摘要
Various methods to analyze industrial accidents have been developed.However,they are not fully utilized to prevent the recurrence of the causes of accidents at this moment.The main reason for this could be that analysis has not been conducted in a thorough manner from the perspective of parties involved in the accident.This paper will therefore present the results of a case analysis according to the situation awareness method which is currently under development.This method compares and finds discrepancies between objective situations and subjective situations perceived by parties to the accident and other persons involved,and then attempts to find the cause of the accident from these discrepancies.As a result of this analysis,large discrepancies were found in the perception of quality standards,work rules,production plans and actual situation at the factory.It also became clear that these discrepancies have been created due to the production-oriented and factory-dependent nature of the company.Furthermore,defects were found in the management system based on the safety system which is currently in place as well as in the craftsman-mentality interface at the workplace.This paper discusses the need to take into account the compatibility of the system to be established with the intrinsic nature of the company.