ABSTRACT
In the present, owing to extensive activities in ergonomics/human factors over a half century, and at the sacrifice of many tragic accidents, the general idea of “to err is human” seems widely recognized in our society. Facing our reality, however, it seems inappropriate to say that incident/accident analysis and corrective actions are well-performed based on this knowledge. Despite improper circumstances that are not compatible with human characteristics, or even exceed human capability, blame for the accident, in many cases, is finally put on the persons concerned. Under the legal notion of “professional negligence” in Japan, the persons concerned are often arrested and prosecuted. Examples of this attribution include a fatal medical
The TEPCO Notion of Human Factors Engineering ............................................. 113 Outline of the Incident/Accident Analysis Method — SAFER ............................. 116
Background and Features of SAFER ................................................................ 116 Three Stages in the Framework of SAFER ....................................................... 117
Improvement of SAFER Based on Experiences On-Site ....................................... 119 Description and Usage of SAFER ......................................................................... 123
Step 1: Understand Human Factors Engineering .............................................. 123 Step 2: Make Event Flow Chart ........................................................................ 123 Step 3: Pick Up Problematic Points .................................................................. 125 Step 4: Make a Background Factors Causality Diagram .................................. 125 Step.5: Think out Preventive Measures ............................................................. 126 Step 6: Prioritize the Countermeasures ............................................................. 127 Step 7: Implement Preventive Measures ........................................................... 129 Step 8: Evaluate the Effects............................................................................... 129
Practical Experiences and Activities for Personnel Training ................................. 129 Concluding Remark: Beyond Procedures .............................................................. 130 Acknowledgments .................................................................................................. 131 References .............................................................................................................. 131
accident in Kyoto in which ethanol was mistakenly injected into a respirator (The Japan Times, 2000). In another incident, a slip of the tongue by flight control resulted in a severe near-miss accident in the skies over Shizuoka in 2001 (Aviation Safety Network, n.d.). And, additionally, a fatal railroad crossing accident where the toll bars were manually opened happened in Tokyo in 2005 (Cabinet Office, 2005). Such views of accidents that attribute causes to individuals tends to lead to countermeasures, depending on one’s mental prowess or courage, falling into a vicious circle of higher demands on individuals and a higher probability of erroneous action.
