A DEMATEL-ISM-BN Model for Causation Analysis of Safety Incidents in Civil Aviation Airport Flight Area
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摘要: 针对机场飞行区安全风险演化路径不清、难以动态预测的问题，研究了集成决策实验室分析、解释结构模型与贝叶斯网络的耦合致因分析模型。基于航空器事件调查报告、文献与专家知识等，构建包含人、机、环、管4个维度的飞行区安全事件致因因素体系。采用改进的决策实验室分析/解释结构模型方法解析致因因素因果关系并构建多级递阶结构：在决策实验室分析阶段融合客观事故致因链与专家判断以提升关系判定的准确性；在解释结构模型层级划分后保留关键跨层级关系，增强网络结构对系统复杂性的刻画能力。将优化后的拓扑映射为贝叶斯网络，通过优化先验概率与条件概率的确定方法，贝叶斯参数估计实现飞行区安全事件概率的正向预测与致因链的逆向诊断。华北地区某机场的实证结果表明：飞行区安全事件先验发生概率为4.26%，证据输入下概率区间为4.38%~14.00%；逆向诊断识别出关键致因链为：部门协调沟通机制不完善→沟通协调配合失误→应急处置失当→飞行区安全事件。与现有研究对比显示，本模型在因素关系识别方面优于依赖问卷的结构方程模型方法，路径逻辑更清晰；在风险推演能力上实现从静态相关分析到动态概率推断的跨越，支持实时预警与根因追溯。案例分析结果与真实事故调查高度吻合，验证模型在飞行区安全管理中具有较高实用价值与可靠性。Abstract: This study proposes a coupled causal analysis model integrating decision making trial and evaluation laboratory, interpretative structural modeling, and Bayesian network to address challenges in clarifying risk evolution paths and enabling dynamic prediction for airport flight area safety. A causal factor system for safety incidents is first constructed, covering human, equipment, environment, and management dimensions, based on aircraft incident reports, literature, and expert knowledge. The improved decision-making trial and evaluation laboratory method integrates objective accident causation chains with expert judgments to enhance relationship identification accuracy. The interpretative structural modeling then establishes a multi-level hierarchical structure, explicitly preserving critical cross-level relationships to better characterize system complexity. This optimized topology is mapped into a Bayesian network. Through improved methods for determining prior and conditional probabilities, the Bayesian parameter estimation enables the forward prediction of incident probabilities and the backward diagnosis of critical causation chains. A case study of an airport in North China demonstrates the model's effectiveness. The prior probability of a flight area safety incident is 4.26%. Under different evidence inputs, the probability dynamically ranges between 4.38% and 14.00%. Backward diagnosis identifies the key causation chain as: "imperfect departmental coordination mechanism → communication and coordination failure → inadequate emergency response → flight area safety incident". Comparisons with existing studies, such as questionnaire-based structural equation modeling, show the proposed model provides clearer path logic and advances from static correlation analysis to dynamic probabilistic inference. The case analysis results align closely with actual accident findings, validating the model's practical utility and reliability in proactive safety management for airport flight areas.
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图 1 飞行区安全事件致因分析框架
Figure 1. Analytical framework for the causation of safety events in the flight area
图 3 机场飞行区安全事件类型频次分布情况
Figure 3. Frequency distribution of airport flight area safety event types
图 4 飞行区安全事件致因因素指标体系
Figure 4. Index system of cause factors of safety incidents in flight area
图 5 致因因素解释结构模型图
Figure 5. Interpretative structural modeling diagram of causative factors
表 1 机场飞行区安全事件致因链（部分）
Table 1. Causal chain of safety events in airport flight area (partial)
事发时间 事发地点 航空器型号 事件类型 事件致因链 2005年2月2日 泰特伯勒机场 CL-600-1A11 起飞时冲出跑道 未取得FAA认证开展包机飞行→航司缺乏运行管控→飞行机组系统性履职缺陷→监管机构未充分监管→飞行员未能确保飞机载重及平衡处于限制范围内→试图在飞机重心远超过前起飞极限的情况下起飞→飞机无法达到预定的起飞速度 2006年8月27日 列克星敦机场 CL-600-2B19 试图从错误跑道起飞 FAA未能要求所有跑道穿越行为都必须获得管制许可→飞行机组在滑行时进行无关话题的交谈→机组滑行时未确定飞机在机场地面的位置→机组起飞前未能交叉检查并核实飞机是否位于正确的跑道上 2013年1月7日 爱德华·劳伦斯·洛根将军国际机场 B787-800 APU电池起火 辅助动力装置（APU）锂离子电池的电池单元内部短路→热失控→串联到相邻的电池单元→冒烟和起火 2017年3月8日 伊普西兰蒂机场 MD-83 中断起飞时冲出跑道 飞机停放位置附近的大型建筑物对地面阵风的影响→产生湍流阵风载荷→MD - 83飞机缺乏能让飞行机组在起飞前检查中发现升降舵卡滞问题的手段→飞机右升降舵出现卡滞状况→起飞时飞机无法拉起→机长及时且恰当地中断起飞→检查员严格遵循标准操作程序→飞机冲出跑道 2019年10月17日 尤纳拉克利特机场 Saab 2000 着陆时冲出跑道 轮速传感器线束的设计存在缺陷→未考虑维护中可能出现的人为失误且未采取防护措施→左主起落架大修时轮速传感器线束布设错误→防滑系统无法正常工作→左外侧轮胎发生故障→飞行机组不恰当决策→飞机制动能力大幅下降→FAA未考量机场跑道安全区的尺寸→飞机冲出跑道 2021年7月5日 延安南泥湾机场 CRJ-900 冲/偏出跑道 机长未按管制指挥沿线掉头滑行→提前掉头转弯→误将跑道边灯当作中线灯起飞→其他机组成员未及时发现偏差→飞机起飞滑跑时刮碰跑道边灯 2022年1月8日 杭州萧山国际机场 TU204C 航空器地面起火 右侧操纵台氧气系统部件氧气泄漏→形成富氧环境→机载设备及系统产生或逸出热量→可燃材料燃烧→火势发展、蔓延→航空器烧毁 2022年1月24日 青岛胶东国际机场 A320-271N 航空器地面拖行中碾轧机务人员 航空公司隐患排查治理不充分→对外委单位和人员培训管理存在缺失→拖机指挥员未按规定携带对讲机→耳机线被轧断未及时指挥停止拖行→背对主轮蹲下拾取检查单→风险情景意识不足→被飞机右内侧主轮碾压 2022年5月12日 重庆江北国际机场 A319-115 偏出跑道 飞机高速滑跑至速度接近V1→责任机长受干扰失去对飞机状态监控→无意识抵动左舵导致飞机非预期左偏→机组未执行标准喊话→机组未能进行有效修正→飞机左偏出跑道 2023年1月13日 约翰·菲茨杰拉德·肯尼迪国际机场 B777-200和B737-900 跑道侵入与中断起飞 航司缺乏足够的风险管控措施→飞行机组滑行时执行多项并行操作任务→受到干扰偏离滑行指令→塔台未察觉到机组滑行偏离→跑道状态灯光系统启动过晚→机组越过跑道等待线→机场场面探测设备-X型（ASDE-X）预警系统启动→塔台管制员迅速取消另一航班的起飞许可 
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表 2 DEMATEL分析结果
Table 2. Analysis results of DEMATEL
因素 fi ei mi ni 因素 fi ei mi ni x1 0.338 0.502 0.841 -0.164 x11 0.651 0 0.651 0.651 x2 0 0.65 0.65 -0.65 x12 0.282 0.432 0.714 -0.151 x3 0.111 0.683 0.795 -0.572 x13 0.407 0.432 0.839 -0.025 x4 0.681 0.111 0.792 0.57 x14 0.232 0.632 0.864 -0.400 x5 0.447 0.111 0.559 0.336 x15 0.123 0.32 0.444 -0.197 x6 0.123 0.037 0.16 0.086 x16 0.747 0 0.747 0.747 x7 0.046 0.901 0.946 -0.855 x17 0.235 0 0.235 0.235 x8 0.165 0.386 0.551 -0.221 x18 0.187 0 0.187 0.187 x9 0 0.665 0.665 -0.665 x19 0.202 0 0.202 0.202 x10 0 0.257 0.257 -0.257 x20 1.143 0 1.143 1.143
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表 3 不同状况下飞行区安全事件发生概率
Table 3. Occurrence probability of safety incidents in flight areas under different conditions
概率类型 证据输入 节点S发生概率/% 先验概率 无 4.26 后验概率 P（x2 = Yes）= 100% 7.28 P（x3 = Yes）= 100% 4.38 P（x9 = Yes）= 100% 6.32 P（x10 = Yes）= 100% 5.34 P（x2 = Yes）= 100% 14.00 P（x3 = Yes）= 100% P（x9 = Yes）= 100% P（x10 = Yes）= 100%
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