Mechanism of industrial accident zero making : Mechanism of industrial accident zero making

• Material Type: 文書・図像類
• Title: Mechanism of industrial accident zero making : Mechanism of industrial accident zero making
• Author/Editor: 東芝エレベータ株式会社; 高野, 研一
• Author Heading: 東芝エレベータ株式会社; 高野, 研一
• Publication, Distribution, etc.: 慶應義塾大学大学院システムデザイン・マネジメント研究科
• Publication Date: 2010
• Publication Date (W3CDTF): 2010
• Periodical title: Active learning project sequence report
• No. or year of volume/issue: 2010
• Volume: 2010
• Pages: 225-257
• Text Language Code: eng
• Target Audience: 一般
• Note (General): type:text; Every year, in Toshiba Elevator Company, 9 maintenance workers are involved in accidents while servicing customer's Elevators. In about one out of these 9 cases a worker dies as a result, while the other cases result in serious injuries. As a result, Toshiba Elevator spends ¥90,000,000 in compensation fees every year in addition to increased workers turnover costs and the impact on employees' morale and company image. The purpose of this report is to study the instances of maintenance worker's accidents in Toshiba Elevator Company and the causes behind them, and to design a plan to recommend for Toshiba Elevator Company to resolve this problem. After using Scenario Graph and CVCA we developed a better overall understanding of the accidents nature and causes. Then through general research and observation and interview of workers, we identified human errors as the major cause of accidents. We will, therefore, focus in this report on the accidents caused by human errors and try to reduce them by improving awareness and alert levels amongst workers, and improving the understanding of accidents' risk causes and the ability to avoid them. To address this problem, we relied on the tools introduced in the ALPS program. We relied on some tools more than others because some of the ALPS' tools proved to be difficult to use or inappropriate for addressing the specific problem at hand. Using Prototyping Rapidly, QFD and Use Case Scenarios we designed a 4 elements solution recommend these four solution elements to be applied. First is the Sharing New Solutions element. This element helps improving the awareness level and the ability to avoid risk sources. The second Branch Manager Visit to Branch Offices element helps improve the awareness level. The third Checking Compliance and Reward element addresses the two requirements that are improving alert level and doing objective risk assessment. Finally, the Group Study and Reward element betters the understanding of risk sources and the ability to avoid these sources of risk. To conclude, we recommend our proposal to Toshiba Elevator Company as a solution for the safety issues faced by its maintenance workers. This solution can help overcoming this problem since it addresses the reduction of human errors that are behind the majority of accidents (about 70%). According to the financial analysis of the solution, we were also able to show that its adoption can be economically sound. Through implementing this solution, Toshiba Elevator will be able to generate a ¥639.4M (NPV) over a 10 years period and will therefore help increase revenues. However, given that the level of depth of this study was affected by limited access to critical accident reports –for internal information privacy reasons,- we recommend that Toshiba Elevator Company uses a contingency plan to deal with pending risks. As defined using the FMEA, there are still 2 major remaining risks. The first risk is regarding the resistance to change. As a matter of fact, the maintenance workers might be reluctant to implement the proposed solution. In general, people don't like uncertainty -and therefore changes,-so the maintenance workers might refuse to adopt the solution. In the occurrence of such issue, senior management (CEO and branch managers) and the Support Group (Safety Division) members should have plans to encourage the maintenance teams and get them to understand the importance of implementing this solution and the risk they incur if the status quo is maintained. The second risk is about the effectiveness of the solution. Since this study was about a social system, it is difficult to assert that results will be attained as planned. Therefore, against expectations, the proposed solution might not be effective enough in reduce human errors induced accidents. In such case, the solution should be reviewed and causes of failure should be identified in order to modify the proposed solution accordingly. We planned a solution validation stage –which we could not conduct within the time frame, information and resources allocated to this study- that we advise Toshiba elevator to implement as an initial pilot phase necessary for the evaluation and fine-tuning of the solution in addition to a yearly review after implementation.; Student final reports Group 6
• Access Restrictions: 限定公開
• Data Provider (Database): 国立情報学研究所 : 学術機関リポジトリデータベース（IRDB）（機関リポジトリ）; https://irdb.nii.ac.jp
• Original Data Provider (Database): 慶應義塾大学 : 慶應義塾大学学術情報リポジトリ