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April 06, 2005

失敗に学ぶものづくり

sippainimanabu
 【今週の一冊】
 ●『失敗に学ぶものづくり』

  著:畑村 洋太郎(講談社)
   2003.10 / ¥1,890

-----------------------------------
 ◆ 燃える一言 ◆
 『ネガティブな人は、失敗から逃げ出しながら自分をダメにしていきます。
       その一方で、ポジティブな人は、失敗を克服しながら
             自分自身をつくりあげていくことができます。』
-----------------------------------
 またしても、三菱ふそうのリコール隠しが発覚しました。
 
 昨年9月に行ったリコール対象車が修理後に、再び火災などの不具合を生じ
 ていたにもかかわらず、半年間も公表していなかったのです。
 
 「問題を隠蔽する体質との決別」を誓った同社が、なぜ「失敗に学ぶ」こと
 ができないのでしょうか。
 
 本書は、「失敗学」の提唱者、畑村先生が材料や建築、土木などの専門家が
 語る過去の失敗と、その失敗からの学び方を編纂したものです。
 
 
 数多くの事例を読み進むと知らされるのは、ものづくりの歴史は「失敗の積
 み重ねとその克服」であるという痛ましい事実です。
 
 鉄道の安全技術として、ATS(自動列車停止装置)と呼ばれる、列車が赤
 信号で停止しなかったときのバックアップシステムが整備されていますが、
 これは国鉄時代からの数多くの列車事故の教訓で発展してきました。
 
 始めは車内警報装置から始まりましたが、その警報を運転士が無視したため
 に160名の死者を出す大惨事が起き(1962年)、自動停止装置付きのATSが
 開発されました。
 
 
 当初のシステムでは、警報が鳴って確認スイッチを押さなければ停止する、
 というもので、格段に安全性は向上しましたが、それでもATSの電源を切
 ったり、確認スイッチを押しても止まらなかったりと、列車の衝突事故はな
 くなりませんでした。
 
 その後もATSは改善を重ねますが、その度毎に盲点を突く事故が発生して
 います。
 
 一方で、安全対策を過信するあまり、運転中に携帯電話を架ける運転士が出
 てきてしまい、ヒューマンエラーの温床になる危険性も指摘されています。
 
 失敗を活かすためには、「この安全装置が設けられた理由は何か」「どんな
 システムなのか」を、知識と経験で受け継ぎ、逆に「どんな失敗がありえる
 か」を予想し対処する方向へ推し進めなければなりません。
 
 
 またエンジニアが失敗に向き合うときには、「自然現象化」を厳に慎むべき
 です。
 
 つまり「なぜ失敗したか?」という原因を話すときに、「私にはできなかっ
 た」と失敗を認めるべきところを、「私」を抜いて、「それは無理だった」
 と、まるで自然現象で起きたかのような説明をしてしまいがちです。
 
 人間が介在したものづくりにおいて、全ては人間に起因するものであり、そ
 れを最初から無理だったかのように片付けてしまうと、問題解決の策を建設
 的に導くことができません。
 
 
 我々は、今後も失敗を繰り返すことでしょう。
 
 そこで大切なのは、「絶対に失敗を起こさないこと」ではなく、「致命的な
 失敗を起こさない」ことです。
 
 失敗を隠しごまかすのではなく、過去や他分野の事例にも真摯に向き合い、
 「他山の石」として広く失敗知識を共有することが、失敗を活かし、軽減す
 る有効な手段なのです。
 ----------------------------------
 ◇ カンドコロ! ◇
 
 「応力腐食割れ」は、引張応力があって、特殊な材料と環境下でしか起きな
 い。
 
 材料を適切にすれば避けられる問題だが、歴史的にも、現在も起きている。
 
 原因は複雑だが、その一つは、加速試験の過信だ。
 
 原子炉など、40年の使用条件を確認するために、使用条件よりも高温な状態
 で疲労試験を行い、評価期間を短くする。
 
 温度が10度上がれば反応速度は倍になることを利用して、例えば50度上げれ
 ば32分の1の試験時間で評価できることになる。
 
 しかし、加速試験はあくまで予測だ。
 
 実際に使用している条件とは異なるのであり、「絶対に壊れない」と考える
 ところに、失敗の原因が潜んでいる。
───────────────────────────────────
 ◆ 熱い行動 ◆
 小さな失敗ほど、「私が失敗した」ことを早く宣言しよう。
 その体験を周囲と共有し、他に起こしそうな失敗もまとめて対処しよう。
 
 自社の誰も見ていない「過去トラブル事例集」を引っ張り出して、斜め読み
 してみよう。
-----------------------------------
 ◆ 燃えるゲージ ◆ | 炎 | 炎 |   | (炎3つが満点)
-----------------------------------
 ◎ 目 次 ◎
 第1章 材料分野―破壊事故に学ぶ
 第2章 土木分野―事故にはいろいろ背景がある
 第3章 建築分野―起こりうる事態をどこまで想定するか
 第4章 大量輸送分野―鉄道の安全は衝突事故の繰り返しによって高まった
 第5章 システム分野―ゼロから新システムを構築する
 第6章 エンジニアの失敗と成長
 第7章 大工の失敗と成長

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