The Essence of Failureology: Identifying Traps from the 'Basis of Judgment' to Prevent Future Occurrences

Introduction

This article summarizes a practical framework for implementing (Quality Management Certification Level 1 holder) recurrence prevention and proactive prevention, based on the author's experience in "learning from failure." Recurrence prevention and proactive prevention The keywords are
the "basis of judgment" of the parties involved and common concepts (knowledge formalization). We convert case studies into "knowledge that can be applied horizontally" to crush accidents before they happen for the first time.

Why is "failure" not utilized? — The Two Walls

1. The wall of stopping at the event itself
   Satisfied with "elucidating physical phenomena" such as equipment, materials, and conditions, without delving into human cognition, judgment, and behavior.

2. The wall of treating it as someone else's problem
   Case reports full of proper nouns do not resonate because "our equipment and products are different." Because they are not abstracted into common concepts, they cannot be applied horizontally.

The true nature of failure lies in the "process"

Detection → Cognition → Judgment → Action → Result (Success/Failure)
Instead of the far right (result), dissect the "basis of judgment that led to the thought that it was okay" on the left. By carefully gathering this basis of judgment = synchronous cause, traps of the same type are exposed.

• Example:

  • "It looks normal, so it's fine" = Normal Appearance Bias

  • "It's the expert's procedure, so it's fine" = Authority-Dependent Reassurance

  • "It worked last time, so it's fine this time" = Overconfidence in Past Cases

Elevating to common concepts: Case → Trap → Knowledge

• Communicating as a case: If the equipment, product, or conditions are different, it won't be "internalized"

• Communicating via traps (common structures): Enables horizontal deployment to other sites and processes

• Refining into common concepts (knowledge): Institutionalizing into education, inspection sheets, and review perspectives

Example of conceptualization

• Case: Entanglement accident while the cover was removed

• Trap: Constant bypassing of safety functions (habituation/efficiency)

• Knowledge Conversion:

  • Inspection Perspective... 'Temporary disabling of safety functions requires a deadline, a responsible person, and restoration verification'

  • Educational Perspective... 'The psychology where allowing something "just this once" becomes normalized'

  • Prevention Perspective... 'Design that cannot be mechanically bypassed / Visualization of operation logs'

Implementation Framework (The shortest course usable in the field)

1. Judgment Grounds Collection Sheet (5-minute version)

• What did you detect?

• How did you perceive it? (What did it look like / how did you understand it)

• What did you judge? (Why did you think "no problem" = judgment grounds)

• How did you act? (Regarding omissions, additions, or deviations)

• What were the results and unexpected facts? (Where did things go differently than expected?)

• What were the extracted **traps (mechanisms)**? (In short phrases)

2. Common Concept Card

• Trap Name (short phrase): ___________

• Psychological/Organizational Factors: ___________

• Conditions where it easily occurs (triggers): ___________

• Visualization Points (strengthening detection): ___________

• Preventive measures: (Design, procedures, training, review): ___________

• 'What could happen here?' Anticipated failures: ___________

③ Implementation of horizontal deployment

• Bring cards to regular meetings, and each department registers at least one anticipated failure relevant to themselves

• Registration → Reflection in inspection sheets/review perspectives → Storage as training material (with search tags)

• Connect recurrence prevention (after it happens) and proactive prevention (before it happens) using the same common concepts

Design points for initiatives

• Do not blame people; refine processes and language: Judgment grounds are assets. Creating a space to draw them out is key

• Identify 'traps' before strengthening checks: Determine the validity of measures based on compatibility with the trap

• Display → Dialogue → Implementation: Showing, discussing, and incorporating into inspection sheets, training, and design is one cycle

• Dual-language operation: 'Technical specific terms' × 'Common conceptual terms': Achieving both expertise and horizontal deployability

Mini-case format (Understanding through introduction, development, turn, and conclusion)

• Introduction (Situation): At the XX line, at □ o'clock, during inspection of △△

• Development (Judgment Grounds): No problems last time, sounds were normal → Reassurance

• Twist (Unexpected Fact): Actually, the sensor was bypassed, logs were unchecked

• Conclusion (Trap/Countermeasure): "Permanent bypass of safety functions"

  • Prevention: Dashboarding logs / Incorporate recovery confirmation into work completion criteria

Start immediately: "Weekly Action"

1. Fill out just one Judgment Grounds Collection Sheet based on a recent incident

2. Summarize traps into Common Concept Cards and come up with one hypothetical failure for each department

3. Convert the identified hypothetical failure into one inspection perspective and implement it from the following week

☆ About the author of this article

☆ Book (Professional Engineer Second-Stage Examination: "Techniques" for Passing in the Shortest Time)