development and introduction of jr east version of the 4m4e analysis method ken kusukami, ryoichi...

Development and Introduction of JR East Version of the 4M4E Analysis Method

Ken KUSUKAMI, Ryoichi IMATA

Safety Research LaboratoryResearch and Development Center of JR East Group

East Japan Railway Company

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East Japan Railway CompanyEast Japan Railway CompanySafety Research LaboratorySafety Research Laboratory

Background of introducing 4M4E analysis method

zero death or injury of customers zero death of employees (including employees of group companies)

Safety Plan 2008

Prevention of accidents

Event of threatening this target = incidentincident

• Accurate analysis of incidentsincidents• Identification of lessons from themIdentification of lessons from them

4M4E analysis method4M4E analysis method

important

Method of solutions

Most of incidents arecaused by human errors

Accident analysis method fromhuman factors’ viewpoint

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It is important to identify• contributing factors of the error• lessons of the incident• appropriate measures

Problems of accident and human error analysis

1. Consider a human error as an accident cause and stop analysis

Overlook the important factors

4M4E analysis method4M4E analysis method

even if not so

2. Think cause of the error superficially (lack of attention, lazy, etc.)

Take inappropriate measures

Repeat the same kind of incidents

Finally an accident occurs

originated as the accident investigation method of NTSB

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Perspectives of 4M4E analysis method

4M:perspectives of contributing factors of errors

4E:Perspectives of measures for preventing errors

4E4EMan (humans)Man (humans)

•Inadequacy of knowledge and skills•Inadequacy of sensitivity to danger, etc

Machine (things)Machine (things)•Difficulty of work and machine operation•Inadequate design of system and equipment,etc

Media (environment)Media (environment)•Limitation of work space•Poor working environment such as lighting and noise, etc

Management (control)Management (control)•Inadequacy of plans, instructions and notices•Insufficiency of cooperation between organizations, etc

Education (humans)Education (humans)•Education of rules and training of skills •Improvement of safety consciousness, etc

Engineering (things)Engineering (things)•Improvement of functions of trains, equipment, and machines•Redesign of human interface, etc

Environment (media)Environment (media)•Improvement of lighting and noise abatement•Improvement of footing and flooring, etc

Enforcement (control)Enforcement (control)•Review of work system and allocation of roles•Review of working procedures and methods, etc

4M4M

Note: The general practice is to use “Example”“Example” instead of “Environment”“Environment”, but JR East has adopted “Environment”“Environment” to better integrate with Man, Machine, Media and Management in 4M

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4M4E analysis

Basic procedure of 4M4E analysis method

Step1 Time Series Analysis

Step2 4M Cause-Tracing Analysis

Step3 4E Solution-Tracing Analysis

Determination of Measures

find problems (errors)

identification of essence of contributing factors

Incident occursIncident occurs

Implement the measuresImplement the measures

describing a process of an incident in time seriesand find problems (errors)

identifying factors and seeking the essence of the factorin the perspective of 4M

considering and concretizingmeasures for the essence of thefactors in the perspective of 4E

evaluating the measuresin order of priority

concretization of measures

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Whole view of 4M4E analysis methodS

tructure An

alysis Sh

eet

Action examinationsolution-tracing analysis

Analysis of contributing factorscause-tracing analysis

MMachineachine

MMediaedia

MManagementanagement

MManan

4E4E4M4MTime series

Analysis, Flow

EEducationducation

EEnforcementnforcement

EEnvironmentnvironment

EEngineeringngineering

Same as aboveSame as above

WhyWhy？？

Incident

Error1

Error2

Error3

Time series analysis Analysis ofcontributing factors

Action examination


WhyWhy？？



What What to doto do？？

What What to doto do？？

① Describing time flowto the incident

② Identifying errors, etc.after analyzing thestructure of the incident

① Analyzing contributing factorsby 4M

② Researching essentialfactors by cause-tracing analysis

① Finding countermeasures by 4E

② Forming concrete measures bysolution-tracing analysis

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Structure Analysis Sheet

Flow of the phenomenon 4M why-why analysis 4E so what analysis

＜Error 1＞＜Error through illusion or

misunderstanding＞<Ａ>

Since the vehicle technicalsystem staff responded that “the cut is complete,” the motorman erroneously thought that the decoupling work had been completed and that it was alright to proceed with shunting.

<Man> <Ａ>The use of language was ambiguous.“The cut is complete” could betaken to mean that preparation forthe decoupling work had beencompleted or that the decouplingwork itself had been completed.

<Media,Management><Ａ>A climate exists in which“oral confirmation ofcompletion” is consideredsufficient.

<Enforcement><immediate Ａ>

Language that is notambiguous should beused.

<Enforcement> <immediate Ａ(2)>Determine a rule stipulating thatwhen the cut is electrical,the message is that “preparationsfor decoupling are complete” andwhen the vehicle itself isDecoupled, the message is“decoupling is complete”

<Enforcement><gradual Ａ>

Ensure that the staff becomes more sensitive to the use of language.

<Enforcement><gradual Ａ(2)>

Extract other situations thatneed care from theperspectiveof language usingCS and other means and feedThe results back throughperiodic training.

<Education ><gradualＡ>Produce materials in order toprovide training on the fragilityof communication and causesof misunderstanding from thehuman factor and obtainunderstanding through periodictraining.

<Man, Management><Ａ>Ambiguous language thatinduces error is being used.

(Note) Those items enclosed in bold lines are “errors.” “contributing factors.” and “effective measures”that have significant impact on the generation of a phenomenon.”Of rhese, the measures that are actually taken (measures with a high level of priority) are shaded.

Example of structural analysisTime seris analysis

4M cause-tracing analysis

4E solution-tracing analysis

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Step1 Time Series Analysis

1. Research and describe the process of the incident in time series1. Research and describe the process of the incident in time series

problem 1 : Error

problem2 : Lack or insufficiency of consideration

Action against rules

Point1Point1　　 describe the process, traced back to the origin of the eventdescribe the process, traced back to the origin of the event

Action not against rulesBut if the person concerned had taken more consideration (it must be possible as a professional), the incident should not have occurred.

Point2Point2　　 pay attention to the relationship between identified problemspay attention to the relationship between identified problems

2. Find every problem (two kinds below) in the process2. Find every problem (two kinds below) in the process

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Step2 4M cause-tracing analysis (why?why?)

1.1. Broadly identify contributing factors Broadly identify contributing factors for errors in the perspective of 4Mfor errors in the perspective of 4M

Identify factors and seeking the essence of the factorIdentify factors and seeking the essence of the factorin the perspective of 4M by the errors in Step1in the perspective of 4M by the errors in Step1

Find the essential factors through this processFind the essential factors through this process

Point1Point1　　 Especially analyze factors Especially analyze factors in perspective other than “human”in perspective other than “human”

2. Seeking the essence of the factors 2. Seeking the essence of the factors by repeating “Why?”by repeating “Why?”Point2Point2　　 Do not forget the perspective of 4M,Do not forget the perspective of 4M, when seeking the essential factorswhen seeking the essential factors

Man Man Machine… …

phenomenaphenomena

Po

int

2P

oin

t 2

ContributingContributing factorfactor

Man Machine Management

Point 1Point 1

Man Machine Media

Why?

Why?

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Step3 4E solution-tracing analysis (so, what to do?what to do?)

Contributing factorContributing factor

Point 1Point 1

Po

int

2P

oin

t 2

Education … …Environment Enforcement

Education Engineering Environment

Engineering… …Enforcement Environment

Considering and concretizing measures for the identified Considering and concretizing measures for the identified essential factors in the perspective of 4Eessential factors in the perspective of 4E

1.1. Broadly consider the measures for Broadly consider the measures for the factors in the perspective of 4Ethe factors in the perspective of 4E

Point1Point1　　 Especially consider measures Especially consider measures in perspective other than “human”in perspective other than “human”

2. Concretize the measure as an action 2. Concretize the measure as an action plan by repeating “So, what to do?”plan by repeating “So, what to do?”

Point2 Do not forget the perspective of 4E,Point2 Do not forget the perspective of 4E, when forming action planwhen forming action plan

measuremeasure

Obtain more effective and concrete measuresObtain more effective and concrete measures

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Effects Expected from 4M4E Analysis

•Measures can be taken against essential contributing factors throughout the incident, not individual error

•Measures can be suggested corresponding to feature and substance of the error

•Measures can be taken against essential contributing factors throughout the incident, not individual error

•Measures can be suggested corresponding to feature and substance of the error

1. Implementation of effective measures

•Cultivating deep understanding of human errors and risky situations in the work

•Enriching contents of training at worksites

•Cultivating deep understanding of human errors and risky situations in the work

•Enriching contents of training at worksites

2. Cultivating understanding of human errors

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Procedure of introduction of 4M4E analysis (2004)

Select one person as “4M4E Instructor” out of accident investigators in a branch office

Select one person as “4M4E Instructor” out of accident investigators in a branch office

Teach 4M4E analysis method to the instructorsTrial introduction after that

Teach 4M4E analysis method to the instructorsTrial introduction after that

SRL checks incident reports and give instructionsSRL : Safety Research Laboratory

SRL checks incident reports and give instructionsSRL : Safety Research Laboratory

Introduction as incident analysis method (2005)Introduction as incident analysis method (2005)

The instructors teach the method to other accident investigators in branch offices and worksites　　

　

The instructors teach the method to other accident investigators in branch offices and worksites　　

　

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Procedure for internal introduction and deployment

2003 2004 2005 2006 2007

　

　　　　　　　　

　

　

　　　　　　

4M4E Analysis Internal Introduction and Development

Test model ofJR EAST Version4M4E analysismethod

Preparation for introduction

Improvement of analysis level

4M4E analysisInstructors’ study session

4M4E analysis lecture*including group companies Lecture using the support tool (from August 2006) At worksite and offices for transport, facilities and constructionAdjustment of differences

In analysis levelPenetration speed up

Maintaining analysis levelImprovement of efficiencyof analysis

Used at branch offices and worksites (directly distributed to worksites)

Used at branch offices and worksites (distributed by safety offices of individual branch offices via individual managing sections)

Sending out of informationabout 4M4E analysis(using the intranet)

Official adoption by Transport Safety Dept.of 4M4E analysis for incidents

4M4E analysisInstructors’training

Development oftraining tools

Development ofanalysis support tools

2003 2004 2005 2006 2007

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•Difficult to understand human factors and errors Insufficient 1. identifying multifaceted factors 2. seeking essence of the factors•Step-by-step education (headquarter-branch-worksite) Effect of training is gradually decreasing•Employee changes Education has to be needed regularly

•Difficult to understand human factors and errors Insufficient 1. identifying multifaceted factors 2. seeking essence of the factors•Step-by-step education (headquarter-branch-worksite) Effect of training is gradually decreasing•Employee changes Education has to be needed regularly

1. Insufficiency of quality of analysis and difference of quality between branches

take much time to make and arrange structure analysis sheet

Disturb concentration on analysis

take much time to make and arrange structure analysis sheet

Disturb concentration on analysis

2. 4M4E analysis requires much time

Problems appearing in the process of introduction

Development of 4M4E AnalysisTraining Tool & Support Tool

Development of 4M4E AnalysisTraining Tool & Support Tool

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4M4E Analysis Training Tool “Naze-Naze-Kun”

Software for PCs (Windows)Software for PCs (Windows)

Scenarios made by occupationsScenarios made by occupations

Understand basic knowledge of human errors Understand basic knowledge of human errors

Understand the point of 4M4E analysis Understand the point of 4M4E analysis

Training can be done either individually or in a groupTraining can be done either individually or in a group

Composed of five scenariosComposed of five scenarios

driverdriverconductorconductorStation employeeStation employee

dispatcherdispatcherRolling stock Rolling stock MaintenanceMaintenance

Facilities Facilities MaintenanceMaintenance

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4M4E Analysis Support Tool “Horisage-Kun”

Analysis support function

Document preparation support function

Support tools for actually conducting 4M4E analysis　 1. Analysis support functionAnalysis support function : : ensure and improve the quality of 4M4E analysis

　 2. Document preparation support functionDocument preparation support function : : facilitate preparing a structural analysis sheet

Provide 3 kinds of support information in analyzing factors and measures 1. Information according to types of incident 2. Information according to error types 3. Information according to described words in the sheet

Automatic optimization of setting and adjustmentsimplification of addition and changeminimization of actions of each operation

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“Structural Analysis Sheet” in the support tool

Why? What to do?Why was error caused？ Why?

So, what to do?

4M cause-tracing analysis4M cause-tracing analysis 4E solution-tracing analysis4E solution-tracing analysisTime series Time series analysisanalysis

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Support information in the support tool “Horisage-Kun”

(1)

(1) Support information by types of incident(2) Support information by error types

(3) Support information by described word

(2) (3)

Support information is automatically displayed according to analysis

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Current situation and future plan

“Training & Support Tool•Used in training and actual incident analysis, including group companies

•Suggesting application to activities for preventing errors in worksites

•Used in training and actual incident analysis, including group companies

•Suggesting application to activities for preventing errors in worksites

　 Present situation and future plan

Regular educationLectures are held regularly at branches and training center• new staff in personnel changes learn the method• present staff improve ability of analysis

Lectures are held regularly at branches and training center• new staff in personnel changes learn the method• present staff improve ability of analysis

•Analytical skills is still developing (difficulty remains) Continuing training using actual examples•Plan to reorganize accident investigation skills and sum them up to the manual

skill : interviewing, reading chart, on-site inspection, etc

•Analytical skills is still developing (difficulty remains) Continuing training using actual examples•Plan to reorganize accident investigation skills and sum them up to the manual

skill : interviewing, reading chart, on-site inspection, etc

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Conclusions of 4M4E Analysis

〔〔 SkillSkill 〕〕Understand human errors Understand human errors and use human factorsand use human factors

〔〔 SkillSkill 〕〕Understand human errors Understand human errors and use human factorsand use human factors

〔〔 AttitudeAttitude 〕〕Make accurate analysis anMake accurate analysis and find lessonsd find lessons

〔〔 AttitudeAttitude 〕〕Make accurate analysis anMake accurate analysis and find lessonsd find lessons

Establishment of the climate “Safety is top priority”

Identifying essential lessons from incidentsIdentifying essential lessons from incidents by using 4M4E Analysisby using 4M4E Analysis

Identifying essential lessons from incidentsIdentifying essential lessons from incidents by using 4M4E Analysisby using 4M4E Analysis

Prevention of accidentsPrevention of accidentsPrevention of accidentsPrevention of accidents Increase of Staff’s skillIncrease of Staff’s skillIncrease of Staff’s skillIncrease of Staff’s skill

Thank you.

East Japan Railway Company

development and introduction of jr east version of the 4m4e analysis method ken kusukami, ryoichi...

Documents

accident cause

human error analysisit

error lessons

death of employees

essence of thefactors

incident appropriate

perspectives of measures

working procedures