他們被制度謀殺了,機組只是不自覺的工具人而已,我們要探究的是,如何揪出元凶
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首先,我必須說很高興終於有司法單位主動介入,調查民航這塊爛瘡疤,但是因為國家考試不考民航法規,而民航法牽涉到很多技術性的概念,純粹由普通刑法來評價確實有些難度。這些民航從業人員違法犯紀,其危害程度不亞於頂新集團的造假;頂新集團是針對全民全面性慢性投毒,航空公司為了績效而違法造假的行為,不啻如針對全民隨機埋入的定時炸彈。
(參考新聞:四秒關引擎 資深機師質疑違反程序)
航空公司機務部門為了圖利公司討好長官,粉飾自己績效,不按規定執行檢修程序,卻在業務文書上登載不實,歷年來就算被民航局查獲,民航也只是行政罰鍰,從來沒有移送,這些被查獲的都是民航局事後稽核查出來的,只是冰山的一角,還有更多等著引爆下一次空難。
正如此次復興空難,顯然機組在第一個發動機失效後,執行程序時關錯發動機,為何一個訓練有素的機長會犯下如此重大且明顯的錯誤?這應該可以證實在他起飛前一定有某些因素困擾他,這印證媒體登載,有人爆料機長提及在前一段航行中發動機異常,機務要他這趟飛回來再修;這種事對機長來說往往造成很大壓力,明知不可為而為之,但若不為,後果也可能造成他個人遭公司秋後算帳,所以可以推導帶著這種預先知道發動機異常的忐忑情境跟壓力,在飛機一起飛時竟然真的發生發動機失效情事,錯愕、慌亂可見一斑。
這可以由機長向塔台發出Mayday求救,是在兩個發動機都失效才發出的就可以證實,因為全世界的機師所受的訓練從入門第一課到退休,是每半年必考科目,而單發失效原則程序都是1.先穩住飛機、2.保持航向、3.上高度避地障,接著呼救,再來才是執行將故障發動機關油門、關電門;因此先前發動機異常的先佔情境,應該是造成他錯愕慌亂的主因,進而導致關錯發動機,而且可能三名駕駛都同樣陷於因為先前發動機異常,機務又不願檢修的陰影,這都必須揉入人性因素(Human Factor, 我不認同用人為因素,ICAO手冊的解釋就是人性)考量,才能最終判斷當時的情境。
事後批評人家時,要設身處地(put yourself into their shoes),想像一下人家當時的情境,不要一開始造神造成這樣,現在又落井下石,太不堪了,固然他們害人害己不應該,但是失速警告stall stall 響了五次,可以判斷他們在最後還是在失速邊緣勉強保持高度,無論是想撐回機場或找落地點,這都是出於拯救生命的善念,他們被制度謀殺了,機組只是不自覺的工具人而已,我們要探究的是,如何揪出元凶,把這幫真正的罪魁禍首杜絕掉。我期待士檢能有所作為。
(作者擔任過國內航空公司機師,經作者授權刊登)
延伸閱讀:不該發生的空難 – 機師憶空難調查報告、復興航空空難 機師現身說法
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三位資深機師同時關錯的機率有多小? 被”已知的”突發狀況嚇? 他們可都是飛行數千小時的老鳥,不是菜鳥。無人反對四秒關機,是早有原因?
二號機故障時高度是否已經很低? 一號機是否完全正常如”飛航專家”說返回機場? (只有一條跑道不是嗎?)根本就”飛回要檢修”了! 一直重開車是因為? 一架飛機的事故,絕對不會只有一兩個人的問題,是一整個機隊,甚至一整個公司的錯失。
在空中要是系統不可靠,身負重任的機師不會把乘客的命拿來賭啊! 降速找地方安全迫降是不是三位機師最確定,傷害最小的選擇?
往者英靈不遠,檢討時說話可否尊敬一點?
這篇文章我不覺得有貶低他們的意思
而對他們最尊敬的做法
就是確確實實、老老實實的把每一項細節錯誤通通檢討出來
而不是只會把尊重掛在嘴邊
否則他們不是白死了?
如果不肯真實的面對承認錯誤
類似的事件永遠還是會發生
另外我也可以告訴你…
古往今來所有的災難事件…
扣掉天然災害
人為因素都遠大於機械因素!!!
告訴我告訴我,你拿什麼告訴我?連個名字都不放你空口白話要說什麼?
你哪來的信心人為因素都遠大於機械因素!!!???更何況你怎麼分人為和機械?
下雨了害你摔車是人為還是機械?當然是人為,誰叫你下雨還不小心騎。
修車師傅沒把你的輪子鎖緊害你龍頭抖動摔車是人為還是機械?
當然是人為,因為師傅沒作好呀。
原廠叫你用一瓶500元的機油你偏偏用480的而且還不回原廠保養是人為還是機械?
當然是人為,誰叫你不回原廠。
你車子買回家半天前懸吊就斷了是人為還是機械?
當然是人為,要嘛就品管不嚴要嘛就設計不良。
哪一個機械不是人為的?除了天災都是人禍,哪有什麼機械、人為。
這篇是之前偶然間逛到的, 某位機長的blog….
http://cougarhsiung.pixnet.net/blog/post/367525235?fb_action_ids=1084273044932393&fb_action_types=og.likes