Last month the investigation committee for the accident
issued the interim report and still detailed operations of the driver
are not found.
Now I will comment on the accident from the standpoints of cormorant
management model and 8.5.2 Corrective action in ISO9001:2000.
1. Cormorant management model
A cormorant fisherman has several reins which hold cormorantsf each
neck. Therefore, a cormorant fisherman is a manager and cormorants
are operators.
In the case of the accident the driver is likened to a cormorant.
The interim report says that the driver did not any operative actions
for forty seconds just before the accident. There left forty seconds
mystery.
But who is a cormorant fisherman for him? How about handling reins?
Is there any mishandling? There are no deep investigations for such
field (refer to gFictitious the first press conference on the derailment
accident of JR West: May.2w, 2005h in Social problems relating ISO9001
corner on this web-site).
2. Corrective action
Before the accident the driver had received disciplinary actions for
thirteen days with wage cut for his overrun mistake in last June.
In this case the disciplinary actions correspond to corrective actions
mentioned in 8.5.2 clause of ISO9001:2000.
If the actions were effective, there would be no accident. So the
responsibility of ineffective corrective actions taken is up to management
(refer to gRe-training as a disciplinary action for an operator with
wage cut: May.1w, 2005h and gTaboo terms in the documents of the re-training
as a disciplinary action: Jun.5w, 2005h in Social problems relating
ISO9001 corner on this web-site).
.
The requirements of reviewing corrective action taken in 8.5.2 f)
clause of ISO9001:2000 should be done strongly and rightly (refer
to gJapanese peculiar problem on Japan note for 8.5.2 f) clause: Aug.2w,
2005h and gSequel to the problem on Japan note for 8.5.2 f) clause:
Aug.3w, 2005h in 8.5 of Individual clauses relating ISO9001:2000 corner
on this web-site).
|