JPH11353301A - Method for evaluating human error analysis - Google Patents

Abstract

PROBLEM TO BE SOLVED: To systematically check the causes, analysis and recurrence preventing measures of human errors in various sections such as design and manufacture. SOLUTION: In a human error evaluation table, factors (B) causing errors are horizontally regulated on respective columns as subject (B-1), hardware (B-2), software (B-3), environments (B-4), person (B-5), and management (B-6) and preventing measures are vertically regulated on respective lines as six items consisting of removal (1), limitation (2), reduction of recognition load (3), reduction of physical load (4), detection (5), and ease of influence (6). When a human error occurs, the contents of the error are written in an error mode line, whether the error corresponds to each of the factors B-1 to B-6 or not is checked and a corresponding factor is extracted. Whether the extracted factor corresponds to each of items (1) to (6) in preventing measures or not is successively checked and a corresponding preventing measure is written.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a human error analysis and evaluation method, and systematically analyzes and evaluates human errors in all industrial fields such as design, manufacturing, etc., and drafts preventive measures without recurrence. It is something that can be done.

[0002]

2. Description of the Related Art In order to guarantee the quality at each stage in the stages of design, manufacture, operation, maintenance, etc. of various plants,
At present, the organization and responsibilities are clarified, manuals are being prepared and work is being standardized, and efforts are being made to improve product reliability. However, it is humans who operate these organizations and work according to manuals and standards.Human errors are a potential factor in human work, and the performance and reliability of plants and machines have been improved today. Also, human error accounts for a large part of the factors that affect the reliability of the entire plant or product.

[0003] Human error is caused by a difference between a function required by humans and a function actually performed by humans, and the result has some adverse effect on the reliability of a plant or a product. That could have an effect. For example, despite having defined standards and procedures, they cannot be followed. There is no defined standard or procedure, and no action should be taken. Deviates from common sense. For example, there is a gap between the functions required by humans and the functions actually performed.As a result, the plant shuts down, the product breaks down, or safety is impaired. It will have a bad influence, such as manufacturing. At present, when such a human error occurs, each stage and each department individually investigates the cause and examines measures to prevent recurrence.

[0004]

As described above, in the present situation, when a human error occurs, its analysis and evaluation are individually performed each time, and trial and error are repeated, and the analysis and evaluation are always performed. No method has been established, and no systematic analysis and evaluation has been conducted, and measures to prevent recurrence have not been thoroughly examined.

Therefore, in the present invention, when analyzing and evaluating a human error, investigation of the cause and measures to prevent the recurrence thereof can be carried out systematically without specialized knowledge, and the method can be implemented without fail by a well-unified method. It is an object of the present invention to provide a human error analysis / evaluation method capable of designing a recurrence prevention measure.

[0006]

The present invention provides the following means (1) to (3) in order to solve the above-mentioned problems.

(1) The person, hardware, software, environment, surrounding persons and management are defined as factors that cause a human error, respectively. Further, as a measure for preventing a human error, deletion of work, physical The following items are defined as items, such as restriction, cognitive burden reduction, physical burden reduction, detection and impact mitigation; when a human error occurs, the error items are arranged as an error mode; A human error, which is selected from factors that cause human error and extracted; the extracted factors are sequentially compared with the human error preventive measures to select corresponding factors; and a human countermeasure is designed based on the selected preventive measures. Error analysis evaluation method.

(2) In the invention of the above (1), each factor of the factor causing the human error, the measure for preventing the human error, and the entry column of the error mode are one.
A human error analysis / evaluation method, wherein the method is described on a single entry display board.

(3) In the invention of the above (1), the specified factor and each item of the preventive measure are stored in a data processing device and can be displayed on a screen as a list;
The human error analysis is characterized in that the error mode is input to the data processing device and entered on the list, and based on the list on the screen, factors are extracted, compared with preventive measures and selected. Evaluation methods.

In the human error analysis / evaluation method (1) of the present invention, each item is defined as a factor causing a human error. For the item "Principal",
Ability, familiarity, psychological and mental status, physical status, etc. are defined. Regarding "hardware",
Machine interface, equipment design, arrangement of equipment piping, etc. are specified. For “software”, information, manuals and standards, educational and training materials, and the like are defined. The “environment” includes work, temperature and humidity, lighting,
Noise, work properties, etc. are specified. In addition, communication, teamwork, and the like are defined for “surroundings”. Furthermore, the “management” defines the organization and management system, the creation of an atmosphere in the workplace, the cultivation of quality awareness, and the like, and all factors of human error are completely covered. To prevent human error, "delete work"
Each item of "physical restriction", "reducing cognitive burden", "reducing physical burden", "detection" and "mitigating impact" is specified,
An error factor that cannot be prevented by the first wall of “deletion” is prevented by the second wall of “restriction”, and if it is still difficult, the error is sequentially prevented by one of the walls. The set error mode that corresponds to the above factors is extracted from the above factors, and each extracted factor is selected from the above preventive measures, so the extraction of human error factors and the preventive measures are systematic This makes it easy for anyone to plan.

In (2) of the present invention, all specified items of factors and preventive measures and the entry of the error mode are all entered as a list on one entry display board. Preventive measures can be made easier.

In (3) of the present invention, all factors, preventive measures, and error modes are input to the data processing device, and are displayed as a list on the screen of the data processing device. Since it is performed on the screen, the analysis and evaluation of human error can be efficiently performed, and a database on human error can be constructed.

[0013]

Embodiments of the present invention will be specifically described below with reference to the drawings. FIG. 1 is a diagram of an evaluation table used when implementing a human error prevention method according to an embodiment of the present invention, FIG. 2 is a diagram illustrating an example of use, and FIG. It is a block diagram of the apparatus which implements a human error prevention method.

In FIG. 1, a column (A) is a portion for writing an error mode that has occurred, and a corresponding error mode described later with reference to FIGS. 6 and 7 is specifically written.
(B) is a column of a factor that causes an error, and is a predetermined item as enclosed in a black frame in the drawing and is commonly used in each field. These factors are as follows: B-1 is a person (person), B-2 is hardware, B-3 is software,
B-4 is an environment, B-5 is a person (surrounding person), and B-6 is a management column, which covers all human errors. For each of the factors B-1 to B-6, specific detailed items are defined as shown in the drawing.

Column (C) is a column for prevention measures, and (1)-
The preventive measures (6) are set in advance as major items of preventive measures for all error modes, and are commonly used in various fields. The contents are (1) exclusion, and the work that causes an error is eliminated, and for example, mechanization and automation are performed.
(2) is a restriction, which physically restricts the work that causes the restriction, such as duplication or the like.

(3) Reduction of cognitive burden, such as creation of standards and procedures, creation of check sheets, etc.
Reduce cognitive burden. (4) is a reduction in physical burden, such as planned staffing.
(5) is detection, which notices the occurrence of an error, and corresponds to, for example, creation of a check sheet, execution of a double check, alarm, and the like. (6) is to mitigate the effects, which is to prevent errors from affecting, such as establishing an emergency response system and creating manuals.

The above preventive measures (1) to (4) are preventive measures before an error occurs, and (5) and (6) are measures to be taken after an action that causes an error. Error factors that cannot be prevented by the first wall of “exclusion” of (1) are prevented by the wall of (2) of “restriction.” If the error is still difficult, the following (3) to (6) It is based on the idea of preventing one of the walls.

As described above, in the evaluation table, the factors causing the error (B) in the thick line of the black frame and the preventive measures (1) to (6) in (C) are preliminarily entered.
Commonly used for analysis of human error in all fields. Analyzing human error using this evaluation table,
When planning a preventive measure, first, the situation and background of error occurrence are arranged in chronological order, and an error mode is extracted.
Fill in the fields.

Next, with respect to the error mode entered in the column (A), each of the factors in each of the columns B-1 to B-6 in the column (B) will be described.
Are sequentially checked to see if one of them is the cause of the error, and if it is the cause of the error, (A)
A corresponding item in the column is marked with a circle and its number, and all error factors are extracted without omission. B-1 extracted with circles
For each of the error factors (1) to (B-6), the preventive measures (1) to (6) in column (C) immediately below are examined as preventive measures in order from (1). If the preventive measures are appropriate, Fill in more detailed content and draft preventive measures.

Next, the actual use of the evaluation table shown in FIG. 1 will be described in detail with reference to FIG. First, as an example of occurrence of an error, an example in which a valve is damaged due to an incorrect selection of parts will be described. When selecting this part, it is necessary to select a part that meets the specifications in accordance with the purchase specification.However, the specification sheet describes the maximum working pressure and the maximum operating pressure difference. The difference is the main cause of the error, and the case where the form is not such will be described as an example.

In the above case, the situation of the error and the circumstances of the occurrence are arranged, and based on the result, first, in the column of the error mode in FIG. Is done. For this item, check each of the columns B-1 to B-6 to see if it causes an error, and usually use the maximum working pressure with a margin instead of the maximum operating pressure difference. Therefore, select “manual / standard” of “accustomed” as the relevant factor.

Next, as “(2)”, “Missing confirmation of manufacturer's approval diagram” is entered. For this item, “Psychological / mental situation” is selected as a factor causing an error, and attention is concentrated on other specifications. It is assumed that the confirmation of the manufacturer approval diagram has been omitted.
In addition, "communication" is selected as a factor of not confirming with the surrounding people. Furthermore, (3) "Conjecture for manufacturer approved diagram" is entered as the error mode, and "Information" is selected for this item, and "Information" is selected for this item. This is due to lack of information due to omission in the purchase specification. . Also, as "fostering quality awareness"
And make a selection that easy assumptions are a factor.

Next, the factors (1) to (6) in the column of the preventive measures (C) are sequentially examined with respect to the factors (1) to (4) extracted as described above. That is, (1) and (2) do not correspond to the preventive measures as shown by the one-dot chain line in FIG.
(3) “Reducing cognitive burden” is appropriate, and “Improvement of purchase specification” is entered as a detailed preventive measure, and a measure is drafted. In the same manner, “reducing cognitive burden” in (3) and “detection” in (5) are appropriate, and “prepare check sheet” is entered as a detailed preventive measure.

Similarly, for the factor, "detection" in (5) of the preventive measures (C) is appropriate, and "education" is entered as the content of the detailed preventive measures. Etc. are drafted. For the factor, (3) "reducing cognitive burden" is appropriate, and "detailed maker diagram improvement" and "issue confirmation letter" are entered as detailed preventive measures, and countermeasures are drafted.

Similarly, the "detection" of (5) is applied to the factor, the "cognitive burden reduction" of (3) is detected and the detection of (5) is applied to (5), “Detection” is selected as a preventive measure, and details of the countermeasure as shown in the figure are entered and can be drafted.

FIG. 3 is a view showing a first embodiment of an apparatus for performing a human error analysis / evaluation method using the evaluation tables described in FIGS. 1 and 2, wherein 1 is a board, and 1 is a board. Is supported and fixed by the support column 3. Reference numeral 2 denotes a human error analysis evaluation table, which is described on the board 1 with the same contents as those shown in FIG. Reference numeral 4 denotes a copying apparatus, which can copy the human error analysis evaluation table 2 on the board 1. Reference numeral 5 denotes a switch, and when the switch 5 is turned "ON", the human error analysis evaluation table is copied on paper.

In the apparatus according to the first embodiment described above, the contents of the human error analysis evaluation table 1 are described on the board 1. That is, (B) is indicated by a hatched portion in the figure.
B-1 to B-6 as factors causing an error and (1) to (6) of (C) preventive measures are described in advance. As described with reference to FIGS. 1 and 2 above, the human error analyst puts the error mode in the column (A), and puts a circle in the column corresponding to the error mode and the factor in the column (B) to indicate the factor. Then, the contents of the preventive measures (1) to (6) in the column (C) are checked, and the corresponding preventive measures are marked with a circle and the detailed contents of the preventive measures are described.

When the evaluation table which has been analyzed in this way and describes the preventive measures is completed, the switch 5 is turned on, whereby the copying apparatus 4 is operated, and the completed evaluation table on the board 1 is copied. Can be taken out. According to the first embodiment, by using the simple board 1, the columns (A) and (C) of the evaluation table shown in FIG. The analysis and evaluation of human error can be easily performed without any specialized knowledge, and the results can be copied immediately.

FIG. 4 shows a system configuration in which human error analysis and evaluation are performed in a mechanized manner. Reference numeral 10 denotes a data processing device, which comprises a personal computer or the like, and 11 denotes an evaluation table storage medium, such as a floppy disk or a hard disk of the personal computer. And the evaluation table described in FIG. 1 is stored.
Reference numeral 12 denotes an error mode / prevention measure input device, which is composed of a keyboard or the like. As shown in FIG. 2, (A) the content of the error mode, the input of an identification code for associating with the factor of (B), and (C) The user inputs the contents of the preventive measures and inputs a code for associating (B) the cause with (C) the preventive measures. Reference numeral 13 denotes an evaluation table printing device, which corresponds to a printer.

The operation of the above-described second embodiment will be described in detail with reference to FIG. First, the evaluation table storage medium 1
1, the content of the evaluation table is loaded into the data processing device 10 and
_{In step 1} , the form of the evaluation table is displayed on the screen. As described above, the evaluation table includes (A) factors B-1 to B-6,
Preventive measures (1) to (6) of (C) are described respectively, and in the figure, these parts are indicated by hatching.

Next, in S ₂ , the analyst inputs an error mode item from the error mode / prevention measure input device 12 into the column (A) of the evaluation table. This state is indicated by a dotted line in column (A). Then analyst at S ₃ is (A)
For each error mode in the column, the factors B-1 to B in the column (B)
-6 is sequentially checked, and if there is a corresponding factor, an identification code (black circle in the figure) is inputted from the error mode / prevention measure input device 12 into the corresponding column, and all error modes are output. Requirements that cause

Next, in S ₄ , the analyst responds to each of the extracted factors (black circles in the figure) by taking preventive measures (1) to (C) in column (C).
(6) is sequentially checked, and if there is a corresponding preventive measure, an identification code (white circle in the figure) is input from the input device 12 into a corresponding column, and all the factors are associated. Then, the details of the preventive measures are entered and described in the columns corresponding to the preventive measures with the respective identification symbols, and the evaluation table is completed. Then Evaluation was completed in S ₅ is a data processing device 10
Is sent to the evaluation table printing device 13 for printing. This printed evaluation sheet is sent to the department that implements the described preventive measures, and is examined to implement the preventive measures.

According to the second embodiment, the factors (B) and (C) preventive measures of the human error analysis / evaluation are input to the storage medium in advance, and the (A) error mode necessary for the data processing apparatus 10 is obtained. Input, factor extraction, and (C) input of correspondence with preventive measures, and output the result from the printing device 13, so that anyone can implement the human error analysis and evaluation table in a simple form. become.

FIG. 6 is a block diagram of an apparatus for implementing a human error analysis / evaluation method according to the third embodiment of the present invention. In the third embodiment, human error analysis / evaluation is performed in one section. In this configuration, data for that purpose is input from each department and can be centrally managed. In the figure, reference numeral 20 denotes a quality management section, which includes a data processing device 21 and an input / output device 22, and collectively manages data from each section.

Reference numeral 30 denotes a design department, which includes a terminal 31 and an input device 3
And a terminal 40 and an input device 42 in the manufacturing section.
And Similarly, 50 is an inspection department, 60 is a purchasing department, each of which has a terminal and an input device, and 70 is a sales department, and 70 has a terminal 71 and an input device 72. As described above, the quality control section 20 forms a network with each section of the entire factory, and collectively obtains information on human errors generated in each section, and can analyze and evaluate the information.

FIG. 7 shows an evaluation table used in the third embodiment, in which the contents of the factor (B) and the column of (C) preventive measures are not shown. This is the same, and in addition to this, in the column of the error mode (A), the hatched columns in the figure describe the reference contents in advance similarly to (B) and (C).

That is, the column of (A) error mode in the evaluation table in FIG. 7 includes (1) design, (2) manufacture, (3) inspection,
(4) Purchasing, (5) The section used by each department of sales is divided into columns, and each section is set in advance with standard error mode patterns ERM (1) to ERM (5). Are listed.

This standard error mode ERM (1)-
8 and 9 show examples of (1) an error mode used in design and (2) an error mode used in manufacturing, which are representative of the ERM (5). Only the outline of them will be described. As shown in FIG. 8, (1) the standard error mode ERM used in the design is used.
As an example of (1), there is (1-1) a mistake regarding provision and transmission of external information, and details thereof are (1) to
(4) is described. Also, as (1-2), a mistake in recognition / confirmation at the time of accepting external information is defined, and its detailed contents are defined as (1) to (4). Similarly, mistakes in judgment and determination are defined as (1-3), mistakes in creation of design documents as (1-4), and confirmation errors after operation are defined as (1-5). The content is specified.

As shown in FIG. 9, (2) an example of the standard error mode ERM (2) used in manufacturing includes (2-1) an internal information processing error relating to the work plan / progress. It is stipulated and its detailed contents are (1) to (5)
Is defined as In addition, (2-2) an error relating to reception of external information is specified, and (1) to (5) are described in detail as detailed contents thereof. or,
An error relating to the operation is defined as (2-3), and the contents of (1) to (3) are described as detailed contents.

In the column (A) of the evaluation table shown in FIG. 7, error modes ERM (1) to ERM (5), which are general standards of each section as described above, are given in advance. When a human error occurs in each part, for example, the design department 30 displays a form of the evaluation table shown in FIG. 7 on the terminal 31 and uses the input device 32 to input a standard error mode ERM (1) in the column (A) of the evaluation table. ), Select the error related to the current error, and select the relevant one.

With respect to these selected error modes, the factors in the column (B) are checked by the same operation as described with reference to FIG. 5, and the corresponding factor columns are extracted by attaching identification codes. When all the factors are extracted,
As in the operation described with reference to FIG.
(6) is sequentially checked, an identification code is attached to the corresponding item, and the detailed contents are input and described.

Similarly, the other manufacturing departments 40, inspection departments 50,
Also in the purchasing department 60 and the sales department 70, when a human error occurs, the input of the error mode necessary for the terminal from each input device and the association with the cause, the association with the extracted preventive measures, and the like in the same manner. Enter a detailed description. All of these input data are quality control department 2
The data is collected by being input to the data processing apparatus 21 of the data processing apparatus, and input / correction is performed by the input / output apparatus 22 as necessary. Preventive measures against these human errors are output, and countermeasures are drafted. Give instructions and take countermeasures.

According to the third embodiment, the analysis and evaluation of human error can be easily and systematically carried out in each section of the factory based on the same idea. Error data can be obtained centrally, and these can be centrally managed and preventive measures can be strongly promoted.

[0044]

According to the human error analysis / evaluation method of (1) of the present invention, a person, hardware, software, environment, surrounding people, and management are defined as factors causing a human error, respectively; As measures to prevent human errors, work deletion, physical constraints, cognitive burden reduction, physical burden reduction, detection and impact reduction are specified as items; when a human error occurs, the error item is set as an error mode. Organize; select and extract the factor corresponding to each error mode from the factors causing the human error; select the corresponding factor by sequentially comparing the extracted factor with the human error prevention measure; It is characterized by taking countermeasures based on preventive measures. In this way,
Extraction of human error factors for error mode,
The planning of the preventive measures can be systematically analyzed, and can be easily implemented by anyone with a uniform form and analytical method.

In (2) of the present invention, in the above (1), the factors causing the human error, the items for preventing the human error, and the error mode entry columns are described on a single entry display board. Because of this, it can be analyzed and evaluated as a list on the board, and it becomes easier to extract the factors and formulate preventive measures.

According to a third aspect of the present invention, in the first aspect of the invention, the specified factor and each item of the preventive measure are stored in a data processing device and can be displayed on a screen as a list. The error mode is input to the data processing device and entered on the list, and based on the list on the screen, extraction of factors, comparison with prevention measures, and selection are performed, so that all error modes are displayed on the screen. Analyzes and evaluations can be made, and accurate and efficient prevention measures can be formulated, and a database on human errors can be constructed.

[Brief description of the drawings]

FIG. 1 is a diagram showing an evaluation table for implementing a human error analysis / evaluation method of the present invention.

FIG. 2 is a diagram illustrating an example of using the evaluation table shown in FIG.

FIG. 3 is a configuration diagram of an apparatus that performs a human error analysis and evaluation method according to the first embodiment of the present invention.

FIG. 4 is a block diagram of an apparatus for executing a human error analysis / evaluation method according to a second embodiment of the present invention.

FIG. 5 is a diagram showing steps for implementing a human error analysis / evaluation method according to a second embodiment of the present invention.

FIG. 6 is a block diagram of an apparatus for implementing a human error analysis / evaluation method according to a third embodiment of the present invention.

FIG. 7 is a diagram showing an evaluation table used in a human error analysis evaluation method according to a third embodiment of the present invention.

FIG. 8 is a diagram showing an example of an error mode used in the first to third embodiments of the present invention and showing contents in a design department.

FIG. 9 is a diagram showing an example of an error mode used in the first to third embodiments of the present invention and showing contents in a manufacturing department.

[Explanation of symbols]

 REFERENCE SIGNS LIST 1 board 2 human error analysis evaluation table 3 support column 4 copying device 5 switch 6 floor 10, 21 data processing device 11 evaluation table storage medium 12 error mode / prevention measure input device 13 evaluation table printing device 22 input / output device 31, 41, 71 Terminal 32, 42, 72 Input device (A) Error mode (B) Factor causing error (C) Preventive measures

Claims (3)

[Claims] Claims: 1. A person, hardware, software, environment, surrounding people and management are defined as factors causing a human error, respectively. Further, as a measure for preventing a human error, deletion of work, physical Restrictions, cognitive burden reduction, physical burden reduction, detection and impact mitigation are defined as items; when a human error occurs, the error items are arranged as error modes; Selecting and extracting factors that cause an error; comparing the extracted factors with the human error preventive measures in order to select a corresponding one; and designing a human error measure based on the selected preventive measures. Analytical evaluation method. 2. An entry display board according to claim 1, wherein the factor causing the human error, each item of the human error prevention measure, and the entry column of the error mode are described on one entry display board. Human error analysis evaluation method. 3. The specified factor and each item of the preventive measure are stored in a data processing device and can be displayed on a screen as a list; the error mode is input to the data processing device and 2. The human error analysis / evaluation method according to claim 1, wherein factors are extracted on a list, and factors are extracted, compared with preventive measures and selected based on the list on the screen.