(1.Ohara Memorial Institute for Science of Labour,Tokyo,Japan; 2.College of Interhuman Symbiotic Studies,Kanto Gakuin University,Kanagawa,Japan)
The way to investigate the cause of an industrial accident is considered.It's important for the staff who investigate an accident to be the person who became independent from a production site.Moreover a special right has to be granted to the staff in the organization.The reason is because it's necessary that they have a different viewpoint from field overseer.The staff's viewpoint is a one related to the importance of the site preservation,necessity of an information feedback and the way to fill out an accident report.It was modeled in the last chapter about a relation of the various factors which have an influence on accident investigation.
According to a famous specialist of accident analysis in Japan,what we learned from an accident today tells “Nothing was learned from an accident in the past”.
It's a difficult problem to analyze the accident which has happened by a real industrial situation because various social factors involve there.It'll be also difficult to learn the result and a lesson from an accident.Therefore if the true cause doesn't become clear,a considered measure is not useful,it's natural not to have that.A specialist's above-mentioned impressions in other words,It's said that the lesson by which I thought it was learned wasn't useful to prevent of accident.And then we have to investigate the true cause to draw a useful moral.
1 How to advance an investigation1.1 An investigation system
The staff that does accident investigation should consist of the person who became independent from the production site.Its reason is that people in the production site are working by the logic over which they give priority to the productivity of the work.Therefore they close for the purpose of hurrying resumption of production more than an investigation of a cause of the accident.
Next it becomes a lot recently,but fortunately the investigation staff who became independent will also think about the case which exists.There are a lot of cases as which the activity isn't functioning sufficiently.One of its causes is in the point that the right of staff in the company is weak more than the administrative of the production site.Therefore it'll be difficult to grasp the inconvenient reality for a production procedures.We'll take up one example.The situation of the accident scene is put out by the logic over which they give priority to production.By an extreme example,an aim on the management side afraid that the true cause is known to society is given priority to,and an investigation is ended on the way.
The second is an upbringing problem of an accident investigation staff.When influence after an accident(the cost and the social value,etc.)is considered specialized staff's education is considered as personnel policy,it won't be loss.But,actually,there are a lot of examples which are placed as the rotation post of the person who shipped a field experience for some years for an investigation staff.It isn't personnel arrangement based on the following idea.Managements think that the staffs don't need an extend special authority and they probably have conversant sense with a production systems.The result,when they become enthusiastic to a safety issue,we see,they're kept away from a production site.If managements have a slogan as safety first,it's necessary to arrange the specialized staff who gave a right.1.2 The importance of the early stage investigation
An initial motion investigation is also important in case of accident investigation like a criminal investigation.Depending on experience,the two or three site photographs which aren't clear were just left,and when the staff went to an investigation,there was also an example which resumed operation in a site already.At this rate,the most important physical environment situation that a truth is told is only a way as a hearing from the person concerned.The contents caught in this case will be something ambiguous,and there is little volume of information as data of fact relevance.Circumstances in the site where we'd like to hurry resumption of production can be understood.Therefore it's important always to prepare the system that you can work on a quick investigation.Giving an example,those are substantiality of means of-communications,more than various staff system and organization of allotment of roles.1.3 Utilization of a scientific method
Equipment related to an accident,an environmental condition,the day's process of operation,a system of duties,staff arrangement etc.and several data should be collected over everything.There is also existence the information which seems unrelated seemingly as data as of the investigation.But at the early stage of the investigation,we'd like to collect data without predictions.Even if the staffs think want data,at the second half of data analysis,there are a lot more cases which aren't obtainable already.It's considered to make a manual for investigation staff and a checklist beforehand as a concrete plan to avoid such failure.
Preservation utilization of the data they were gathered is also the matter which is a linchpin.To stop the following accident,the followings are important.There are the prediction of a relation between a production system and an accident,a relation between a new technology and an accident,a relation between an employment pattern and an accident and a completely new accident.
One of the points to do scientific accident analysis is a simulation of a phenomenon.When it's an accident to happen outside the assumption,a scientific analytical method of an accident exists only to follow up the accident which occurred and acquire much information from there.When not clearing the reproduction cost,an investigation system,internal consensus,circumstances etc.in a site and many obstacles,a difficult thing can understand realization.But when it's a big accident relatively easily when it's a small accident,it doesn't always seem an impossible thing from the angle of the consequence.1.4 The angle of the data analysis
A point of view and the concept how to see collected data are the problem into which the root of accident analysis is formed.It can be said that there was a main angle of the accident analysis in the past in the cause and responsibility pursuit in Japanese society.But the fact by which this way of thinking brought many evils to recurrence prevention of an accident,historic,it's clear.Many accidents generated by the environment(equipment,process and system)and a point of tact with a worker(interface)at a part.Therefore the idea that they ask about accident responsibility only in a human concerned is a partial way of thinking.It's important to think “An accident occurred by the incompatible result with the environment and human”,not to think “An accident occurred by human improper behavior”.Because you can get a cue of measure drafting to nothing from the former way of thinking.On the other hand,when standing as the other way of thinking,the reason that a mismatch with the environment has happened with a person can be grasped.It's possible to find making of the manual I tend to use and the key idea makes do development of educational program.When supporting such point of view,a recent behavioral science and knowledge of cognitive science offer much information.1.5 A feedback of result
It is the important not to forget the feeding survey result back to a department related to an accident.Every individual is estimating that with various speculations about the cause of the accident for saying the person concerned of an accident concerned(they made a mistake or,for a section chief who protected them).It's important to feed the truth of an objective accident based on a scientific method back and unify evaluation related to an accident.Even if such action is done from the angle as the safety training to a site,the great effect is shown.Because the analysis example which occurred at its workplace,it is useful as a realistic lesson more than information on textbook.
2 Consideration about an accident report
A report to supervisory office and the company highest level is asked one just after the accident-generation for,and there is a case with which a report is made without the cause's being elucidated sufficiently.And then we suggest the followings.Since doing use another making on an accident report(summary plate and in-depth plate),how is it? It can be understood that the accident report written with the format has the fixed significant aspects.But it's difficult to think that it's also significant from the angle as the case that is the significant taste in the external(for example,anti-supervisory office)meaning,the cause investigation of an accident and the recurrence prevention.But the person in charge of an accident report often tends to fall into this misunderstanding.There is no how to do for governing legal authority's and in the company processing's being given priority to from the temporal restrictions of report submission.It'll take time of several months for this correspondence processing by a big accident.Therefore it can be understood that those correspondence becomes the feeling that this accident processing has already ended as the psychological situation of the person in charge in the time settled for the time being.The point of view to which I say “why now” also exists from the in the company atmosphere.
Therefore,we think an accident report according to its use for a solution of this problem.Namely those are a report of the in depth edition and the newsletter edition for outside the company.Below is the way in detail to achieve such report style.First,for,we'd like to recommend to add the part an investigation staff mentions free-lance.The second plan is the case that a taboo isn't set up to the matter which should be indicated on an accident report.For example we often hear an opinion of the staff who said “I'd like to hear an opinion of an accident person concerned”,but there are a lot of examples which end by the excuse to which I say “There is quite difficult problem,and(human rights questions)”.This is impossible by the system that a solution is entrusted to only an investigation staff.It's important for enough consensus making about the importance of the company-wide accident investigation from usual to be formed.
3The model of the factors that obstructs accident analysis
The Fig.1 is the model which we got a hint from Swiss Cheese Model by Reason(1997) famous for advocating modeled after the process an accident generates.When making the accident analysis,the disincentive which lies ahead and a process of cause investigation work were modeled.We assume that an accident occurs when a hole in each protection bed(defect part)pierced by the model of Reason.Now that an accident occurred certainly,it's fact that there were some defects in a protection wall.But it's difficult work to make it clear where the cause was and what that was from the angle of the investigation into the cause.
1)in the figure is a wall as the accident person concerned an investigation staff faces first.It's usual that various factors involve a background of person concerned's statement.We have to grasp the main factor which led to an accident,putting those in order.A point important to that time is the past example in which that a cause of the accident is limited to only person concerned' s mistake in a site doesn't exist first(way of thinking as an organization accident).If this wall doesn't rip,so an investigation is ended and a cause of the accident will end by a conclusion that it just depended on human error of a site person concerned.
2)in the figure indicates the case when an investigation developed to a field overseer.This is also the important stage at the inside of an investigation.This viewpoint is the very subtle leaving location caught between walls on both sides so that it may be also understood from a figure.For example “Person concerned's say is also understood.” but the viewpoint as one “A request from a boss can't help be also accepted.” A good case is the attitude which tries to think one will be a wall,and an administrator will stop influence to the highest level and attribute a cause of the accident to human error of a site worker one-sidedly.Accident investigation is obstructed on this wall,and there are most settled examples.When getting some clues to get in touch with the highest level from the inside on this wall and advancing it to the next stage,you may say that you could get a fixed outcome as accident investigation in the organization.
When an investigation develops to the highest level of the business establishment indicated in
3)in the figure,they become able to approach the root-like factor of an accident.When it's possible to find a lurk factor of an accident concerned during a safety control guideline,the distribution degree of resources and personnel policy etc.,an outcome of accident investigation becomes big.When the drafting process of the back recurrence preventive measure is considered,an attention point at this stage is a case that survey result here will make the big sense for the future(investment of resources,personnel arrangement and safety ensuring plan etc.).
4)in the figure is the last wall where it lie ahead in an investigation.This stage is the ideal chance to check an overall factor.The angle of the analysis is turned to a safety ensuring system of organization and safe culture.When this problem could be settled,accident investigation achieved the purpose perfectly.
Now finally,even if an investigation ends perfectly,a problem how to utilize the result in the future is left.There are few examples which passed through the perfect route as shown in 5)on the figure.An investigation is blocked on some walls of the way in many cases,and is brought to an end.
When we think back,“social sense of values about safety” has caused remarkable reformation via a nuclear accident in Chernobyl and Fukushima.Such social trend is a so-called fair wind from the angle as easiness of advancing accident investigation.This wind is seized well,and “It's learned in the past” and would like to make the accident investigation to which I say “We draw a useful moral” develop more.
-  Reason J.Managing the risks of organizational accident[M].ASHGATE Publishing Limited,1997.