Basic cause of recent many industrial and medical accidents
in Japan(Oct.3w,2003)

1. On Nikkei business journal
Against the article on the causes of recent industrial accidents written by Prof.Karatsu in Nikkei business journal issued 22/ Sept., a reader, working on working site, posted on the journal issued 6/ Oct. that the causes, he thought, were cheating bureaucratic safety management and decreasing of veteran professionals due to their retirements from working site.

I saw similar phenomena in machine checklists for the safety management.
In a job site where about twenty automatic machines were working, two operators checked machine conditions before starting machines according to check items on the checklists. There were many items to be checked on each checklist and the operators entered check marks completely. Internal auditors admired them. But an auditor wondered there would be not enough time for the operators to do such many checks and finally found their marks were written together after the day off.

2. Mishaps in medical surgery
A young doctor made surgery with medical manuals in hand and the case died due to his poor skill.
Ironically ISO9001: 2000 requires in 4.4.3 Document control that relevant versions of applicable documents are available at point of use and the doctor had the relevant versions of applicable documents in hand. But his quality was worst!

g ISO9001 for Small Businesses; What to do; Advice from ISO/TC 176h is a great book.
It explains that it is not usually necessary to describe to a trained forklift driver how to operate a forklift. If the operator cannot operate the forklift, the answer is not written instructions but training.

3. Displays that no one see
I often have seen displays at the workstations describing what good work looked like, but workers did not see the displays as they had mastered the way as they had repeatedly done the operations.
To make everything available runs the risk of employees feeling they are being taught to suck eggs----a sure case of demoralization.
Toyota makes clear difference between education and training. Education means to acquire systematic knowledge and training means to make a trainee do good job without manuals.