Resilient systems are able to perform as needed in changing environments with a variety of perturbations and constraints. Resilience engineering as a new approach to patient safety is to understand mechanisms of systems’ resilience (flexible, autonomous, and efficient) and implement resilience in health care systems.Our study found that proactive safety management in practice based on resilience engineering requires following strategies: reconciliation of work-as-imagined and work-as-done on safety procedures to dampen variability; understanding of interactions within a system or among systems and designing systems for total optimization; identification and use of simple rules governing interactions in autonomous distributed systems to resolved emerged complex problems; and dynamic captures of everyday clinical work with quantitative data

The purpose of this study was to development a systematic scheme to evaluate non-technical skills for surgeons on the Japanese contexts. As to develop evaluation scheme, we gathered information about medical accidents, specifically death cases, in Japanese health care settings and analyze it. As a result, more than half of cases have been identified to be caused by lack of non-technical skills. And we set up the evaluation scheme of non-technical skills for surgeons and gathered data of them using this scheme. We found that an item of leadership was low score comparing other items. And we also pointed out that, scores of surgeons being evaluated was higher than that of not being evaluated

This study aims to develop multi-layered resilient systems for safety control of transportation under unanticipated events, as well as a new legal theory for analyzing negligence that can reflect human characteristics of situation recognition and decision making with insufficient information under time stress. Three research units (viz., the human factors research unit, the engineering design research unit, and the authority and responsibility research unit) are defined to develop (1) evaluation and training methods for resilience of an individual as well as an organization, (2) design guidelines for resilience of engineering systems, (3) a dual control theoretic system that tries to perform the maximum possible safety control while allowing human intervention whenever the human is ready to do so, and (4) a new legal theory that clarifies authority and responsibility among humans and machines under risk environment

The study aimed to develop educational materials for game-based learning for healthcare students on patient safety, specifically about team performance and error prevention. We developed a time schedule and a set of educational contents for a 180 minute-class. Marshmallow Challenge, a known team exercise, was introduced in the class with a debriefing sheet focusing on non-technical skills that we developed, followed by a lecture, group discussion about an adverse event, and a lecturer's feed back to student responses. When such edcuation was provided to medical and nursing students of three universities, they seemed to achieve the goal of learning. We also developed a serious game to experience medication errors due to look-alike or sound-alike names. In the trial of the game conducted by 16 clinicians and researchers, failure patterns or improving processes n verifying medication during the game were similar to ones in the actual practice. They also felt the game entertaining

本研究は，想定外リスク環境下でも交通移動体の安全確保が可能なレジリエンスを備えた多層的安全制御システムの開発と，時間・情報制約下での人の認知・判断の特性を踏まえた刑事過失責任に関する新しい法理論の提案を目指すものである。そのために，全期間に渡って三つの研究アスペクト（ヒューマンファクター，エンジニアリングデザイン，権限と責任）を設け，個別目標を定めて研究を遂行することにしている。平成25年度の研究成果は以下のとおりである。
ヒューマンファクター研究アスペクトでは，2011年3月の東日本大震災とそれに伴う津波に際して鉄道乗務員らがとった行動を調査・分析し，緊急時にレジリエントな対応がとれた要因を抽出した。さらに，レジリエントな対応に結びつく態度・スキルを訓練する手法を開発し，鉄道社員に試行して効果を検証した。
また，レジリエンスを実装するに際して，組織が管理すべき要件について検討した。特にチームにおいて，各人のレジリエンス行動のミスマッチが機能共鳴型事故を招くことを明らかにし，当該形態の事故抑止について考察した。
エンジニアリングデザイン研究アスペクトでは，想定外事象発生時にシステム破たんをきたさないようにするためのレジリエントなヒューマンマシンインタフェースの例として，ロボットハンドを通じて人と機械が協調するシステムを提案し，想定外事象発生時の支援情報提示系を設計して上記協調作業システムへインストールした。
権限と責任研究アスペクトでは，自動運転走行中に想定外事象が発生した際，人の判断・制御の余地を残しながらも，機械がその知識・能力の範囲内で最大限の制御を行う双対制御論的システムを開発した。また，刑事過失責任の根拠となる「危険性の予見」について，英米法と日本法(ドイツ法)を比較し，結果回避可能性との間に必要な因果関係の認定方法の違いについて調査した。

This study aims to develop multi-layered resilient systems for safety control of transportation under unanticipated events, as well as a new legal theory for analyzing negligence that can reflect human characteristics of situation recognition and decision making with insufficient information under time stress. Three research units (viz., the human factors research unit, the engineering design research unit, and the authority and responsibility research unit) are defined to develop (1) evaluation and training methods for resilience of an individual as well as an organization, (2) design guidelines for resilience of engineering systems, (3) a dual control theoretic system that tries to perform the maximum possible safety control while allowing human intervention whenever the human is ready to do so, and (4) a new legal theory that clarifies authority and responsibility among humans and machines under risk environment

Human error is the source ofa reason of industrial accidents. Human error tends to be covered by worker's attention. However, this means that work apparatus or a work system are hard to use. Work systems must be improved. For that purpose, it is necessary to clarify the occurrence conditions of human error, and an error prevention methods must be developed. In this research, the cognitive models which clarify the relation between conditions and human error were discussed. Based on the models, development of the system design guideline for error prevention was aimed. Cognitive models were collected. Moreover, the accident examples in nuclear power plants etc. were collected broadly. The cause of the human errors was considered using the models. Consequently, It was shown that recognized type human error, especially inner description type slip error, increases as a worker becomes skillful. The experiments were conducted to investigate the relation between a skillful process and cognitive change. Consequently, since knowledge will be accumulated inner if a worker becomes skillful, a worker can do prediction action. However, the worker tend to omit judgment and miss the change of situation, and that theworker conducts a careless type error. Interviews in industrial work shops were held to investigate the description styles and contents of the "system design guideline for error prevention" which should be useful for the actual industrial workshops, and based on the investigation, the design guideline was developed in this study

Communication analysis was conducted to investigate human interfaces conditions of TV communication systems from the view points of cognitive ergonomice.The following results were obtained through the experiments.a) Such human interface conditions as screen size and eye contact feasibility affects conversation characteristics.b) Subjects do not gaze at the TV screens which display the conversation partners, however, they glance the screens when emotional conversations were communicated.Based on the serults, I can conclude that TV screen which display the conversation partners are required to ensure the emotional communication. However the screen conditions as human interfaces must be taken into consideration because they affects communication or conversation charactersitics

近年の大きな産業構造変化、設備の老朽化などのため、多様で大規模な産業災害が多発するようになってきた。最近のJR脱線事故や原子力発電所事故、自動車リコール隠しなど,これらの災害の従来にみられなかった特徴は、経営・管理の組織と人の機能不全が、災害を誘起し、かつ拡大したことにある。これはまさに、企業経営におけるリスクマネジメントの欠如にほかならない。産業災害のリスクマネジメントは、製品(もの)のリスクベースメンテナンス(RBM)という工学的視点のみでは不十分で、企業経営そのもののなかに位置付ける必要がある。一方、災害の結果として社会には、安全技術のみならず産業そのものへの不信感が芽生えており、この不信感を払拭するため、社会と産業の間に社会科学的視点に立脚したリスクコミュニケーションの実行が有用である。このように安全・安心な社会構築のために、経営学、工学および社会科学を融合したリスクマネジメント体系の構築が必要である。これを「産業災害リスクマネジメント科学」と名付け、その創出と展開を目的とした企画調査を行い、科学研究費補助金(特定領域研究)の新規発足研究領域の応募のための準備を行った上で,「安心・安全社会の構築を目指す産業災害リスクマネジメント科学の創出と展開」と題した研究申請を行った。さらに,本年度の成果として,平成19年3月に,本研究の調査研究成果シンポジウムを開催し,「特定領域研究」の準備状況,研究進捗状況ならびに研究体制等について意見交換を行った