Development and Introduction of JR East Version of the 4M4E Analysis Method Ken KUSUKAMI, Ryoichi IMATA Safety Research Laboratory Research and Development Center of JR East Group East Japan Railway Company

Background of introducing 4M4E analysis method Safety Plan 2008 zero death or injury of customers zero death of employees (including employees of group companies) Event of threatening this target = incident important Prevention of accidents Accurate analysis of incidents Identification of lessons from them Method of solutions Most of incidents are caused by human errors 4M4E analysis method Accident analysis method from human factors’ viewpoint

Problems of accident and human error analysis 1. Consider a human error as an accident cause and stop analysis even if not so 2. Think cause of the error superficially (lack of attention, lazy, etc.) Overlook the important factors It is important to identify contributing factors of the error lessons of the incident appropriate measures Take inappropriate measures Repeat the same kind of incidents 4M4E analysis method Finally an accident occurs originated as the accident investigation method of NTSB

Perspectives of 4M4E analysis method 4M:perspectives of contributing factors of errors 4E:Perspectives of measures for preventing errors 4M 4E Education (humans) Man (humans) Inadequacy of knowledge and skills Inadequacy of sensitivity to danger, etc Education of rules and training of skills Improvement of safety consciousness, etc Machine (things) Engineering (things) Difficulty of work and machine operation Inadequate design of system and equipment,etc Improvement of functions of trains, equipment, and machines Redesign of human interface, etc Media (environment) Environment (media) Limitation of work space Poor working environment such as lighting and noise, etc Improvement of lighting and noise abatement Improvement of footing and flooring, etc Management (control) Enforcement (control) Inadequacy of plans, instructions and notices Insufficiency of cooperation between organizations, etc Review of work system and allocation of roles Review of working procedures and methods, etc Note: The general practice is to use “Example” instead of “Environment”, but JR East has adopted “Environment” to better integrate with Man, Machine, Media and Management in 4M

Basic procedure of 4M4E analysis method Incident occurs Step1 Time Series Analysis describing a process of an incident in time series and find problems (errors) find problems (errors) Step2 4M Cause-Tracing Analysis 4M4E analysis identifying factors and seeking the essence of the factor in the perspective of 4M identification of essence of contributing factors Step3 4E Solution-Tracing Analysis considering and concretizing measures for the essence of the factors in the perspective of 4E concretization of measures Determination of Measures evaluating the measures in order of priority Implement the measures

Whole view of 4M4E analysis method Structure Analysis Sheet

Structure Analysis Sheet 4E solution-tracing analysis Time seris analysis 4M cause-tracing analysis

Step1 Time Series Analysis 1. Research and describe the process of the incident in time series Point1　describe the process, traced back to the origin of the event 2. Find every problem (two kinds below) in the process Point2　pay attention to the relationship between identified problems problem 1 : Error Action against rules problem2 : Lack or insufficiency of consideration Action not against rules But if the person concerned had taken more consideration (it must be possible as a professional), the incident should not have occurred.

Step2 4M cause-tracing analysis (why?why?) Identify factors and seeking the essence of the factor in the perspective of 4M by the errors in Step1 Broadly identify contributing factors for errors in the perspective of 4M Contributing factor phenomena Point1　Especially analyze factors in perspective other than “human” Why? Point 1 … … Man Man Machine 2. Seeking the essence of the factors by repeating “Why?” Man Machine Management Point2　Do not forget the perspective of 4M, when seeking the essential factors Point 2 Man Machine Media Why? Find the essential factors through this process

Step3 4E solution-tracing analysis (so, what to do?what to do?) Considering and concretizing measures for the identified essential factors in the perspective of 4E Broadly consider the measures for the factors in the perspective of 4E measure Contributing factor Point 1 Point1　Especially consider measures in perspective other than “human” Education Engineering Environment 2. Concretize the measure as an action plan by repeating “So, what to do?” … … Education Environment Enforcement Point 2 Point2 Do not forget the perspective of 4E, when forming action plan … … Engineering Enforcement Environment Obtain more effective and concrete measures

Effects Expected from 4M4E Analysis 1. Implementation of effective measures 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 2. Cultivating understanding of human errors Cultivating deep understanding of human errors and risky situations in the work Enriching contents of training at worksites

Procedure of introduction of 4M4E analysis (2004) Select one person as “4M4E Instructor” out of accident investigators in a branch office Teach 4M4E analysis method to the instructors Trial introduction after that The instructors teach the method to other accident investigators in branch offices and worksites　　　 SRL checks incident reports and give instructions SRL : Safety Research Laboratory Introduction as incident analysis method (2005)

Procedure for internal introduction and deployment 4M4E Analysis Internal Introduction and Development 2003 2004 2005 2006 2007 Test model of JR EAST Version 4M4E analysis method Preparation for introduction 4M4E analysis Instructors’ training 4M4E analysis Instructors’ study session Improvement of analysis level 4M4E analysis lecture *including group companies Lecture using the support tool (from August 2006) At worksite and offices for transport, facilities and construction Adjustment of differences In analysis level Used at branch offices and worksites (directly distributed to worksites) Penetration speed up Development of training tools Maintaining analysis level Used at branch offices and worksites (distributed by safety offices of individual branch offices via individual managing sections) Improvement of efficiency of analysis Development of analysis support tools Sending out of information about 4M4E analysis (using the intranet) Official adoption by Transport Safety Dept. of 4M4E analysis for incidents 2003 2004 2005 2006 2007

Problems appearing in the process of introduction 1. Insufficiency of quality of analysis and difference of quality between branches 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 2. 4M4E analysis requires much time take much time to make and arrange structure analysis sheet Disturb concentration on analysis Development of 4M4E Analysis Training Tool & Support Tool

4M4E Analysis Training Tool “Naze-Naze-Kun” Software for PCs (Windows) Training can be done either individually or in a group Station employee dispatcher Rolling stock Maintenance Facilities Maintenance conductor driver Composed of five scenarios Scenarios made by occupations Understand basic knowledge of human errors Understand the point of 4M4E analysis

4M4E Analysis Support Tool “Horisage-Kun” Support tools for actually conducting 4M4E analysis 　1. Analysis support function : ensure and improve the quality of 4M4E analysis 　2. Document preparation support function :  facilitate preparing a structural analysis sheet Analysis support function 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 Document preparation support function Automatic optimization of setting and adjustment simplification of addition and change minimization of actions of each operation

“Structural Analysis Sheet” in the support tool Time series analysis 4M cause-tracing analysis 4E solution-tracing analysis Why was error caused？ So, what to do? Why? Why? What to do?

Support information in the support tool “Horisage-Kun” Support information is automatically displayed according to analysis (1) (2) (3) (1) Support information by types of incident (2) Support information by error types (3) Support information by described word

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 Regular education Lectures are held regularly at branches and training center new staff in personnel changes  learn the method present staff  improve ability of analysis 　Present situation and future plan 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

Conclusions of 4M4E Analysis Establishment of the climate “Safety is top priority” 〔Skill〕 Understand human errors and use human factors 〔Attitude〕 Make accurate analysis and find lessons Identifying essential lessons from incidents by using 4M4E Analysis Prevention of accidents Increase of Staff’s skill

East Japan Railway Company Thank you.