East Japan Railway Company

Presentation on theme: "East Japan Railway Company"— Presentation transcript:

1 East Japan Railway Company
Development of human factors training tool for rail operators in emergencies or unusual situations Ken KUSUKAMI Director Safety Research Laboratory Research and Development Center of JR East Group East Japan Railway Company Good morning. My name is Ken KUSUKAMI, Director of Safety Research Laboratory for East Japan Railway Company. We have developed human factors training tool for rail operators in cases of emergency or other unusual situations, which we call abnormal situations. JR東日本研究開発センター　安全研究所　所長の楠神です。 我々が開発したヒューマンファクターを考慮した運転士に対する異常時エラー訓練ツールについて紹介します。 Safety Research Laboratory

2 Contents of presentation
East Japan Railway Company Contents of presentation Background and purposes of development Features of the Training Tool Evaluation of the Training Tool Today, I’ll introduce this training tool in the following order. First, ・Background and purposes of development Second, ・Features of the Training Tool And Third, ・Evaluation of the Training Tool プレゼンテーションの内容は、 ・（表示のとおり） ・（同上） です。 Safety Research Laboratory

3 Background and purposes of development
East Japan Railway Company Background and purposes of development 　Installation of train safety systems has reduced accidents caused by human error in normal situations. 　It is difficult to prevent errors in abnormal situations, since systems do not take them into account. Two approaches are necessary to prevent an accident. 1. Information support system (hardware) 2. Education and training (software) First, the background and purposes of development. In our company, the installation of train safety systems such as an Automatic Train Stop System called ATS, has reduced accidents caused by human error in normal or typical, situations. On the other hand, it is difficult to prevent errors in abnormal situations, since systems do not take them into account. As a result, accident risk in abnormal situations increases. We think that there are two approaches effective against such risk. One is “Information support system (hardware)” The other is “Education and training (software)” The Training Tool I am going to introduce is regarded as the latter approach. 研究の背景と目的です。 運転士はトラブルや事故等の予期しない事態が発生しても、迅速かつ的確に対処することが求められます。 ■ATSやATCの整備などが行われています。 　その結果、平常時のエラーは減少してきています。 ■異常時におけるヒューマンエラーについては、 　システムだけで十分にバックアップすることは難しいのが現状です。 異常時のエラーについては、2つの対策が考えられます。 １．（表示の通り） ２．（表示の通り） 我々は「２．（表示の通り）」に着目しました。 Today’s presentation 　 Safety Research Laboratory

4 Confirmation of knowledge of recovery procedures
East Japan Railway Company Examinations of effective contents of training To improve performance in abnormal situations, experiencing actual abnormal situations is effective. Current state of training 　(Training Center) training using actual rolling stock and simulators  Once every two years 　(Worksite) 2-hour Education and training every month To improve operator’s performance in abnormal situations, it is most effective to experience the actual situation. So, our current state of training is as follows: “Training using actual rolling stock and simulators” is carried out in a Training Center. But it is only once every two years. On the other hand, for 2 hours “training on site” is conducted more frequently, that is, every month. But the typical contents are reconfirmation of previously acquired knowledge of recovery procedures and rules. So we think new training method for abnormal situations is necessary at worksites. 運転士の異常時パフォーマンスを向上させるには、実際の異常時を体験することが効果的です。 JR東日本における運転士の定期訓練は、次の2種類があります。 ・「訓練センターで行われる実際の列車やシミュレータを活用した訓練」これは2年に1度程度です。 ・「運転現場で行われる毎月2時間の教育訓練」 現場の訓練は、運転取扱い手順やマニュアルの確認などが主体です。 このような訓練では、運転士にとって異常時が発生した際の状況や実際の作業のイメージが難しいです。 そこで、我々は、職場における新しい異常時訓練が必要だと考えました。 Typical contents Confirmation of knowledge of recovery procedures Necessity for new training method for abnormal situations at worksites. Safety Research Laboratory

5 Conditions of using Training Tool
East Japan Railway Company Conditions of using Training Tool The tool is to be used for routine training sessions. Required time for one lesson is to be about 30 minutes. Training can be conducted either individually or in a group, using a personal computer. In a group session, a single coaching staff member can take the role of tool instructor. First, we specified the conditions of using the Training Tool, based on interviews with coaching staff at worksites. The tool is to be used for routine training sessions at a worksite, which we mentioned above as 2-hour training a month. Required time for one lesson is to be about 30 minutes. Training can be conducted either individually or in a group, using a personal computer. In a group session, a single coaching staff member can take the role of tool instructor at operators’ worksite. Coaching staff are operators belonging to the worksite and their jobs are to teach and train operators both on real trains and at the worksite. Generally, they should also conduct the routine training sessions. 指導員へのインタビュー結果に基づいて、訓練ツールは次のものとしました。 ・（表示の通り） ・（同上） Based on interviews with coaching staff

6 Features of the Training Tool
East Japan Railway Company Features of the Training Tool Identify five serious errors in abnormal situations through risk analysis of the operators’ tasks Adopt four-stage lesson to deepen operator’s understanding of points in error prevention Use coaching staff’s capability to improve effectiveness of learning. Next, I will explain the three features of the Training Tool ・Feature 1 : To identify five serious errors in abnormal situations through risk analysis of the operators’ tasks ・Feature 2 : To adopt four-stage lesson to deepen operator’s understanding of points in error prevention And ・Feature 3 : To use coaching staff’s capability to improve effectiveness of learning. I’ll explain these features one by one. 訓練ツールは次のような特長をもっています。 ・（表示の通り） ・（同上） Safety Research Laboratory

7 Feature1: Serious errors in abnormal situations
East Japan Railway Company Feature1: Serious errors in abnormal situations Case studies and statistical analysis of incidents Interviews with coaching staff Risk analysis of the operators’ tasks 1. Definition of situation in which serious error easily occurs First, about identification of serious human errors in abnormal situations. Ｗe conducted risk analysis of the operators' work through case studies and statistical analysis of incidents and interviews with coaching staff. Based on this, we specified the types of accidents to be prevented, regardless of whether the type has actually occurred already or not. Next, we identified types of serious human error which could cause the accident, and the particular human weakness related the error 一口に異常時といっても、その発生パターンは多様です。そこで、 ・インシデントデータの分析 ・現場等へのインタビュー調査 ・運転業務のリスク分析を行いました。 そして、当該事象を引き起こす要注意なヒューマンエラー内容やその発生状況・誘発要因を分析しました。 また、各エラーの内容やエラーに至るプロセスを踏まえ、エラー防止を考える上でポイントとなる「人間の弱点」をひとつずつ選定しました。 2. Definition of human weakness related to each error

8 Feature1: Definition of serious errors in abnormal situations
2. Definition of human weakness related to the error Situations vulnerable to error occurrence Human weakness 1 Reducing speed to prevent accidents in cases of natural disasters Risk in interrupted operation 2 Train safety procedure to prevent a secondary accident General human behavior in emergency situations 3 Operation after safety system (ATS-P etc.) starts working Overconfident assumptions 4 Dealing with signal failure Uncertain knowledge 5 Dealing with brake failure Over-concentration of attention As a result, we identified five dangerous situations we should pay attention to. The left column of this table shows “situations vulnerable to error occurrence” 1 Reducing speed to prevent accidents in cases of natural emergencies 2 Train safety procedure to prevent secondary accidents 3 Operation after safety system (ATS-P etc.) starts working 4 Dealing with signal failure 5 Dealing with brake failure 検討結果をもとに訓練プログラムとして作成することにした５つの要注意エラー場面が表の左側です。 １（表示の通り） ２（同上） ３（同上） ４（同上） ５（同上）

9 Feature1: Definition of human weakness which is related to each error.
1. Definition of serious error 2. Definition of human weakness related to the error Situations vulnerable to error occurrence Human weakness related to error 1 Reducing speed to prevent accidents in cases of natural disasters Risk in interrupted operation 2 Train safety procedure to prevent a secondary accident General human behavior in emergency situations 3 Operation after safety system (ATS-P etc.) starts working Overconfident assumptions 4 Dealing with signal failure Uncertain knowledge 5 Dealing with brake failure Over-concentration of attention Next, as a way to provide a hint for preventing the errors, we singled out one human weakness related to each error. The right column of the table shows these weaknesses. For example, in the second scenario of “Train safety procedure to prevent a secondary accident”, the tool shows that operator’s surprise and fear at the accident decrease his performance and explain the reasons of it from human factor’s viewpoints. Other human weaknesses are “risk in interrupted operation”, “Overconfident assumptions”, and so on. 要注意エラー場面ごとにひとつずつ選定した「人間の弱点」は、表の右側です。 例えば、「２　列車防護の取扱い」では、 異常時で不安や恐怖が発生すると、作業の質の低下が発生しやすいとされています。 ①注意の一点集中 ②わかっているのに思い出せない ③確認する余裕や慎重さが失われる このような「異常時の人間特性」を挙げています。 5 scenarios

10 Safety Research Laboratory
Feature2: Ideas to deepen operator’s understanding of points in error prevention - four-stage lesson - The training tool helps the operators: 1. Understand the seriousness of accidents through a typical accident case Understand the background and basis of rules 3. Understand the relevant human factors 4. Learn effective countermeasures The second feature of the tool is a four-step lesson. In order to deepen the operator’s understanding of points in error prevention, we think the following four-stage lesson would be the most effective. 1. To understand the seriousness of accidents through a typical accident case 2. To understand the background and basis of rules 3. To understand the relevant human factors 4. To learn effective countermeasures 運転士に要注意エラーを防止するためのポイントを理解させ、 実際の異常時場面でそれを思い出させるために、次のような４つの構成にすることにしました。 １（表示の通り） ２（同上） ３（同上） ４（同上） Safety Research Laboratory

11 Feature2: Four-stage lesson
First of all, to prime the trainee’s learning attitude, the tool shows the seriousness of accidents caused by the operator’s human error. Stage 1 First of all, to prime the trainee’s learning attitude, the tool shows the seriousness of the accident caused by the operator’s human error. Stage 2 The tool shows that the procedure has been set up to prevent an accident, so each point in the procedure is important. ４つの構成について、説明します。 まず、ステージ１では、（表示の通り）。 次に、ステージ２では、（表示の通り）。 Next, the tool shows that the procedure has been set up to prevent an accident, so each point in the procedure is important.

12 Safety Research Laboratory
Stage 3 Stage 4 In addition, the tool presents human weaknesses which disturb the operators’ behavior in an abnormal situation, even though they may understand the rules and procedures. Based on the above-mentioned remark, the tool discusses skill and technique important to cope with abnormal situations and the points that all operators must keep in mind. Stage 3 In addition, the tool presents human weaknesses which disturb the operators’ behavior in an abnormal situation, even though they may understand the rules and procedures. Stage 4 Based on the above-mentioned remark, the tool discusses skill and technique important to cope with abnormal situations and the points that all operators must keep in mind. ステージ3では、（表示の通り）。 ステージ4では、（表示の通り）。 Safety Research Laboratory

13 Feature3: Using coaching staff’s capability and experience
East Japan Railway Company Feature3: Using coaching staff’s capability and experience The training effect is not great enough if trainees only see the flow of these presentations on the screen. The training tool Go back and forth in each stage The coaching staff A simple guide for instructors talk about their own experience and ideas. let operators talk about their experience. let operators have group discussions. have operators discuss places where errors tend to occur on their railway lines. The third feature of this tool is using coaching staff’s capability and experience. The training effect is not great enough, if trainees only see the flow of these presentations on the screen. It is quite important for operators to take the contents seriously as their own problem and think, applying them to their own driving environment. We think that this role should be allotted to the coaching staff. For example, they are expected : ・To talk about their own experience and ideas. ・To let operators talk about their experience. ・To let operators have group discussions. ・To have operators discuss places where errors tend to occur on their railway lines. Training should go back and forth between the tool and coaching staff in each stage. So, we made a simple guide for coaching staff to support this way of training. 訓練効果を高めるために、指導員を活用することにしました。 指導員とは、運転士の育成・指導を主な業務として各現場に配置されている専門のスタッフで、 現場の定期訓練は、指導員が講師役になって実施されるのが一般的です。 訓練ツールの内容を、パソコン場面で一方的に見ているだけでは、訓練の効果は限定されます。 そこで、運転士に自分の問題として受け止めさせ、主体的に考えさせる役割を指導員に担わせることにしました。 具体的には、 ・（表示の通り） といったものです。 さらに、指導員を支援するために「指導員テキスト」を事例ごとに作成しました。 Support

14 Demonstration of training tool
East Japan Railway Company Demonstration of training tool Now, I'll show you a part of scenario 2: Train safety procedure to prevent a secondary accident. Demonstration is only given in the first stage of the above four, because of limited time. The first stage is “To understand the seriousness of accidents through a typical accident case“. では、訓練ツールをご紹介しましょう。 「列車防護の取扱い」をご覧ください。 Safety Research Laboratory

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16 Evaluation of the Training Tool
East Japan Railway Company Evaluation of the Training Tool The results of a questionnaire survey Five stage evaluation*, N=25 Ability to project oneself with tool 4.5 Ease in demonstrating the seriousness of human error in accidents 4.9 Ease in understanding reasons for rules and operation methods Ease in comprehending how human weakness causes error in abnormal situations 4.7 The tool gives some hints about how to prevent human errors 4.3 Time of explanation for each scenario is appropriate 4.4 Ease for coaching staff to apply in training The guide for instructors is easy to understand 4.1 Ease of training tool use In order to evaluate the tool, we conducted a questionnaire survey with the coaching staff. 訓練ツールについて、指導員を対象に5段階評価のアンケートを行いました。 1 2 3 4 5 Five stage evaluation*: disagree agree

17 The results of a questionnaire survey <1>
East Japan Railway Company The results of a questionnaire survey <1> Important items are given high scores. Ability to project oneself with tool 4.5 Ease in demonstrating the seriousness of human error in accidents 4.9 Ease in understanding reasons for rules and operation methods Ease in comprehending how human weakness causes error in abnormal situations 4.7 The tool gives some hints about how to prevent human errors 4.3 Time of explanation for each scenario is appropriate 4.4 Ease for coaching staff to apply in training The guide for instructors is easy to understand 4.1 Ease of training tool use This table shows the results of the evaluation as the mean scores on a five-point scale (N=25). Important items such as “Ease in imagining the seriousness of human error in accidents.” and "Ease in comprehending how human weakness causes error in abnormal situations.” etc. are given high scores. 「ヒューマンエラーが発生した際の事故の怖さがイメージできる」 「異常時の人間行動の弱点がわかる」といった、 本ツールで重視した項目に高い評価を得ることができました。

18 The results of a questionnaire survey<2>
East Japan Railway Company The results of a questionnaire survey<2> The score about the guide for instructors is rather low. Ability to project oneself with tool 4.5 Ease in demonstrating the seriousness of human error in accidents 4.9 Ease in understanding reasons for rules and operation methods Ease in comprehending how human weakness causes error in abnormal situations 4.7 The tool gives some hints about how to prevent human errors 4.3 Time of explanation for each scenario is appropriate 4.4 Ease for coaching staff to apply in training The guide for instructors is easy to understand 4.1 Ease of training tool use On the other hand, the score of “the guide for instructors is easy to understand” is rather low. We analysed the cause. 一方、「指導員テキストがわかりにくい」という項目が、他に比べて低い評価となりました。 この原因について検討をしました。

19 The reason why the evaluation of the guide is comparatively low
East Japan Railway Company The reason why the evaluation of the guide is comparatively low “Guide for instructors”＝an assembly of hints for training The coaching staff have to design training. Recommendations to the coaching staff are: ”Study before the training” The guide we made for coaching staff is merely an assembly of hints for training. So, it was rather hard for them to make a training plan. So, we recommend “Study before the training” to the coaching staff. For example, before the training, ・Plan the training with reference to the guide ・Rehearse questions and explanations using their experience and ideas. 指導員テキストは、一般的なマニュアルと違い、 マニュアルを見ればそのまま訓練を進めることができるようには作られていません。 訓練を進める上でのヒント集となっています。 そこで、我々が指導員に推奨しているのは「事前の学習」です。 具体的には、 ・（表示の通り） ・（同上） といったものです。 Plan the training with reference to the guide Rehearse questions and explanations Experience Idea

20 Conclusions East Japan Railway Company Thank you for your attention.
This training tool was introduced in routine training sessions at operators’ worksites and JR East General Education Center in April 2008. JR East will make a steady and continuous effort to help all staff understand human factors more deeply and to raise awareness of the importance of safety. This training tool was introduced in routine training sessions at operators’ worksites and JR East General Education Center in April 2008. JR East will make steady and continuous effort to help all staff understand human factors more deeply and to raise awareness of the importance of safety. Thank you for your attention. 最後に、 この訓練ツールは、2008年4月からJR東日本の乗務員区所の定期訓練や研修センターでの訓練で導入されています。 JR東日本では、今後ともヒューマンファクターに関する社員の理解を深め、さらなる安全性の向上に努めていきます。 ご清聴、ありがとうございました。 Thank you for your attention.