１．Detection of taboo terms such as “conform”, “watch out” and” soul-searching”
in corrective action reports
About thirty years ago when I was a consultant for improvement of manufacturing
activities, I often checked past corrective action reports at the beginning
of consulting. Only two or three minutes were enough to check the reports,
even if they were a pile of papers, because my aim of the checks was
to find terms such as “conform”, “watch out” and” soul-searching” in
the reports. Because I believe those words are taboo terms for effective
corrective actions.
One word of such ones in the reports surely indicates total absence
of effective corrective action constitution in a factory.
2. Think-over reports by the operator of JR West
The operator of the dreadful train crash April 25 on JR West line, who
was dead at the accident, received re-training as the disciplinary action
for his overrun mistake in last June for thirteen days. He was forced
to write documents about the causes and corrective actions for his mistake.
This month the reports which are consisted with twenty reports are made
open by a monthly journal.
When I read the documents, I surprised that I found the documents were
full of taboo terms. The documents clearly predicted ten months before
the dreadful train crash on April 25 from my standpoint of view of taboo
terms.
The following words are ones I found in the reports as taboo terms.
(1) Terms relevant to cause of mistakes
[not conscious of][ scared][ aimlessly][not attentive][ so absorbed
in other thought][ my mind away for a second][ overconfident][ not so
careful]［made a snap judgment］[dub][ conceited][loose rein][ kid myself][lack
of professionalism][Slip into other doing][Too relax][Hang loose][Mental
weakness][Lack of a sense of impending crisis]
(2) Terms relevant to the corrective action
[Confirm consciously][Concentrate not thinking unnecessary matters][Never
be caught napping][With the highest tension][Early judgment] [Steadily]
[Avoid self-satisfied] [Absolutely][Focused][Not so hasty][Study hard][Never
tell a lie again]
The result of the thirteen days’ disciplinary actions was the reoccurrence
of the dreadful train crash on April 25, including the reoccurrence
of false reports by the dead operator.
Reading the documents, if you have common sense, you will be easy
to predict the reoccurrence of his mistakes. The document with full
of taboo terms means the operator did not do true self-reflection
and only writing being sensitive to seniors' mood. The selection of
words which are meaningless and usually used by small boys might lead
to his low morale and his intention to try reoccurrence.
About ten months later, his intention was realized as the dreadful
train crash on April 25 and his death.
3. Background of root causes
There has been paradigm where such documents are prevailed (refer
to “Two different paradigms related toISO9000: Mar.1w, 2003” in Basic
knowledge corner of this web-site).
ISO9000 sometimes calls for all kinds of detailed documents and have
made companies believe that if they put together detailed documents
the rule will be followed. But facts have been totally different. |