別冊Ⅱ：障害分析手法 - IPA

1 II 2020 3 16 IT II Copyright 2014-2020 Information-technology Promotion Agency, Japan IPA II II 1 2 3 5 6 IMSAFER 7 7 IMSAFER 8 RCA 14 15 HAZOP 16 FTA 18 FMEA 19 STAMP SYSTEMS- theoretic ACCIDENT MODEL AND PROCESSES 21 STPA system - theoretic process analysis 23 CAST Causal analysis using STAMP 30 IT 32 33 33 33 33 35 36 37 38 39 42 1

2 IT F HAZOP FTA FMEA ImSAFER RCA IT HAZOP FTA FMEA STAMP STPA CAST 2 1 2 ImSAFER Improvement for medical system by Analyzing Fault root in human Error incident 3 RCA Root Cause analysis 4 IT IT 5 HAZOP Hazard and Operability Studies ICI Imperial Chemical Industries FMEA 6 FTA Fault Tree analysis Bell Labs.

3 7 FMEA Failure Mode and Effects analysis HAZOP 8 STAMP Systems- theoretic Accident Model and Processes MIT 9 STPA system - theoretic process analysis MIT STAMP 10 CAST Causal analysis using STAMP MIT STAMP 3 a b 4 1 QCD c 4 d 3 CSV SYSTEMS

4 1. 2. 5 2 A D D

5 A A D 6 A D B SLA 7 ImSAFER a b ImSAFER Improvement for medical system by Analyzing Fault root in human Error incident SAFER Medical SAFER Systematic Approach For Error Reduction IT 4 c 1 2 3 3 Level I 2

6 Level II Level III 1 4 8 3 5 4 6 7 ImSAFER IPA ImSAFER IT IT ImSAFER IT 1 A A B C C 4 1 B C / 9 2 A 4 1 B C 3 2 3 IT

7 M-SHEL m S H E L-L m-SHEL 1 1 2 2014 - 10 A 4 1 B C A (GW KAWAHATA KAWAMATA (GW KAWAHATA KAWAMATA GUI 2 KAWAMATA 2 KAWAMATA KAWAHATA GUI 11 1 2 4 m-SHEL))

8 M-SHEL m m S S H H E E L-L L-L 1 2 2 3 4 - - 12 5 1 2 - 2014 21 13 m-SHEL

9 IT 6 7 ImSAFER 14 RCA a b Veterans Affairs VA National Center of Patient Safety NCPS VA NCPS c 5