Предотвратите человеческие ошибки, управляя точками изменения, такими как управление изменениями 4M и управление 3H
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4M change management and 3H management
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- 4/5 (Thursday)
- About human error reduction
About human error reduction As already mentioned, defects and accidents occur when a number of mistakes overlap. This is represented by the Swiss cheese model below. Even if each slice of cheese has a hole (causing an accident), as long as the holes in all the cheese slices do not overlap, there will be no defects or accidents. However, even if there are no defects or accidents, if the holes (cause of accidents) are left as they are, someday all the holes will be aligned and light will pass through (accidents will occur). In fact, if we continue to exclude in-process defects through inspections, someday, inspection mistakes and oversights will occur, and defects will flow out to the customer. If you think so, many people think that the probability of serious accidents and defects is not high. However, when a serious defect or accident actually occurs, all sorts of things are happening leading to the accident, "I can only think that it is the work of the devil." Even in my own experience, there have been times when defective products were produced due to a combination of adverse conditions that made me think, "Well, how can there be so many things at the same time?" However, if even one of these mistakes had been prevented, the accident (or outflow of defective products) might have been avoided. Even if it is "coincidence" that individual factors overlap, each factor is happening as it should. Therefore, in order to prevent accidents (or outflow of defective products), it is important to reduce each factor as much as possible. The books referenced on this site are introduced on the following pages. reference books Link to this site is free. (Site administrator iLink Co., Ltd.) Download 93.16 Kb. Do'stlaringiz bilan baham: 
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