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国际民航组织安全管理国际民航组织安全管理
系统（系统（SMSSMS）课程）课程
讲义讲义Nº2 – Nº2 –
AnyfieldAnyfield机场事故机场事故
Contents
一、事件经过
二、原因分析
调查结果
小组讨论
建议
逻辑
结构
三 、 表格填写
前言
阅读事故
有关文本
小组讨论 文字编辑 PPT制作
工作流程
调查分析+合理建议+整改=安全
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Anyfield机场1一架双引擎喷
气运输机5名机组成员和63名乘客，在其起飞运行时与
一个侵入离场跑道的只有一个机组成员的双引擎螺旋桨
小飞机相撞。这两架飞机由于碰撞遭到严重破坏。随后
的大火烧毁了飞机，同时造成大部分乘客死亡。
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机场是一个中型机场，一条跑道连接着一些十字路口（或
腾空）。这是一个管制机场，控制塔位于距北跑道中间400米的位
置。由于不少通勤型航空公司已开始来往于Anyfield，Anyfield交
通流量逐渐上升。
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.
虽然机场处于一年中雾天很常见的一个地区，但是它并没有配备地
面活动雷达（SMR），也没有特殊的滑行道照明设施供低能见度条
件下使用。
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Anyfield是略有不足，但到目前为止，并不认为需
要加强对于在Anyfield运行的限制。有一个离散的频率（地面管制）
处理滑行的航空器。
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.
在碰撞时，伴随雾的坡度，平均能见度约700米，这是恰好足以让
塔控制员看到跑道的中间部分。新建成的Anyfield机场候机楼扩展
出来的部分在阻挡了控制员的视野，正好是侵入跑道的飞机进入跑
道的位置。
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（管制员）是一个非常有经验的控制员。他曾在ATC
工作多年，在几个主要管制中心，在意外发生日期仅8个月前被转
移到Anyfield作为OJT-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 experience–had 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.
碰撞时，ATCO1独自一人在塔台，作为他的助理/地面管制员
ATCO2 - 远不如ATCO1经验丰富- 曾短暂离开塔台上厕所。他们都
完成他们的第三个连续夜班，由于已经从前一天晚上22:00值班到
现在，在事故发生时30分钟内就可以换班。
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.
喷气飞机的机组来往于Anyfield的经验丰富。从他们的角度来看，
事故发生在早晨，在ATC航路上没有不什么正常。他们在的雾条件
下格外小心地滑行到跑道，获得起飞许可后，在提出申请前起飞推
力之前，确认他们在跑道中心线列队正确。
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.
双引擎活塞式飞机的飞行员不熟悉Anyfield机场，被送到那里去短
时间内接收两天前由于天气原因不得不转飞到Anyfield的一架飞机。
上厕所回来发
现联系不上小
飞机
双引擎螺旋桨
小飞机
（误入跑到）
一架双引擎喷
气运输机
（正起飞）
管制
员1
管制
员2
同时进行管
制和地面两
席位的工作
在预计移交时
间发现运输机
一直无应答。
上厕所前给小
飞机发布滑行
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
现场时面对的是几乎烧毁完全的飞机残骸 。
一、事件经过
跑道相撞
他没有从他能
看到的那部分
跑道观察到离
场的喷气飞机
二、原因分析
调查结果
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ATCO1是非常有经验的，但是他在Anyfield 塔台独自工作的
次数很有限。在初夏他才验证的塔台管制评级，在那之后，他在大
部分的换班后参与到在职培训（OJT）指导工作由于人员短缺，他
被要求必须像所有其他管制员一样值参与夜班工作。在该事故发生
时仅仅是他在Anyfield-TWR的班次中，第二次遇到雾/低能见度条
件。第一次是在前一天晚上，当时几乎没有任何交通，因为那是在
周六到周日的晚上。
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 didn't 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在许多年前曾出现过车辆入侵跑道的情况，也是在这种类
似该事件的气象条件情况下。当时的建议之一是安装一个SMR，同
时在所有跑道交叉口设置停止阻挡。当局决定，鉴于需要使用SMR
有限的天数（雾天），安装SMR的收益和支出并不匹配。安装停止
阻挡也是如此。但是我们可以用画在跑道十字路口旁边的草地上的
图标代替SMR和停止阻挡，提示看到图标的人，他们前面有“跑道”。
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 men's 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 isn't
equipped with a frequency-coupling installation.
Transmissions on one frequency can't be heard by stations
on the other frequency.
当清晨交通开始繁忙起来时，ATCO1 ATCO2分别在独立的R / T频
率上工作。ATCO2说他不得不再次去洗手间，ATCO1同意，打算
自己在两个工作频率上工作。为了做到这一点，因为Anyfield塔台
没有配备频率耦合装置，声音在一个频率上的传输不能被其他频率
听到，ATCO1不得不在在两个相距约三米的管制席位间来回走动。
调查结果
The piston-engined aircraft's 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 .
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 didn't help much either.
活塞式引擎飞机的飞行员在前一天晚的深夜才到达Anyfield。经过
短暂的睡眠，他以尽可能少的时间赶到机场，他的公司希望飞机尽
可能迅速地回到其大本营。在最快地完成所需的准备后，他去到他
的飞机，并向管制员申请滑行到跑道的滑行许可。他获得许可，开
始在跑道上滑行，但很快就发现自己迷失在笼罩在云里雾里的不熟
悉的机场。事实上，没有任何标志命名各种滑行道交叉，这也并没
有多大帮助。
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 I'm 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磁带表明，活塞飞机的飞行员呼叫叫地面管制员（通过R /
T）并提出“渐进式滑行指令”要求。 ATCO2回答，询问他的位置。
飞行员说：“我相信我接近F交叉口”，ATCO2回答：“在F交叉口向
前滑行”。事实上，飞行员已经通F交叉口，应该滑行到平行滑行道。
ATCO2发出指令，虽然在技术上是正确的，但是造成活塞飞机飞
行员滑行进入了喷气机正在进行起飞滑跑的跑道。由于两飞机的通
信发生在不同的频率上，两飞行员都不知道发生了什么事。
After the collision, it took ATCO1 several minutes to realize
something was wrong. Of course he hadn't 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.
撞机事件发生后， ATCO1花了好几分钟才明白出现了情况。当然，
他没有从他能看到的那部分跑道观察到离场的喷气飞机，但是他最
初将其（没观察到喷气飞机起飞）归因于雾和/或地面管制频率的交
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 weren't as they should be, when his
transmissions to the jet remained unanswered.
因为除了雾，新建成的航站楼的延伸部分，挡住了他的视线，
ATCO1无法看到跑道发生了碰撞。因此，直到他想起将飞喷气转
移到下一个管制员（离场管制员）时一直没有得到喷气飞机的答复，
他才意识到事情发展偏离了预定的情况。
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在事故发生后不久返回，在同一时间报告没有同
在滑行的双螺旋桨取得任何联系。 ATCO1然后决定提
醒消防队，但因为他不知道指派消防队去哪儿，同时救
援车辆艰难地通过被雾笼罩的机场，更是使得宝贵的救
援时间损失掉了。当他们终于赶到事故现场时，面对几
乎烧毁完全的飞机残骸，他们发现他们能做的不多了。
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):
如果遵循其他事件发生后的建议安装一个SMR，这将提供以下线的防御
（降序）：
Proper taxi-instructions could have been given to the "lost" aircraft.
•正确的滑行指令可能已经发给了“迷路”的飞机。
The ATCOs would have observed the runway-intrusion.
空管人员将已经观察到跑道入侵。
The collision-site would have been easily identified.
•碰撞现场将被容易识别。
Adequate instructions could have been given to the rescue-vehicles.
•合适的指令，可能已经发给了救援车辆。
This goes for the stop-bars as well. Had they been installed, the twin
-prop more likely than not wouldn't have entered the runway.
这同样适用于停止阻挡装置。如果他们已经被安装，双螺旋桨较可能不会
已经进入跑道。
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.
最起码，在Anyfield，通过限制在机场活动区运行的航空器的数量
的特殊低能见度运行程序（LVO）应该已经被开发并投入使用。管
制员应该已经完成这些特别的程序的工作训练。最好通过模拟器训
练，以帮助他们应付可能发生的异常情况。
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
wasn't even aware it would constitute a line-of-vision
problem from the TWR.
在与机场当局的谈话中，空管管理层应坚决反对候机楼扩建的计划。
但是，由于没有任何业务管制员（没有出席会议由于人员短缺）反
映，空管管理层甚至不知道它会构成对塔台视线的影响。
调查结果
ATCO1 shouldn't 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不应该找不到自己的位置，他不应该迫使自己在
两个工作位置工作。 管制席位应该在任何时候都有足够
的工作人员，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发生。因为它
是，这些系统被航空当局认为是“可选”的，所以只有少
数管制单位安装了它。
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)
管理层应确保，OJT-指导员有机会保持在教学岗位上，安排没有不用指导
学员的定期值班。这些班次应具有足够的挑战性，让教练来实践他的技能
（换句话说：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
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, hadn't been able to acquaint himself
with working at Anyfield TWR under low visibility-conditions.
Ideally, they wouldn't have scheduled him for unsupervised duty
when low visibility was forecast.
如果当时有一个精心设计的与责任名册相关的培训课程，管理层将意识到，
ATCO1虽然合格，但是不能够单独在低能见度条件下在Anyfield塔台工作。
在理想的情况下，他们不会已经安排他在预测到的低能见度的那天在不受
监督的情况下值班。
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 wouldn't have given
the pilot irrelevant information.
专用LVO培训会将 使ATCO2意识到所涉及的危险，提醒他要更加积极的
去引导“迷路”的正在滑行的飞行员。最起码，他不会给飞行员无关的信息。
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 wouldn't 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.
连续夜班工作时，从事认知任务（如管制工作）的人，在第二次及以后的
夜晚，他的表现会急剧下降，尤其是凌晨03:00点至早07:00点之间，这是
一个科学事实。 ATCO1在进行他在Anyfield的第三个连续的夜班，这可
以解释为什么他没有认识到有潜在危险的情况，在其他情况下，他将不会
错过。当设计管制员排班名册时，最好能使连续夜班的数量保持在绝对最
低水平。
调查结果
Based on the meteorological forecast, and
taking into account the propeller-aircraft's
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.
根据气象预测，并考虑到螺旋桨飞机的飞行员
是不熟悉Anyfield，可能会认为航空运营商派
两名飞行员去接收飞机会更好些。即使CRM
（班组资源管理）的知识有限，安排第二个飞
行员也可以防止其他飞行员以同样的方式行事。
小组讨论
小组讨论
飞行员（此处针对小飞机）：
R / T磁带表明，活塞飞机的飞行员在发现自己迷失在
笼罩在云里雾里的不熟悉的机场后呼叫叫地面管制员
（通过R / T）并提出“渐进式滑行指令”要求。 ATCO2
回答，询问他的位置。飞行员说：“我相信我接近F交叉
口”，ATCO2回答：“在F交叉口向前滑行”。事实上，
飞行员已经通F交叉口，应该滑行到平行滑行道。
ATCO2发出指令，虽然在技术上是正确的，但是造成活
塞飞机飞行员滑行进入了喷气机正在进行起飞滑跑的跑
道。由于两飞机的通信发生在不同的频率上，两飞行员
都不知道发生了什么事。
对待不熟悉的机场，应该提前做好熟悉工作，同时在
滑行道上迷路时应该和管制员保持联络，加强联络，确
实弄明白现在所处环境再采取进一步行动。
小组讨论
小型飞机的航空器运营人：
不应该在可预见的低能见度天气下，安排
仅仅一个不熟悉机场的飞行员去接收飞机。
应该安排2飞行员会更好。
小组讨论
管制员：
对待航站延伸部分楼遮挡对跑道的视线的
情况没有及时反映。
管制员1：
对anyfield没有足够经验，就不要让自己
处于低能见度没人监管时同时监管塔台和
地面两个席位的不理处境。
管制员2：
对待迷路的航空器没有给予充分的关注与
指引。在上班的时候离岗是不对的。
小组讨论
管制管理层：
排班不合理。安排了连续的夜班。
沟通不合理，不了解实际情况，不知道航
站楼会遮挡一线管制员视线。没有及时提
出反对航站楼扩建的意见。
没有吸取上一次车辆误入跑道的经验，建
立完善低能见度运行规则，安排培训；或
安装SMR ；或安装停止阻挡装置。
没有认识到管制员1不具备在机场低能见
度时没有监管条件下工作的能力。
建议
建议
合理排班
完善低能见度运行标准
安装SMR 或停止阻挡装置
完善双岗制
解决人员短缺问题
三、表格填写
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