明），也没有特殊的滑行道照明设施供低能施供低能见度条度条件下使用。件下使用。一、事件经过一、事件经过Air Traffic Control at Anyfield is slightly understaffed,but so far it was not thought necessary to impose restrictions on operations to and from Anyfield.There is a discrete frequency(Ground Control)to handle taxiing aircraft.空中交通管制在空中交通管制在Anyfield是略有不足，但到目前是略有不足，但到目前为止，并不止，并不认为需需要加要加强对于在于在Anyfield运行的限制。有一个离散的运行的限制。有一个离散的频率（地面管制）率（地面管制）处理滑行的航空器。理滑行的航空器。At the time of the collision,the average visibility was around 700 meters with fog-banks,which is just sufficient to allow the tower-controller to see the middle part of the runway.The controllers view at the intersection where the intruding aircraft entered the runway however was obstructed by the newly constructed extension to the terminal building at Anyfield Airport.在碰撞在碰撞时，伴随，伴随雾的坡度，平均能的坡度，平均能见度度约700米，米，这是恰好足以是恰好足以让塔控制塔控制员看到跑道的中看到跑道的中间部分。新建成的部分。新建成的Anyfield机机场候机楼候机楼扩展展出来的部分在阻出来的部分在阻挡了控制了控制员的的视野，正好是侵入跑道的野，正好是侵入跑道的飞机机进入跑入跑道的位置。道的位置。一、事件经过一、事件经过The Air Traffic Controller(ATCO)was a very experienced controller.He had been working in ATC for many years,at several major facilities,and had been transferred to Anyfield to act as an OJT-instructor only eight months before the date of the accident.空中交通管制（管制空中交通管制（管制员）是一个非常有）是一个非常有经验的控制的控制员。他曾在。他曾在ATC工作多年，在几个主要管制中心，在意外工作多年，在几个主要管制中心，在意外发生日期生日期仅8个月前被个月前被转移到移到Anyfield作作为OJT-指指导员。At the time of the collision,the ATCO1 was alone in the control-tower,as his Assistant/Ground Controller ATCO2 of far less experiencehad briefly left the TWR to answer a call of nature.They were both completing their third consecutive nightshift,had come on duty at 22:00 hours the previous evening and were due to be relieved within thirty minutes when the accident occurred.碰撞碰撞时，ATCO1独自一人在塔台，作独自一人在塔台，作为他的助理他的助理/地面管制地面管制员ATCO2-远不如不如ATCO1经验丰富丰富-曾短曾短暂离开塔台上离开塔台上厕所。他所。他们都都完成他完成他们的第三个的第三个连续夜班，由于已夜班，由于已经从前一天晚上从前一天晚上22:00值班到班到现在，在事故在，在事故发生生时30分分钟内就可以内就可以换班。班。一、事件经过一、事件经过The crew of the jet-aircraft was experienced operators to and from Anyfield.From their point of view,on the morning of the accident there was nothing unusual in the way their flight was handled by ATC.They taxied to the runway with the extra caution required by the fog-conditions,and after being cleared for take-off they made certain they were lined up correctly on the runway-centerline before applying take-off power.喷气气飞机的机机的机组来往于来往于Anyfield的的经验丰富。从他丰富。从他们的角度来看，的角度来看，事故事故发生在早晨，在生在早晨，在ATC航路上没有不什么正常。他航路上没有不什么正常。他们在的在的雾条件条件下格外小心地滑行到跑道，下格外小心地滑行到跑道，获得起得起飞许可后，在提出申可后，在提出申请前起前起飞推推力之前，确力之前，确认他他们在跑道中心在跑道中心线列列队正确。正确。The pilot of the twin-engined piston-driven aircraft was unfamiliar with Anyfield Airport,having been sent there at short notice to collect an aircraft that had to divert into Anyfield two days earlier for weather-reasons.双引擎活塞式双引擎活塞式飞机的机的飞行行员不熟悉不熟悉Anyfield机机场，被送到那里去短，被送到那里去短时间内接收两天前由于天气原因不得不内接收两天前由于天气原因不得不转飞到到Anyfield的一架的一架飞机。机。上厕所回来发上厕所回来发现联系不上小现联系不上小飞机飞机双引擎螺旋桨双引擎螺旋桨小飞机小飞机（误入跑到）（误入跑到）一架双引擎喷一架双引擎喷气运输机气运输机（正起（正起飞）管制管制员员1管制管制员员2同时进行管同时进行管制和地面两制和地面两席位的工作席位的工作在预计移交时在预计移交时间发现运输机间发现运输机一直无应答。一直无应答。上厕所前给小上厕所前给小飞机发布滑行飞机发布滑行指令指令消防队救援车辆由于不清楚事发的准确地点，和雾天通行困难赶到消防队救援车辆由于不清楚事发的准确地点，和雾天通行困难赶到现场时面对的是几乎烧毁完全的飞机残骸现场时面对的是几乎烧毁完全的飞机残骸。一、事件经过一、事件经过跑道相撞跑道相撞他没有从他能他没有从他能看到的那部分看到的那部分跑道观察到离跑道观察到离场的喷气飞机场的喷气飞机 二、原因分析二、原因分析2.1调查结果2.1调查结果Although ATCO1 was very experienced,he had only worked a limited number of solo-shifts in Anyfield TWR.Having validated his TWR-rating in early summer,he had been involved in giving on-the-job-training(OJT)instruction on most of his shifts after that.As a consequence of the staff-shortage he was required to work his share of nightshifts like all other controllers.The shift in which the accident occurred was only his second where he had worked at Anyfield TWR under foggy/low visibility conditions;the first had been the previous night,when there was hardly any traffic as it was the night from Saturday to Sunday.虽然然ATCO1是非常有是非常有经验的，但是他在的，但是他在Anyfield 塔台独自工作的塔台独自工作的次数很有限。在初夏他才次数很有限。在初夏他才验证的塔台管制的塔台管制评级，在那之后，他在大，在那之后，他在大部分的部分的换班后参与到在班后参与到在职培培训（OJT）指）指导工作由于人工作由于人员短缺，他短缺，他被要求必被要求必须像所有其他管制像所有其他管制员一一样值参与夜班工作。在参与夜班工作。在该事故事故发生生时仅仅是他在是他在Anyfield-TWR的班次中，第二次遇到的班次中，第二次遇到雾/低能低能见度条度条件。第一次是在前一天晚上，当件。第一次是在前一天晚上，当时几乎没有任何交通，因几乎没有任何交通，因为那是在那是在周六到周日的晚上。周六到周日的晚上。2.1调查结果A number of years ago there had been an incident at Anyfield involving runway-intrusion by a vehicle,under similar meteorological conditions as in this case.One of the recommendations at that time was the installation of a SMR,together with stop-bars at all runway-intersections.The authorities decided that in view of the limited number of days(with fog)that would warrant the use of a SMR,the benefit of having a SMR didnt match the costs of having one installed.The same applied for the installation of stop-bars,but in lieu of those,painted signs had been put in the grass next to the runway-intersections,informing those who noticed them there was a runway ahead.Anyfield在在许多年前曾出多年前曾出现过车辆入侵跑道的情况，也是在入侵跑道的情况，也是在这种种类似似该事件的气象条件情况下。当事件的气象条件情况下。当时的建的建议之一是安装一个之一是安装一个SMR，同，同时在所有跑道交叉口在所有跑道交叉口设置停止阻置停止阻挡。当局决定，。当局决定，鉴于需要使用于需要使用SMR有限的天数（有限的天数（雾天），安装天），安装SMR的收益和支出并不匹配。安装停止的收益和支出并不匹配。安装停止阻阻挡也是如此。但是我也是如此。但是我们可以用画在跑道十字路口旁可以用画在跑道十字路口旁边的草地上的的草地上的图标代替代替SMR和停止阻和停止阻挡，提示看到，提示看到图标的人，他的人，他们前面有前面有“跑道跑道”。2.1调查结果As the early morning-traffic began to come alive,ATCO1 and ATCO2 were each working an independent R/T-frequency.When ATCO2 announced he had to visit the mens room for a second,ATCO1 told him to go ahead,intending to work both frequencies by himself.In order to do so,ATCO1 had to physically move between two control-positions in the TWR that are about three meters apart,for Anyfield TWR isnt equipped with a frequency-coupling installation.Transmissions on one frequency cant be heard by stations on the other frequency.当清晨交通开始繁忙起来当清晨交通开始繁忙起来时，ATCO1 ATCO2分分别在独立的在独立的R/T频率上工作。率上工作。ATCO2说他不得不再次去洗手他不得不再次去洗手间，ATCO1同意，打算同意，打算自己在两个工作自己在两个工作频率上工作。率上工作。为了做到了做到这一点，因一点，因为Anyfield塔台塔台没有配没有配备频率耦合装置，声音在一个率耦合装置，声音在一个频率上的率上的传输不能被其他不能被其他频率率听到，听到，ATCO1不得不在在两个相距不得不在在两个相距约三米的管制席位三米的管制席位间来回走来回走动。2.1调查结果The piston-engined aircrafts pilot had arrived in Anyfield late the night before.After a short sleep he went to the airport quickly in order to waste as little time as possible,for his company wanted the aircraft back at its home base a.s.a.p.After the minimum of preparation needed,he went to his aircraft and called ATC for approval to taxi to the runway.He obtained the clearance and began taxiing,but soon found himself lost at the foggy,unfamiliar airport.The fact that there were no signs denominating the various taxiway-intersections didnt help much either.活塞式引擎活塞式引擎飞机的机的飞行行员在前一天晚的深夜才到达在前一天晚的深夜才到达Anyfield。经过短短暂的睡眠，他以尽可能少的的睡眠，他以尽可能少的时间赶到机赶到机场，他的公司希望，他的公司希望飞机尽机尽可能迅速地回到其大本可能迅速地回到其大本营。在最快地完成所需的准。在最快地完成所需的准备后，他去到他后，他去到他的的飞机，并向管制机，并向管制员申申请滑行到跑道的滑行滑行到跑道的滑行许可。他可。他获得得许可，开可，开始在跑道上滑行，但很快就始在跑道上滑行，但很快就发现自己迷失在自己迷失在笼罩在云里罩在云里雾里的不熟里的不熟悉的机悉的机场。事。事实上，没有任何上，没有任何标志命名各种滑行道交叉，志命名各种滑行道交叉，这也并没也并没有多大帮助。有多大帮助。2.1调查结果The R/T-tapes showed that the piston-pilot then called G/C(by R/T)and asked for progressive taxi-instructions.ATCO2 replied by asking his position.The pilot said:I believe Im approaching Foxtrot-intersection,to which ATCO2 answered:At Foxtrot taxi straight ahead.In fact the pilot had already passed Foxtrot,and should have turned onto the parallel taxiway.The instruction from ATCO2,though technically correct,caused the pilot to taxi onto the runway where the jet was in its take-off roll.Since the communications to both aircraft took place on different frequencies,neither pilot was aware of what was happening.R/T磁磁带表明，活塞表明，活塞飞机的机的飞行行员呼叫叫地面管制呼叫叫地面管制员（通（通过R/T）并提出）并提出“渐进式滑行指令式滑行指令”要求。要求。ATCO2回答，回答，询问他的位置。他的位置。飞行行员说：“我相信我接近我相信我接近F交叉口交叉口”，ATCO2回答：回答：“在在F交叉口向交叉口向前滑行前滑行”。事。事实上，上，飞行行员已已经通通F交叉口，交叉口，应该滑行到平行滑行道。滑行到平行滑行道。ATCO2发出指令，出指令，虽然在技然在技术上是正确的，但是造成活塞上是正确的，但是造成活塞飞机机飞行行员滑行滑行进入了入了喷气机正在气机正在进行起行起飞滑跑的跑道。由于两滑跑的跑道。由于两飞机的通机的通信信发生在不同的生在不同的频率上，两率上，两飞行行员都不知道都不知道发生了什么事。生了什么事。After the collision,it took ATCO1 several minutes to realize something was wrong.Of course he hadnt observed the departing jet passing on the section of the runway that was visible to him,but he initially blamed that on the fog patches and/or being distracted by traffic on the G/C frequency.撞机事件撞机事件发生后，生后，ATCO1花了好几分花了好几分钟才明白出才明白出现了情况。当然，了情况。当然，他没有从他能看到的那部分跑道他没有从他能看到的那部分跑道观察到离察到离场的的喷气气飞机，但是他最机，但是他最初将其（没初将其（没观察到察到喷气气飞机起机起飞）归因于因于雾和和/或地面管制或地面管制频率的交率的交通使他分心。通使他分心。And apart from the fog,ATCO1 was unable to see the part of the runway where the collision had taken place because of the newly built extension of the terminal building blocking his view.So it was not until he wanted to transfer the departing jet to the next controller(Departure Control)that he became aware things werent as they should be,when his transmissions to the jet remained unanswered.因因为除了除了雾，新建成的航站楼的延伸部分，新建成的航站楼的延伸部分，挡住了他的住了他的视线，ATCO1无法看到跑道无法看到跑道发生了碰撞。因此，直到他想起将生了碰撞。因此，直到他想起将飞喷气气转移到下一个管制移到下一个管制员（离（离场管制管制员）时一直没有得到一直没有得到喷气气飞机的答复，机的答复，他才意他才意识到事情到事情发展偏离了展偏离了预定的情况。定的情况。ATCO2,who returned shortly after the accident,at the same time reported having no contact with the taxiing twin-prop.ATCO1 then decided to alert the fire-brigade,but as he had no idea where to send them,more precious time was lost as the rescue-vehicles tried to make their way across the foggy airport.When they finally arrived at the accident-site,they found there was little they could do as the wreckage of the aircraft had almost burnt-out completely already.ATCO2在事故在事故发生后不久返回，在同一生后不久返回，在同一时间报告没有同告没有同在滑行的双螺旋在滑行的双螺旋桨取得任何取得任何联系。系。ATCO1然后决定提然后决定提醒消防醒消防队，但因，但因为他不知道指派消防他不知道指派消防队去哪儿，同去哪儿，同时救救援援车辆艰难地通地通过被被雾笼罩的机罩的机场，更是使得宝，更是使得宝贵的救的救援援时间损失掉了。当他失掉了。当他们终于赶到事故于赶到事故现场时，面，面对几几乎乎烧毁完全的完全的飞机残骸，他机残骸，他们发现他他们能做的不多了。能做的不多了。2.1调查结果Had a SMR been installed following the recommendation after the other incident,this would have provided the following lines-of-defense(in declining order):如果遵循其他事件如果遵循其他事件发生后的建生后的建议安装一个安装一个SMR，这将提供以下将提供以下线的防御的防御（降序）：（降序）：Proper taxi-instructions could have been given to the lost aircraft.正确的滑行指令可能已正确的滑行指令可能已经发给了了“迷路迷路”的的飞机。机。The ATCOs would have observed the runway-intrusion.空管人空管人员将已将已经观察到跑道入侵。察到跑道入侵。The collision-site would have been easily identified.碰撞碰撞现场将被容易将被容易识别。Adequate instructions could have been given to the rescue-vehicles.合适的指令，可能已合适的指令，可能已经发给了救援了救援车辆。This goes for the stop-bars as well.Had they been installed,the twin-prop more likely than not wouldnt have entered the runway.这同同样适用于停止阻适用于停止阻挡装置。如果他装置。如果他们已已经被安装，双螺旋被安装，双螺旋桨较可能不会可能不会已已经进入跑道。入跑道。2.1调查结果At the very least,special procedures for Low Visibility Operations(LVO)at Anyfield should have been developed and in force,limiting the number of movements at the field.The ATCOs should have been trained in working with these special procedures,ideally on a simulator,to help them cope with the unusual situation once it occurred.最起最起码，在，在Anyfield，通，通过限制在机限制在机场活活动区运行的航空器的数量区运行的航空器的数量的特殊低能的特殊低能见度运行程序（度运行程序（LVO）应该已已经被开被开发并投入使用。管并投入使用。管制制员应该已已经完成完成这些特些特别的程序的工作的程序的工作训练。最好通。最好通过模模拟器器训练，以帮助他，以帮助他们应付可能付可能发生的异常情况。生的异常情况。In their talks with the airport-authorities,ATC management should have firmly opposed the plans for extension of the terminal-building.But,as a result of not having any input from the operational ATCOs(who were not available to attend the meetings due to staff-shortage),management wasnt even aware it would constitute a line-of-vision problem from the TWR.在与机在与机场当局的当局的谈话中，空管管理中，空管管理层应坚决反决反对候机楼候机楼扩建的建的计划。划。但是，由于没有任何但是，由于没有任何业务管制管制员（没有出席会（没有出席会议由于人由于人员短缺）反短缺）反映，空管管理映，空管管理层甚至不知道它会构成甚至不知道它会构成对塔台塔台视线的影响。的影响。2.1调查结果ATCO1 shouldnt find himself in a position where he was forced to work two positions by himself.At all times ATC-positions should be sufficiently staffed to allow the traffic to be handled in a safe manner.ATCO1不不应该找不到自己的位置，他不找不到自己的位置，他不应该迫使自己在迫使自己在两个工作位置工作。两个工作位置工作。管制席位管制席位应该在任何在任何时候都有足候都有足够的工作人的工作人员，使得交通流量以安全的方式运行。，使得交通流量以安全的方式运行。The installation of a frequency-coupler might have helped prevent the collision from occurring.As it is,these systems are considered optional by the aviation-authorities,so only few ATC-facilities have them.频率耦合器的安装可能有助于防止碰撞的率耦合器的安装可能有助于防止碰撞的发生。因生。因为它它是，是，这些系些系统被航空当局被航空当局认为是是“可可选”的，所以只有少的，所以只有少数管制数管制单位安装了它。位安装了它。2.1调查结果Management should ensure that OJT-instructors are given the opportunity to stay current at the positions where they are supposed to teach,by scheduling the instructor for duties without trainees at regular intervals.Such duties should be sufficiently challenging of nature to allow the instructor to practice his skills(in other words:shifts without traffic may look good in a roster,but are of no value for currency-maintaining purposes)管理管理层应确保，确保，OJT-指指导员有机会保持在教学有机会保持在教学岗位上，安排没有不用指位上，安排没有不用指导学学员的定期的定期值班。班。这些班次些班次应具有足具有足够的挑的挑战性，性，让教教练来来实践他的技能践他的技能（换句句话说：没有交通流量的班次可能会在名册看起来好看，但：没有交通流量的班次可能会在名册看起来好看，但对于保持于保持交通流量没有价交通流量没有价值）Had there been a well-devised training-curriculum that was correlated with the duty-roster,management would have recognized that ATCO1,although qualified,hadnt been able to acquaint himself with working at Anyfield TWR under low visibility-conditions.Ideally,they wouldnt have scheduled him for unsupervised duty when low visibility was forecast.如果当如果当时有一个精心有一个精心设计的与的与责任名册相关的培任名册相关的培训课程，管理程，管理层将意将意识到，到，ATCO1虽然合格，但是不能然合格，但是不能够单独在低能独在低能见度条件下在度条件下在Anyfield塔台工作。塔台工作。在理想的情况下，他在理想的情况下，他们不会已不会已经安排他在安排他在预测到的低能到的低能见度的那天在不受度的那天在不受监督的情况下督的情况下值班。班。2.1调查结果Dedicated LVO-training would have made ATCO2 aware of the dangers involved,alerting him to be more positive in guiding the lost taxiing pilot.At the very least he probably wouldnt have given the pilot irrelevant information.专用用LVO培培训会将会将 使使ATCO2意意识到所涉及的危到所涉及的危险，提醒他要更加，提醒他要更加积极的去极的去引引导“迷路迷路”的正在滑行的的正在滑行的飞行行员。最起。最起码，他不会，他不会给飞行行员无关的信息。无关的信息。It is a scientific fact that when consecutive nightshifts are worked,the performance of persons engaged in cognitive tasks(such as ATC)decreases dramatically in the second and later nights,especially between 03:00 hrs and 07:00 hrs.ATCO1 at Anyfield was on his third nightshift in a row,which could explain why he failed to recognize a potentially dangerous situation that he wouldnt have missed under other circumstances.When designing shift-rosters for ATCOs it is advisable to keep the number of consecutive nightshifts to an absolute minimum.连续夜班工作夜班工作时，从事，从事认知任知任务（如管制工作）的人，在第二次及以后的（如管制工作）的人，在第二次及以后的夜晚，他的表夜晚，他的表现会急会急剧下降，尤其是凌晨下降，尤其是凌晨03:00点至早点至早07:00点之点之间，这是是一个科学事一个科学事实。ATCO1在在进行他在行他在Anyfield的第三个的第三个连续的夜班，的夜班，这可以可以解解释为什么他没有什么他没有认识到有潜在危到有潜在危险的情况，在其他情况下，他将不会的情况，在其他情况下，他将不会错过。当。当设计管制管制员排班名册排班名册时，最好能使，最好能使连续夜班的数量保持在夜班的数量保持在绝对最低最低水平。水平。2.1调查结果Based on the meteorological forecast,and taking into account the propeller-aircrafts pilot was unfamiliar with Anyfield,it may be argued that the air operator would have done better to send two pilots to collect the aircraft.Even with limited knowledge of CRM-principles,a second pilot could have prevented the other pilot from acting the way he did.根据气象根据气象预测，并考，并考虑到螺旋到螺旋桨飞机的机的飞行行员是不熟悉是不熟悉Anyfield，可能会，可能会认为航空运航空运营商派商派两名两名飞行行员去接收去接收飞机会更好些。即使机会更好些。即使CRM（班（班组资源管理）的知源管理）的知识有限，安排第二个有限，安排第二个飞行行员也可以防止其他也可以防止其他飞行行员以同以同样的方式行事。的方式行事。2.2小组讨论2.2小组讨论飞行行员（此（此处针对小小飞机）：机）：R/T磁磁带表明，活塞表明，活塞飞机的机的飞行行员在在发现自己迷失在发现自己迷失在笼罩在云里雾里的不熟悉的机场笼罩在云里雾里的不熟悉的机场后呼叫叫地面管制后呼叫叫地面管制员（通（通过R/T）并提出）并提出“渐进式滑行指令式滑行指令”要求。要求。ATCO2回答，回答，询问他的位置。他的位置。飞行行员说：“我相信我接近我相信我接近F交叉交叉口口”，ATCO2回答：回答：“在在F交叉口向前滑行交叉口向前滑行”。事。事实上，上，飞行行员已已经通通F交叉口，交叉口，应该滑行到平行滑行道。滑行到平行滑行道。ATCO2发出指令，出指令，虽然在技然在技术上是正确的，但是造成活上是正确的，但是造成活塞塞飞机机飞行行员滑行滑行进入了入了喷气机正在气机正在进行起行起飞滑跑的跑滑跑的跑道。由于两道。由于两飞机的通信机的通信发生在不同的生在不同的频率上，两率上，两飞行行员都不知道都不知道发生了什么事。生了什么事。对待不熟悉的机待不熟悉的机场，应该提前做好熟悉工作，同提前做好熟悉工作，同时在在滑行道上迷路滑行道上迷路时应该和管制和管制员保持保持联络，加，加强联络，确，确实弄明白弄明白现在所在所处环境再采取境再采取进一步行一步行动。2.2小组讨论小型小型飞机的航空器运机的航空器运营人：人：不不应该在可在可预见的低能的低能见度天气下，安排度天气下，安排仅仅一个不熟悉机一个不熟悉机场的的飞行行员去接收去接收飞机。机。应该安排安排2飞行行员会更好。会更好。2.2小组讨论管制管制员：对待航站延伸部分楼遮待航站延伸部分楼遮挡对跑道的跑道的视线的的情况没有及情况没有及时反映。反映。管制管制员1：对anyfield没有足没有足够经验，就不要，就不要让自己自己处于低能于低能见度没人度没人监管管时同同时监管塔台和管塔台和地面两个席位的不理地面两个席位的不理处境。境。管制管制员2：对待迷路的航空器没有待迷路的航空器没有给予充分的关注与予充分的关注与指引。在上班的指引。在上班的时候离候离岗是不是不对的。的。2.2小组讨论管制管理管制管理层：排班不合理。安排了排班不合理。安排了连续的夜班。的夜班。沟通不合理，不了解沟通不合理，不了解实际情况，不知道航情况，不知道航站楼会遮站楼会遮挡一一线管制管制员视线。没有及。没有及时提提出反出反对航站楼航站楼扩建的意建的意见。没有吸取上一次没有吸取上一次车辆误入跑道的入跑道的经验，建，建立完善低能立完善低能见度运行度运行规则，安排培，安排培训；或；或安装安装SMR；或安装或安装停止阻停止阻挡装置装置。没有没有认识到管制到管制员1不具不具备在机在机场低能低能见度度时没有没有监管条件下工作的能力。管条件下工作的能力。2.3建议2.3建议合理排班合理排班完善低能完善低能见见度运行度运行标标准准安装安装SMR 或停止阻或停止阻挡挡装置装置完善双完善双岗岗制制解决人解决人员员短缺短缺问题问题三、表格填写三、表格填写LOGO