2022 年 41 巻 p. 1-10
In this study, we were able to clarify the tacit knowledge that can be understood only from the experience of a large-scale water disaster by firefighters. In Chapter 1, there is a limit to what can be grasped by the “Near miss database”. found. In Chapter 2, we conducted a hearing survey on understanding the details of the disaster and making decisions during activities, and organized the contents of the hearing using the "event flow chart." In Chapter 3, we conducted a questionnaire survey and identified the root cause using "why-why analysis", evaluated the identified root cause, and examined the causal relationship. Finally, in Chapter 4, we extracted what was actually testified about the root cause, and clarified the findings and tacit knowledge obtained from it.