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大綱
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摘要
鐵道一直是陸上最穩定、最快速的移動手段，乘載著所有旅行者酸甜苦辣的回憶與離家遊子的思鄉哀愁。然而近幾年，國內外重大的鐵道事故頻傳，帶來的是一個叉一個家庭破碎的悲劇。其中最為人知的莫過於2018年10月21
日發生的6432次普悠瑪自強號出軌事故，該事故造成18
死215
傷，當時帶給台灣莫大的震撼。隨著事後調查的進行，發現了當初該班列車尚未發車前，在機務段就已有相同的故障發生，然而該編組列車卻還是被推上線運轉載客，進而造成後續的悲劇。台鐵出車的標準似乎是有很大的瑕疵，該如何科學化的、有系統的制訂一套出車的標準，並兼顧一
定程度的出車可靠度呢？
於是，本研究將目光轉到航空產業，發現文獻中提到最低設備清單(MEL)的想法與
前述想法有許多雷同處。因此，本研究針對 MEL
的起源、特性、建立方式、形式以及曾引起的相關問題進行討論與整理，並試著利用當中提到的故障樹分析(FTA)舆失效模式影響分析(FMEA )針對 6432次的事故進行分析。然而受限於資料本身的保存與紀錄方式，兩者皆未能達到理想的分析。於是本研究亦整理從 MEL
的形式上所歸納出的規律，針對普悠瑪號之系統提出一份簡易的版本，並且探討將事故經驗納入的方式。
關鍵宇：最低設備清單、故障樹分析、失效模式影響分析、鐵道事故
Abstract
Railway system is the most stable and
rapid way to take people from a place to another, carrying various
memories and feeling of nostalgia of all travelers. However, a great
amount of serious train accident occurred around the globe in the past
few years, bringing sorrow and tragedy to countless families. One of
the well-known accidents is No. 6432 Puyuma Express Train Accident,
occurring in 2018/10/21 with 18 deaths and 215 injuries, shocked
Taiwan society deeply.
with the progress of the post-accident investigation, the investigator
discovered that the same malfunction had been existing long before the
train left the depot, however the train still
went to service without changing trainset,
which resulted in the later accident. It seems that there is a huge
flaw in the standard of train dispatch of Taiwan Railway
Administration. (TRA)
Which leads
to a question, how to establish a scientific and systematic dispatch
standard with maintaining a certain degree of dispatch reliability.
Therefore, the
research turns to aviation industry for inspiration, and find out that
the concept of Minimum Equipment List (MEL) shares some similarities
with previous thoughts.
Hence,
the research makes some discussion focusing on many aspects of MEL,
including its origin, its properties, how it is established, its
format and problems it had been involved in, and tries to analyze the
No. 6432 Puyuma Express Train Accident with the method of MEL
mentioned in the literature, including Fault Tree Analysis (FTA) and
Failure Mode Effect Analysis. (FMEA)
However, with the
limitation of how the critical information is preserved and recorded,
both of the analysis do not lead to ideal results. Thus, the research
turns to find the pattern from the format of MEL, and create a
simplified version of MEL for the Puyuma train, and also discuss the
way to combine the advice from post-accident investigation reports.
Keywords: Minimum
Equipment List, Fault Tree Analysis, Failure Mode Effect Analysis,
Railway Accident
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