Based on a true example of an accident caused by engineer errors, the paper discusses the reason, points out the importance and measures of improving S/A of crews in Engineer Resource Management.

• 通过实例介绍，分析了该例事故中轮机员在情景意识方面的失误，剖析了情景意识薄弱的深层次原因，指出提高情景意识的途径。