Methodology for Analyzing Organizational Accidents and Methods for Preventing Human Errors

本研究项目介绍了一种组织方法，以防止人为错误的方法，并提出了一种分析事故的方法。研究结果分为以下五类.日本的组织事故分析和方法论：我们从组织事故的角度分析了日本发生的三起事故。特别是，我们的研究关注的沟通过程，并指出，广为人知的结果是错误的。在此基础上，尝试建立事故分析方法.分析组织事故的基本通用模型：分析了地铁脱轨事故、东海村危急事故、牛奶食物中毒等更多的组织事故，提出了解释多领域组织事故机理的基本通用模型.当前的调查报告和利用报告的新的社会制度：我们抽象了一些问题，在日本的正式调查方法和调查机构的组织事故。在此基础上，我们提出了一个新的社会系统或组织，以利用所有的事故报告，并显示了该组织的具体作用.事故与人为因素的预防：研究了医院和航空公司的事故报告系统的使用情况，并指出了阻碍其有效使用的一些原因.信任与风险沟通：我们的实验研究追求的是一种过度自信和不信任的机制，这种机制经常导致人为错误，并与安全文化有关。

This research project introduced an organizational approach to methods of preventing human errors and to propose a methodology for analyzing of accidents. The results are classified into five categories as below.1. Analysis of organizational accidents in Japan and a methodology : We analyzed three accidents that occurred in Japan, from the point of organizational accident view. Especially, our research paid attention to communication process and indicated that widely known results were mistaken. On the basis of the results, we tried to build a methodology for analyzing of accidents.2. Basic common model for analyzing organizational accidents : We analyzed more organizational accidents such as subway derailment accident, criticality accident at Tokai-mura, food poisoning by milk, and proposed a basic common model for explaining mechanism of organizational accidents in many fields.3. Current investigation reports and a new social system for utilizing the reports : We abstracted some problems about the formal way to investigate organizational accidents and organizations for investigating in Japan. On the basis of the results, we proposed a new social system or organization for utilizing all reports of accidents and showed a concrete role of the organization.4. Prevention of accidents and human factors : We researched how incident reporting systems were utilized in some hospitals and airplane companies, and indicated some reasons of impeding the effective utilization.5. Trust and risk communications : Our experimental research pursued a mechanism of overconfidence and distrust that often caused to human errors and were related with safety culture.