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1 2009 1 1977 3 27 KLM 583 KLM (1)

2 1998 2006 *1 1 *1 International Civil Aviation Organization ICAO 234 2009 2 1 1998 1999 2000 2001 2002 2003 2004 2005 2006 856 300 757 579 667 466 207 712 751 9,211 9,006 9,066 8,747 8,326 7,702 7,358 6,871 6,352 ICAO International Air Transport Association IATA I 1 1 *2 *2 1997 41,967 1959 1996 21,728 (2)

3 1903 1980 2 1998 1999 2000 2001 2002 2003 2004 2005 2006 19 20 18 13 11 7 9 17 12 856 300 757 579 667 466 207 712 751 10 10 ICAO Annual Report of the Council 2001 1 31 10 CRM TEM (1)

4 ICAO 1970 1980 National Aeronautics and Space Administration NASA 2009 3 60% 3 3 % 56 21 13 4 Boeing 2004 statistical summary (2) CRM Crew Resource Management 1976 NASA 36 1 NASA 1979 Cockpit Resource Management CRM 1981 SMI Success Motivation Institute CRM 1995 Federal Aviation Administrations FAA 1998 10 CRM

5 CRM CRM 1 1980 6 Cockpit Crew Crew Error Management Threat TEM Threat and Error Management CRM CRM CRM CRM BRM 75 90%* 2009 4 BRM Bridge Resource Management BTM Bridge Team Management CRM BRM * Washington State Department of Ecology CRM CRM 65 70%* Stanford University CRM ACRM Anesthesia Crisis Resource Management ACRM

6 CRM * Department of Health & Human Services (3) TEM Threat and Error Management 1980 CRM 1994 Line Operation Safety Audit LOSA 6 CRM TEM TEM 2006 ICAO ICAO Undesired Aircraft State UAS Threat 4

7 The University of Texas Human Factors Research Project TRC 2009 5 Error 5 The University of Texas Human Factors Research Project TRC UAS 6 The University of Texas Human Factors Research Project TRC TEM TEM 7 TEM 2009 6 TEM TEM

8 3 TEM Anticipation Recognition Recovery TEM CRM CRM TEM CRM TEM 1980 CRM TEM 234 2009 2 2008 3 2005 2005 2007 DC10 2005 1 20 The University of Texas Human Factors Research Project Defensive flying for pilots An introduction to Threat and Error Management US Department of Transportation & Federal Aviation Administration.

9 Advisory Circular CRM Crew Resource Management Boeing Statistical Summary of Commercial Jet Airplane Accidents 2007 American Psychological Association 2008 Making Air Travel Safer Through CRM Professor of Psychology University of Texas On error management :lessons from aviation Washington State Department of Ecology Focus on Bridge Resource Management Department of Health & Human Services CRM and its Application in Medicine