1. Development and Introduction of JR East Version of the 4M4E Analysis Method
Ken KUSUKAMI, Ryoichi IMATA
Safety Research Laboratory
Research and Development Center of JR East Group
East Japan Railway Company

2. Background of introducing 4M4E analysis method
Safety Plan 2008
zero death or injury of customers
zero death of employees
(including employees of group companies)
Event of threatening this target
= incident
important
Prevention of accidents
Accurate analysis of incidents
Identification of lessons from them
Method of solutions
Most of incidents are
caused by human errors
4M4E analysis method
Accident analysis method from
human factors’ viewpoint

3. Problems of accident and human error analysis
1. Consider a human error as an accident cause and stop analysis
even if not so
2. Think cause of the error superficially (lack of attention, lazy, etc.)
Overlook the important factors
It is important to identify
contributing factors of the error
lessons of the incident
appropriate measures
Take inappropriate measures
Repeat the same kind of incidents
4M4E analysis method
Finally an accident occurs
originated as the accident investigation method of NTSB

4. Perspectives of 4M4E analysis method
4M:perspectives of contributing
factors of errors
4E:Perspectives of measures
for preventing errors 4M 4E
Education (humans)
Man (humans)
Inadequacy of knowledge and skills
Inadequacy of sensitivity to danger, etc
Education of rules and training of skills
Improvement of safety consciousness, etc
Machine (things)
Engineering (things)
Difficulty of work and machine operation
Inadequate design of system and equipment,etc
Improvement of functions of trains,
equipment, and machines
Redesign of human interface, etc
Media (environment)
Environment (media)
Limitation of work space
Poor working environment such as lighting
and noise, etc
Improvement of lighting and noise abatement
Improvement of footing and flooring, etc
Management (control)
Enforcement (control)
Inadequacy of plans, instructions and notices
Insufficiency of cooperation between
organizations, etc
Review of work system and allocation of roles
Review of working procedures and methods, etc
Note: The general practice is to use “Example” instead of “Environment”, but JR East has adopted “Environment” to better integrate with Man, Machine, Media and Management in 4M

5. Basic procedure of 4M4E analysis method
Incident occurs
Step1
Time Series Analysis
describing a process of an
incident in time series
and find problems (errors)
find problems (errors)
Step2
4M Cause-Tracing Analysis
4M4E analysis
identifying factors and seeking the essence of the factor
in the perspective of 4M
identification of essence of contributing factors
Step3
4E Solution-Tracing Analysis
considering and concretizing
measures for the essence of the
factors in the perspective of 4E
concretization of measures
Determination of Measures
evaluating the measures
in order of priority
Implement the measures

6. Whole view of 4M4E analysis method
Structure Analysis Sheet

7. Structure Analysis Sheet
4E solution-tracing analysis
Time seris analysis
4M cause-tracing analysis

8. Step1 Time Series Analysis
1. Research and describe the process of the incident in time series
Point1　describe the process, traced back to the origin of the event
2. Find every problem (two kinds below) in the process
Point2　pay attention to the relationship between identified problems
problem 1 : Error
Action against rules
problem2 : Lack or insufficiency of consideration
Action not against rules
But if the person concerned had taken more consideration (it must be
possible as a professional), the incident should not have occurred.

9. Step2 4M cause-tracing analysis (why?why?)
Identify factors and seeking the essence of the factor
in the perspective of 4M by the errors in Step1
Broadly identify contributing factors
for errors in the perspective of 4M
Contributing
factor
phenomena
Point1　Especially analyze factors
in perspective other than “human”
Why?
Point 1 … …
Man
Man
Machine
2. Seeking the essence of the factors by repeating “Why?”
Man
Machine
Management
Point2　Do not forget the perspective of 4M,
when seeking the essential factors
Point 2
Man
Machine
Media
Why?
Find the essential factors through this process

10. Step3 4E solution-tracing analysis (so, what to do?what to do?)
Considering and concretizing measures for the identified essential factors in the perspective of 4E
Broadly consider the measures for
the factors in the perspective of 4E
measure
Contributing factor
Point 1
Point1　Especially consider measures
in perspective other than “human”
Education
Engineering
Environment
2. Concretize the measure as an action plan by repeating “So, what to do?” … …
Education
Environment
Enforcement
Point 2
Point2 Do not forget the perspective of 4E,
when forming action plan … …
Engineering
Enforcement
Environment
Obtain more effective and concrete measures

11. Effects Expected from 4M4E Analysis
1. Implementation of effective measures
Measures can be taken against essential contributing factors throughout the incident, not individual error
Measures can be suggested corresponding to feature and substance of the error
2. Cultivating understanding of human errors
Cultivating deep understanding of human errors and risky situations in the work
Enriching contents of training at worksites

12. Procedure of introduction of 4M4E analysis (2004)
Select one person as “4M4E Instructor” out of accident investigators in a branch office
Teach 4M4E analysis method to the instructors
Trial introduction after that
The instructors teach the method to other accident investigators in branch offices and worksites　　　
SRL checks incident reports and give instructions
SRL : Safety Research Laboratory
Introduction as incident analysis method (2005)

13. Procedure for internal introduction and deployment
4M4E Analysis Internal Introduction and Development
2003
2004
2005
2006
2007
Test model of
JR EAST Version
4M4E analysis
method
Preparation for introduction
4M4E analysis
Instructors’
training
4M4E analysis
Instructors’ study session
Improvement of
analysis level
4M4E analysis lecture
*including group companies
Lecture using the support tool (from August 2006)
At worksite and offices for transport, facilities and construction
Adjustment of differences
In analysis level
Used at branch offices and worksites
(directly distributed to worksites)
Penetration speed up
Development of
training tools
Maintaining analysis level
Used at branch offices and worksites
(distributed by safety offices of individual branch
offices via individual managing sections)
Improvement of efficiency
of analysis
Development of
analysis support
tools
Sending out of information
about 4M4E analysis
(using the intranet)
Official adoption by Transport Safety Dept.
of 4M4E analysis for incidents
2003
2004
2005
2006
2007

14. Problems appearing in the process of introduction
1. Insufficiency of quality of analysis and difference of quality between branches
Difficult to understand human factors and errors
 Insufficient identifying multifaceted factors
2. seeking essence of the factors
Step-by-step education (headquarter-branch-worksite)
 Effect of training is gradually decreasing
Employee changes
 Education has to be needed regularly
2. 4M4E analysis requires much time
take much time to make and arrange structure analysis sheet
Disturb concentration on analysis
Development of 4M4E Analysis
Training Tool & Support Tool

15. 4M4E Analysis Training Tool “Naze-Naze-Kun”
Software for PCs (Windows)
Training can be done either individually or in a group
Station employee
dispatcher
Rolling stock Maintenance
Facilities Maintenance
conductor
driver
Composed of five scenarios
Scenarios made by occupations
Understand basic knowledge of human errors
Understand the point of 4M4E analysis

16. 4M4E Analysis Support Tool “Horisage-Kun”
Support tools for actually conducting 4M4E analysis
　1. Analysis support function :
ensure and improve the quality of 4M4E analysis
　2. Document preparation support function :
 facilitate preparing a structural analysis sheet
Analysis support function
Provide 3 kinds of support information in analyzing factors and measures
1. Information according to types of incident
2. Information according to error types
3. Information according to described words in the sheet
Document preparation support function
Automatic optimization of setting and adjustment
simplification of addition and change
minimization of actions of each operation

17. “Structural Analysis Sheet” in the support tool
Time series
analysis
4M cause-tracing analysis
4E solution-tracing analysis
Why
was error
caused？
So,
what to do?
Why?
Why?
What to do?

18. Support information in the support tool “Horisage-Kun”
Support information is automatically displayed according to analysis
(1)
(2)
(3)
(1) Support information by types of incident
(2) Support information by error types
(3) Support information by described word

19. Current situation and future plan
“Training & Support Tool
Used in training and actual incident analysis, including group companies
Suggesting application to activities for preventing errors in worksites
Regular education
Lectures are held regularly at branches and training center
new staff in personnel changes  learn the method
present staff  improve ability of analysis
　Present situation and future plan
Analytical skills is still developing (difficulty remains)
Continuing training using actual examples
Plan to reorganize accident investigation skills and sum them up to the manual
skill : interviewing, reading chart, on-site inspection, etc

20. Conclusions of 4M4E Analysis
Establishment of the climate “Safety is top priority”
〔Skill〕
Understand human errors and use human factors
〔Attitude〕
Make accurate analysis and find lessons
Identifying essential lessons from incidents
by using 4M4E Analysis
Prevention of accidents
Increase of Staff’s skill

21. East Japan Railway Company
Thank you.