Abstract
This study proposes the simplest way of performing an investigation into the cause of an occupational accident. A typical approach is the basic cause analytical method based on the 4Ms (Man, Machine, Method, Management). However, the results of this analysis on 129 fatal accident cases indicate that 60 percent or more of those accidents can be attributed to causes such as incomplete communication or configuration management. Consequently, an attempt is made to extract fundamental causes by adding a time-oriented (or life-cycle) analysis to the "what's and why's analysis" methods of the conventional 4Ms and the informational causes. However, extraction of the basic causes is not always linked to clarification of specific substantive accident prevention measures. Therefore, an additional study is performed to examine the fundamental cause determination method in order to clarify the fundamental causes from the viewpoints of (a) ethics, (b) technology, (c) organizational management and (d) social systems. This is referred to as the fundamental cause determination method based on the BFI matrix (Basic, Fundamental, Inherently). In this case, useful references involve the "Comprehensive machinery safety standard" published in 2006 as well as "Safety management methods using IT". Furthermore, in terms of technical measures relating to change control procedures, what is believed to be useful is building a support system (called the configuration management system), in which the methods under development in the functional safety field (IEC61508 et al.), the quality management field (ISO09000 family) and the project management field (PMBOK, et al.) are extended to include even the configuration management in the occupational safety field. The above-mentioned method is used for occupational accident analyses relating to the use of large centrifugal machines. As a result, an inherently reliable accident prevention measure is clarified and its effectiveness is demonstrated.
