Toyota 與品質問題的事先防範和魅力產品的開發

這篇報導把手段當成目的 搞不清楚品質管理之真義
不過當參考信息收入

【盤點2010】品質篇：品質問題的事先防範和魅力產品的開發廣受關注

2010/12/08 00:00

出席混合動力車「普銳斯」召回記者發佈的豐田代表董事社長豐田章男（2010年2月9日）（點擊放大）

　　鋻於全球性競爭的激化，如果繼續進行「打地鼠式」* 的開發，企業將難以生存下去。筆者的這種印象在今年更加強烈。《日經製造》4月號的特集也進行過報 導，筆者覺得品質問題像今年這樣如此引起社會廣泛關注是前所未有的。以豐田的混合動力車「普銳斯」為首，三洋電機的顯像管電視機（2004年10 月～2005年9月生產的部分產品）和夏普的對開門冰箱（1996年～2001年生產的48款產品）等多種產品均出現了品質問題（參閱豐田宣佈召回「普銳斯」等4款最新混合動力車——全球共約43萬7000輛）。

　　其中還包括放在以前不會被視為品質問題的、只是用戶在操作過程中覺得不順手的情況。但現在，用戶的意識發生了變化，連這些情況也都視作品質問題。某廠 商的技術人員對此做出了如下評價：「如果廠商說『這是顧客的主觀感覺問題』，那麼會被認為是一個不誠實的公司。廠商需要比以前更為週到地考慮產品是被如何 使用的」。總之，當今社會要求廠商必須在有限的開發期限內提高產品品質，而且涉及到此類主觀感覺的情況也要包括在內。

　　目前許多產品都是在全球同步上市。不同於原來先在日本上市、然後在美國、最後是歐洲和亞洲這種依次開拓市場的做法，容易因為一個品質問題而牽扯到全球市場，從而蒙受巨大損失。從這一觀點出發，企業也必須在品質問題上做到防患于未然。

　　不過，網際網路的進步和多功能化的發展使其難以實現。由於多種產品與網際網路相連、多功能產品越來越多，因此與品質問題相關的原因也大量增加。即使是 單獨可以順利運行的功能，也會由於其他功能的影響而出現故障。如果繼續採用在開發過程中反覆進行試驗、一個一個解決出現的問題這種「打地鼠式」的既有開發 方法的話，早晚會碰壁。

　　因此，近年方法論再次吸引了人們的目光。方法論是一種為了提高產品企劃、開發以及生產一線的組織能力，應該以何種順序、如何考慮或推進某件業務體系化 的方法。通過提高組織能力，可以最大限度地發揮成員的能力。例如，要想在在有限的開發期限內事先防止出現品質問題，就必須提高開發一線的組織能力。

　　比如，「田口方法（Taguchi Method）」可以設計出對使用條件、使用部材的偏差以及使用部材的劣化等「干擾」具有「免疫力」的設備；可以將產品多種特性中的相關關係考慮在內進行檢查；可以高效檢查複雜嵌入的軟體等，因此有助於事先防止出現品質問題。

　　田口方法在創造具有吸引力的新型產品上也很重要。對顧客具有吸引力的產品，大多在實際生產過程中具有較大的難度。要想開發出對顧客具有吸引力的產品， 就必須採用不同於原來的方案、開發出新技術，當然出現品質問題的幾率將會高於採用現有方案或技術時的情況。要想在有限的時間內徹底降低故障機率，可以解決 系統性品質問題的田口方法將發揮作用。

　　從生產出暢銷產品這一觀點出發，簡單地事先了解一下其他方法就會發現，「品質功能展開（QFD）」、「商品策劃7工具（P7）」以及「TRIZ」等方 法的使用也很重要。現在可以經由網際網路，通過用戶正在使用的商品，直接收集到何種功能被頻繁使用或沒有使用等資訊。如果能夠對此類資訊進行充分整理和分 析，將有利於確立暢銷商品的理念。而且，QFD有助於進行此類整理和分析。（記者：富岡 恒憲）

*hc案 這翻譯不對 請參考第四代管理

■日文原文
【専門記者が振り返る】メソッド、この一年──品質問題の未然防止や魅力的な商品開発で注目度高まる

■相關報導
豐田宣佈召回「普銳斯」等4款最新混合動力車——全球共約43萬7000輛

日產將在日本召回83萬輛車，中國召回10萬輛

南韓現代將在美國召回13萬9500輛新款「索納塔」

《德訓篇》Ecclesiasticus

《德訓篇》Ecclesiasticus

"生活在19世紀末20世紀初那個特定的時代，吉卜林親身體驗了歐洲文明向全世界的兇猛擴張，也不可避免的經歷了隨之而來的第一次世界大戰。在此期間吉卜林遭受了他人生中最大的痛苦，他的大兒約翰（John）犧牲在1915年的盧斯之戰中，為此吉卜林自責地寫下了「如果有人問我們為什麼死，告訴他們，因為我們的父輩說了謊。」（If any question why we died/ Tell them, because our fathers lied）， 這句話的來由可能是因為吉卜林送兒子參軍時，為兒子很差的視力做了很多努力才獲得批准。為了彌補心中的創傷，吉卜林加入了費邊帝國戰爭治喪委員會（現為共 和國戰爭治喪委員會），這個組織負責英國戰爭中犧牲人員的墓地建設，吉卜林對這個項目最大的貢獻是為這個項目挑選了一句聖經中的短句「Their Name Liveth For Evermore」，刻在了幾個較大的戰爭墓地的紀念碑上，同時他也記錄了他的兒子所在的愛爾蘭衛隊的歷史。"

English

---

Their Name Liveth For Evermore

他們的遺體必被人安葬，名譽必留於永世；

Sirach 44.14, KJV

《便西拉智訓》，天主教譯作《德訓篇》Ecclesiasticus

，是基督新教次經的一部份，成書期大約在公元前180 年到前175年間。它屬於天主教和東正教《舊約聖經》的一部份，但不包括在新教的《舊約聖經》裡，在猶太人的重要經典《塔木德》及其他拉比文學裡，它被引 用過幾次。這篇書在公元後與其他次經一同被收錄在希臘語的七十士譯本中，並被天主教及東正教接納為正典的一部份。不過，大多數新教教會都不接納本書篇為正 典

***

Deming 博士的 Out of the Crisis第10章標準與法規

引用它作為章訓

有的人不出聲，

是因為他不知所答；有的人不出聲，

因為他知道何時該說話。

明智人緘囗不言，

直等相宜的時候；自誇和愚昧的人，

卻不看時機。

多言的人，必招人厭惡。

《德訓篇》思高聖經 20︰6-8

Deming–Stephan* algorithm

Variant: iterative proportional fitting An algorithm, given by Deming and Stephan in 1940, that can be used to fit log-linear models to contingency tables. The algorithm matches marginal totals by using iterative scaling of a table whose entries are initially all equal to unity. Essentially the same algorithm allows one to revise sample margins to preserve known population values: depending on context this is known as the Cross–Fratar procedure, raking, or structure-preserving estimation (SPREE).

*Frederick Franklin Stephan

(1903–71; b. Chicago, IL; d. Princeton, NJ) American demographer. A graduate of U Illinois (BA, 1924), Stephan gained his MA from U Chicago (1926) and joined the faculty of U Pittsburgh in 1927. After a spell at Cornell U, he joined the faculty at Princeton U in 1947, initially as Professor of Social Statistics in the sociology department, subsequently transferring to the statistics department. He was Editor of the Journal of the American Statistical Association from 1935 to 1940. He collaborated with Deming on the 1940 paper that introduced the Deming–Stephan algorithm. He was President of the ASA in 1966.

他的訃文是由 Deming 博士撰寫的


本詞條出自

Oxford Dictionary of Statistics. A Dictionary of Statistics. Second edition revised. Copyright © Oxford University Press, 2008. All rights reserved.

紐約時報關於人口普查單位之更自主法案挫敗的社論

紐約時報關於人口普查單位之更自主法案挫敗的社論

Editorial

Defeat for Census Reform

Published: December 26, 2010

With an assist from the Obama team, House Republicans and a handful of Democrats have defeated a sound bipartisan measure to reform the Census Bureau.

Related

• Times Topic: Census

The bill — which had already passed the Senate unanimously — would have granted the bureau director more autonomy to address longstanding political and bureaucratic problems in the execution of the decennial census and other important bureau surveys. A majority of House members — 200 Democrats and 1 Republican — voted in favor of reform, but the bill needed a two-thirds majority to pass because it was brought up under a fast-track procedure.

The administration’s objections had more to do with turf issues than substance. Gary Locke, the commerce secretary whose department houses the census, objected to one provision that called for the director to report directly to the secretary rather than to a midlevel commerce official, saying that it undercuts a secretary’s prerogative to organize the department.

Reorganization is precisely the point. For decades, the current reporting structure has impeded decision-making and deepened problems at the census. Mr. Locke also objected to a provision that would have allowed the director to share views with Congress that are not necessarily the views of the administration. Mr. Locke’s concerns were especially disruptive because he waited until the night before the vote to put them in a letter to House members.

House Republicans — who wanted an independent Census Bureau last year when they feared that Democrats would try to exert undue political control over the agency — happily cited Mr. Locke’s objections to justify their opposition.

The bill’s supporters included seven former bureau directors from both parties and hundreds of statistical, professional, public policy and civil rights organizations. They understood that the bill would have encouraged consistent, professional management of the bureau — crucial to the scientific integrity of census data and to the quality of the decisions and policies based on the data. The administration and a minority in the House did the cause of good government a disservice.

Toyota 根留日本 管理成本

Toyota aims to lower break-even point for Japan operations

(Reuters) - Toyota Motor Corp (7203.T) is aiming to significantly lower the break-even point for its Japanese operations through a slew of improved manufacturing processes, a top executive said on Friday.

Toyota President Akio Toyoda has said he wants to maintain domestic production of at least 3 million vehicles a year in Japan to protect jobs and the tradition of manufacturing, or "monozukuri," at home despite headwinds from a stronger yen.

Toyota is more exposed to a firm yen than rivals Honda Motor Co (7267.T) and Nissan Motor Co (7201.T) since it produces a bigger portion of its vehicles in Japan, and is under intense pressure to lower costs or take the politically difficult step of shifting more of its production overseas.

Nissan has especially been aggressive in pursuing ways to shield itself against a strong yen by importing more parts, as well as some cars, from overseas.

"We're trying to be able to operate at 85 yen (to the dollar) and 70 percent capacity utilization," Atsushi Niimi, executive vice president in charge of manufacturing, told reporters.

As the global financial crisis hammered sales and left much of its production capacity unused, Toyota embarked on efforts to make its domestic factory lines more flexible and introduce other changes to be able to break even at capacity utilization of 70 percent, equivalent to daily production of 12,000 units.

But that had assumed a dollar rate of 90 yen, far more favorable than the current 83 yen level.

Niimi said improvements in processes could reduce Toyota's capital spending by about 40 percent, limiting annual expenditure to about 700 billion yen ($8.4 billion) for the next five years or so. That is about half what it used to spend at its peak.

One measure Toyota is taking is to make its engine assembly process more compact.

"We used to believe that the most efficient scale for an engine assembly line was about 18,000 units a month," Niimi said. "But now we think half of that is better."

He said that because emissions and fuel economy regulations were evolving all the time, engine production would fall to half in two to three years, hurting the pace of depreciation.

By changing the layout of the engine production process and making other changes, Niimi said Toyota's engine production could be 20 percent more cost-competitive than Volkswagen AG (VOWG_p.DE), which he said was probably the leader now.

"Depreciation-wise, Volkswagen's engine (production) cost is probably about 30 percent cheaper than ours," he said. "But we think we can win by 20 percent with our new processes."

Last week, Toyota forecast its sales in Japan to fall 17 percent to a 37-year-low of 1.3 million units in 2011, worse than a 9.9 percent drop predicted for the overall market by the Japan Automobile Manufacturers Association. It plans to produce 3.1 million vehicles in Japan, meaning 58 percent would be exported.

Before the global financial crisis, management had talked of sustaining minimum domestic output of 3.8 million vehicles.

(Editing by Edwina Gibbs)

Pope to China Christians: 'Show courage'

Pope to China Christians: 'Show courage'

Pope Benedict XVI urges China's Christians not to give up hope, in spite of limits to their freedom, in his Christmas Day message from the Vatican.

----

Pope at the BBC: God surprises us

---

• China limits new cars in Beijing

  New rules take effect in China that restrict car purchases for 2011 by two-thirds in an effort to combat rising traffic woes in the capital, Beijing.

China defends Africa trade role

六三三支票是無知或蓄意欺詐選民

"馬英九有許多競選承諾，例如六三三支票，因為不可抗力的外在因素而跳票，但大家都能體諒他，不會苛求他非要如期兌現；但反政治性置入行銷完全不受外在因素控制，為或不為，一念而決，他至今未兌現這張支票，是不為也非不能也，嚴重失信於民。"


六三三支票是無知或蓄意欺詐選民
因為大選前半年國際問題已出現了

座談題目: 我的中國經驗與其限制/Redistricting Looms Large in Congress

感謝大家的報名參與:
座談題目: 我的中國經驗與其限制。
時間: 2011年1月8日 周六 10:00-12:00

地址：台北市新生南路三段88號2樓
電話：（02） 23650127

報名參加者

陳忠信
陳寬仁
胡慧玲
蘇錦坤
David Hung (美國)
林公孚
張慶麟
熊維強
黃玉鳳
劉玉燕 (下半場)

座談題目: 我的中國經驗與其限制 (3)

台灣近15年的國民平均收入與薪資分布
應是受到全球化中國崛起的絕大影響
然而行政院主計處的統計值都只是最後的結果
誰能解釋和新調整
http://www.dgbas.gov.tw/mp.asp?mp=1
-----
美國2010年的人口調查數據已在國會掀起新一波的政治風暴
Redistricting Looms Large in Congress* (詳下文)
(紐約時報 對了它的旅游報導 "重慶"Lost in Chongqing , China )

****
2010年12月25日 與 Ken 談些日本的獨特的防止安全手法
晚上在NHK 新聞看到他們慎重其事: 祭 2005年的交通事故--慎重其事

• 環保資訊 月刊 (這基金會是台灣的鞋業大王豐泰的貢獻 我印象很深刻)
  

Kenny 再指導如何弄電腦通訊 (我的pc中毒)
----
李瞻 :世界新聞史/新聞採訪學 吳俊升: 教育哲學大鋼

2010年12月25日 在台大學生活動中心 取得過去的教科書3本
都是很有歷史的書 可見教育界的舊勢力
----
Ken Su 的齋明寺訪櫻
神游一番:齋明寺到永平寺
---
一周來的胡適的世界 可以交差: 錢復回憶錄中的胡適

Redistricting Looms Large in Congress

By MICHAEL COOPER and SABRINA TAVERNISE

Published: December 24, 2010

The political jockeying over how to draw new Congressional districts began in earnest this week after new census data showed almost a dozen seats shifting to the South and West, leaving Republicans poised to build on their gains from November’s midterm elections and forcing several northern Democratic incumbents to begin plotting to save their jobs.

Enlarge This Image

J.D. Pooley/Getty Images

Representative Dennis J. Kucinich, a Democrat from Ohio, may lose his seat when Republicans redraw the state’s districts.

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• FiveThirtyEight: Nate Silver's Political Calculus
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The biggest immediate danger to incumbent Democrats will be in the Rust Belt, where Michigan, Pennsylvania and Ohio are all losing Congressional seats and Republicans now control the state governments, giving them the power to draw the new political maps. Politicians liken this process to a game of musical chairs, wondering who will be left without a seat. With Ohio losing two seats, political analysts expect the Republicans to eliminate a Democratic seat from the Cleveland area — possibly the one now held by Representative Dennis J. Kucinich.

“My Aunt Betty called me after the news report, and she says, ‘Dennis, what are we going to do — are they putting you out of Congress?’ ” Mr. Kucinich said in an interview, explaining that he would try not to worry about it right now, since it is beyond his control. But he added that “the fundamental rule of politics is you have to have a district to run.”

Republicans, meanwhile, are preparing for the more enviable task of drawing up new Congressional districts in states where they are strong. Their victories in statehouse elections gave them control of redistricting in five of the eight states that are gaining seats, including the two biggest winners, Texas, which is adding four, and Florida, which is adding two.

That has made Don Gaetz, the chairman of the Florida State Senate’s Reapportionment Committee, a popular man. There was the friendly hug he got from a member of Congress, who offered that his district’s current lines were just fine, and the ambitious fellow lawmaker who sidled up to him at a meeting, saying that he had a great idea for a possible district.

“I’m just a lowly state senator from the panhandle of Florida, but I have all sorts of new friends,” Mr. Gaetz marveled. “Members of Congress who didn’t know I existed, and people who would like to be in Congress who I didn’t know existed.”

The next step comes in February, when the Census Bureau will begin releasing detailed local demographic data, allowing the actual redrawing of districts to begin. In states losing Democratic seats, this will be the moment party elders start asking veteran lawmakers if they might like to retire, and younger lawmakers if they might want to seek other offices or accept comfortable positions somewhere else. This will also be the moment that tenacious Democrats quietly commission polls to see how they might fare against their ostensible Democratic allies.

Some of this is already beginning to play out in Massachusetts, where the all-Democratic House delegation will shrink to 9 seats from 10. Even before the demographic data, which will give officials a better idea of which districts might be merged, is in, there is talk of trying to get a member to run for the seat of Senator Scott P. Brown, a Republican.

Republicans also stand to gain ground in states that are not adding or losing seats, thanks to their victories in state elections this year. When Republicans won control of both houses of the North Carolina legislature in November for the first time since Reconstruction, they also gained control of the redistricting process. By state law they will draw the maps, and the Democratic governor, Beverly Perdue, will have no veto over them. Some Republican lawmakers there believe they can draw lines that would allow them to pick up at least two seats.

The most likely immediate impact of the coming redistricting, political analysts said, is that Republicans will be able to use their new power in the nation’s statehouses and governor’s mansions to draw new districts that will help the party strengthen its hold on the 63 seats in Congress that it picked up in November. When the new data comes in, both parties will use sophisticated computer software to begin carving up districts through politically creative cartography. But Republicans will have the upper hand, giving them the opportunity to add Republican voters to many districts where the party’s candidates won by narrow margins this year, making it easier for them to be re-elected.

“The Republicans are going to have their hand on the computer mouse, and when you have your hand on the computer mouse, you can change a district from a D to an R,” said Kimball W. Brace, president of Election Data Services, who has worked on redistricting for state legislatures and commissions.

Redistricting, it is often said, turns the idea of democracy on its head by allowing leaders to choose their voters, instead of the other way around. The new lines are drawn once a decade, after every census, to make sure that all Congressional districts have roughly the same number of people, to preserve the one-person, one-vote standard. But as a practical matter, both Democrats and Republicans often use it as an excuse to gerrymander districts for their own political advantage. This time, Republicans are better positioned to do it.

Tim Storey, an expert on redistricting at the National Conference of State Legislatures, said that Republicans were in their strongest position to draw lines in decades. Of the districts drawn by state legislatures, he said, Republicans have the power to unilaterally draw 196, four times as many as the Democrats. A decade ago, he said, Democrats had the advantage.

Texas will test the hopes of both parties. Democrats said that since much of the population growth was among minorities that traditionally support Democrats, they should benefit when Texas’s four new Congressional districts are drawn. Republicans, who control the process, said that much of the growth took place in Republican areas, so they will be able to draw more Republican seats. Tension lingers from the state’s redistricting in 2003, when Representative Tom DeLay, then the House majority leader, helped Republicans gain a large advantage in Texas’ House delegation.

Martin Frost, a former Democratic congressman whose district in the Fort Worth area was split during that redistricting, said he thought the Democrats would have a good chance of getting two of the four new seats, especially given the federal Voting Rights Act, which is supposed to ensure that the new lines do not dilute the voting power of minorities. And he said that the first order of business for Republicans would likely be to consolidate the gains they have made in recent elections by strengthening the districts of the party’s incumbents.

But Representative Joe L. Barton, a senior Republican from Texas who has been involved in redistricting for years, said that most Republican officeholders in Texas needed little help. He speculated that three of the four new seats would go to Republicans. “We, the Republicans, don’t feel we have to do anything radically partisan, primarily because the current map basically reflects the demographics of the state,” he said. “But if we’re going to have a fight, I’m glad I’ve got an R by my name.”

Of the 10 states losing seats, Democrats will draw the maps in only two: Massachusetts, where a Democrat will of necessity lose a seat, and Illinois, where they will try to eliminate a Republican seat. New York is losing two Congressional seats, and since the Democrats just lost control of the State Senate, they will have to come up with a compromise plan. In the past, that has meant eliminating one seat in each party; now, some lawmakers are pushing to create an independent redistricting commission.

Both parties also have experienced lawyers working on their redistricting efforts, since the courts will inevitably play a big role in the end. The Voting Rights Act limits how districts can be drawn in many states. Republicans have turned it to their advantage in the past, by packing so many Democratic voters into some minority districts that their power was diluted in neighboring districts. And where new lines are drawn, court challenges often follow.

Political analysts said that Republicans were poised to add anywhere from a net of 3 to a net of 15 Republican-leaning seats. But they note that the impact can be short-lived.

In times of upheaval, said Michael Barone, who covers redistricting exhaustively as a co-author of “The Almanac of American Politics,” it can be hard to predict how voters in some districts will behave. “When opinion changes,” he said, “it turns out some of those 53-percent districts aren’t yours anymore.”

好消息! 戴明博士的文集出版有望

Dear Hanching,

I am currently talking with publisher McGraw-Hill about the possibility of putting together a book based on Deming's papers and speeches. I thought you would like to know, as you were one of those who recommended that this be done.

I, too, hope we get to meet sometime.

Happy holidays,

Joyce

中國的顧問第一名：胡適博士、胡大顧問/ 杜威的《倫理學》

• • 
    
    • 杜威的《倫理學》
    • 中國的顧問第一名：胡適博士、胡大顧問

Pygmalion in the Classroom

文藝是國民精神所發的火光，同時也是引導國民精神的前塗的燈火。這是互為因果的……. (魯迅 從鬍子說到牙醫1925 收入 墳)

Justing 轉寄神秘的16號 (很棒的文章!) 給一些親愛的朋友。

這篇教育小說可能是戴明博士推薦的參考書之一例:

Pygmalion in the Classroom, by Robert Rosenthal and Lenore Jacobson (Holt, Rinehart, and Winston, 1969)(p27-c2, TNE) 或請參考Peter Scholtes的戴明領導手冊。

上周六與林公談趙老師。今天去他的趙家酒店。希望他也可以破而後立，多給些微觀的分析。其實，我還記得1995或1996年品管學會在台灣大學舉行年會，請田口演講，中途，我說田口先生沒什麼新意，趙先生哈哈….。那可能是我最後一次參加年會。今天收到月刊，又是許多會議的照片，很快讓它歸位……早上我在想上月日本的主題演講「品質経営の原点にかえり 先駆者の知恵に学ぶ」在說些什麼….. http://www.juse.or.jp/tqm/160/

日本戴明獎負面個案 (1)

"曾有人說，所有日本的工業界對品質皆有最佳的經驗。事實卻並不是如此。在本書所舉的許多不是這樣做的可怕例子中，有五個是來自日本。"

"不少服務業者曾獲得日本戴明獎，例如竹中工務店，是一家建築營造公司，於1979年贏得戴明獎。他們研究辦公室、醫院、工廠、旅館、火車、地下鐵等使用者的需求，他們也用電腦繪圖來降低重畫工程圖的成本，並在土壤、岩石地層移動，及相關之機器設備方面的研究，不斷地改善營建施工方法。另一個建築及營建公司--鹿島工務店，也於1982年獲得戴明獎。而清水營建公司也於1983年獲此獎。此外，關西電力公司，它的業務為供應大阪、名古屋，及日本中部地區的用電，為世界上最大的電力公司，是在1984年贏得戴明獎。"

鹿島、ビル施工ミス　鉄骨傾いたまま建設　大阪

2010年12月16日4時1分

　大手ゼネコンの鹿島（東京）が大阪市内で２１階建てのビルを建設した際、鉄骨１本が横に６～７センチ傾いたのに、現場の工事事務所長がそのままビルを完 成させていたことが鹿島への取材で分かった。同社は安全面に問題はないと説明している。大阪市は１１月、建築基準法に基づき、安全性を確認するよう指導し た。

　鹿島によると、２００７から０８年にかけてＪＲ大阪駅近くの大阪市北区内で工事した際、地下１階から３階までわたす十数メートルの鉄骨のうち１本が、測 量ミスのため傾いた。鹿島社員の工事事務所長はミスに気づいたが、工事を続行。３階より上につないだ別の鉄骨を逆方向に傾けて補正したという。設計会社に 提出した資料には、設計図通りに完成したと記載していた。

　これらの事実関係は鹿島本社や関西支店には報告されなかったが、その後、内部告発とみられる情報がインターネット上に流れ、鹿島は今年１０月に調査を開 始し、大阪市に報告した。市から指導を受けた鹿島は、第三者の検査機関に安全性の確認を依頼し、「構造的に問題ない」との結論を受けたという。工事事務所 長は同社に「工事をやり直せば工期に間に合わないと思った」と話しているという。

　鹿島本社の広報担当者は「施工ミスをして申し訳ない。工事事務所長を処分し、各支店が現場を監督する体制を強化する」と説明している。市建築指導部は「鉄骨の傾きがわかった段階で安全性を確認すべきであり、問題だ」と指摘している。

no system can understand itself

America: Y ur peeps b so dum?
Online Journal
As William Edwards Deming famously demonstrated, no system can understand itself, and why it does what it does, including the American social system. ...


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System to prevent flawed financial results not working

BY HIRONORI KATO STAFF WRITER

2010/12/10

Under a system introduced in fiscal 2008, listed companies in Japan are obliged to vouch for the veracity of their financial results.

The aim is to gain greater transparency and trust in financial markets.

But even after many companies announced they had issued "valid" results, critics say the system is not working because a number of companies revised their initial assessments.

Some were forced to do so after being hit by scandal.

Under the system, listed companies are obliged to report to the Financial Services Agency each year to say whether steps they had taken to ensure the veracity of their financial results are "valid" or "seriously flawed."

The system was introduced under the Financial Instruments and Exchange Law and took effect in the year ended March 2009.

Even if a company reports a flaw with its internal controls, it is not liable for punishment by the FSA.

According to a research by The Asahi Shimbun, at least 17 companies have revised their evaluation of internal controls after having earlier pronounced them as "valid."

Of these, four corrected their assessment for two years running.

Many of the companies were forced to change their assessment of their internal controls and to correct asset securities reports after fictitious transactions and front-loading of sales surfaced.

Mercian Corp., a leading winery, corrected its assessment in August after it emerged in late May that the company was involved in fictitious deals in marine feed business and falsifying expense sheets.

The correction came after Mercian said in March that its internal controls worked effectively when it evaluated transactions, including potentially risky ones.

A third-party investigation concluded the assessment was erroneous because personnel in charge of internal controls knew next to nothing about the marine feed business.

Yoshihiro Machida, a professor of auditing at Aoyama Gakuin University, said Mercian's initial assessment may not have been appropriate in the first place.

"The purpose of introducing the system was to allow an accurate understanding of actual conditions of an organization," he said. "(The company) should not have jumped to the conclusion that its internal controls were valid."

Some analysts question the trustworthiness of auditing by auditing firms.

An auditing firm usually endorses a self-appraisal of a company in its audit report on the company's internal controls.

Kintetsu Corp., a railway company, reversed its assessment of internal controls on financial results for fiscal 2008 and 2009 to "seriously flawed" after improper accounting by a subsidiary emerged.

KPMG Azsa, which audited Kintetsu's subsidiary, approved both initial and revised assessments, which contradicted each other.

Yoshinao Matsumoto, a professor of auditing at Kansai University, said that an auditing firm should be held responsible if its fails to detect irregularities.

"If companies habitually revise their assessments, people will no longer trust the system," he said. "An auditing firm should provide more in-depth explanation to investors."

The ratio of companies that assessed their internal controls as "seriously flawed" was 1.8 percent by September since the system began.

After March this year, it was only 0.9 percent.

The figure in the United States, which introduced a similar system about four years ahead of Japan, was more than 10 percent for the first two years.

The FSA plans to moderate an expression to "important inadequacy that should be disclosed" from "seriously flawed" for fiscal 2011 financial results to get the system to take root.

It said the change will be made because companies have a strong tendency to resist the term "seriously flawed."

a "major transformation" in its approach to safety needed

• DECEMBER 8, 2010

Overhaul of Oil Industry Urged

Spill Panel's Co-Chairman Calls for New Approach to Safety to Prevent Disasters

By STEPHEN POWER

The oil and gas industry needs a "major transformation" in its approach to safety to avoid another big offshore-drilling disaster, a leader of the presidential panel investigating the BP PLC accident plans to tell a gathering of industry officials Wednesday.

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Workers clean tarballs Monday off Waveland beach in Mississippi. Months after the BP spill ended, the oil globules are still washing up on Gulf shores. William K. Reilly, co-chairman of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, also plans to say that BP and two other companies involved with the doomed Macondo well—Halliburton Co. and Transocean Ltd.—made "breathtakingly inept and largely preventable" missteps, according to a copy of his prepared remarks viewed by The Wall Street Journal.

His speech also calls for improvements in the training and expertise of federal regulators, who "failed us miserably" in their oversight of offshore drilling before the April 20 explosion of the Deepwater Horizon rig that left 11 workers dead and triggered the worst offshore spill in U.S. history.

But the bulk of Mr. Reilly's remarks—to be delivered in New Orleans at a conference of attorneys for U.S. oil and gas companies—focuses on the industry, and what Mr. Reilly says is the absence of "a shared industry culture that puts a premium on safety and risk management."

"The interest group that could most threaten the future viability of offshore drilling is the oil and gas industry itself," Mr. Reilly says in the speech. "There has to be a recognition that the industry has not made safety a high enough priority. We need a major transformation in the oil and gas industry's understanding of what it means to put a priority on creating a safety culture. This is an industrywide challenge that can't simply be laid at the feet of a few rogue players."

Mr. Reilly's speech is significant, because it comes as his panel is preparing to deliver a report next month to President Barack Obama that could influence future regulation of the industry. Although Mr. Reilly says in the speech that his comments are only "personal observations," his views are likely to influence the panel's findings. His views could also carry weight in the industry because of his background: A Republican who ran the Environmental Protection Agency under President George H.W. Bush, Mr. Reilly is also a longtime board member of ConocoPhillips, though currently on leave from the post.

Halliburton said Tuesday it "remains confident that all the work it performed with respect to the Macondo well was completed in accordance with BP's specifications for its well-construction plan and instructions."

BP declined to comment.

Transocean said "the calculations, blueprints and step-by-step construction procedures for the well were crafted by BP engineers and approved by federal regulators in advance of—and in some cases, during—the construction process itself."

In recent days, oil industry leaders and their congressional allies have blasted the Obama administration for its decision last week to maintain a longtime ban on drilling in the eastern Gulf of Mexico and the Atlantic coast. In a conference call with reporters this week, the president of the American Petroleum Institute, Jack Gerard, said the administration's decision threatened U.S. jobs and energy needs, and was inconsistent with the lifting in October of a temporary moratorium on drilling in the central and western Gulf of Mexico.

But Mr. Reilly, in his speech, says an "embarrassing reality" exposed by the BP spill is that the technical expertise of government regulators "has lagged far behind" that of industry, and that it will take time for regulators to catch up. In that context, it is "regrettable but not really surprising that regulatory officials are reluctant to sign their names to new [drilling] permits."

Mr. Reilly goes on to complain that industry officials "stood by and let disaster happen" in the Gulf, even though "certain companies were well known within the industry to be laggards when it came to a safety culture." With oil and gas firms increasingly drilling in deeper water, he argues that the odds of another catastrophe will rise if the industry doesn't take action. He suggests the industry establish a safety institute that would conduct audits of companies' safety practices and cultures, and whose work would be shared with insurers and companies' boards.

Such an institute, he adds, would be similar to "Inpo"—the Institute of Nuclear Power Operations, which was created in 1979 following the nuclear accident at the Three Mile Island plant in Pennsylvania. That group, whose inspection teams conduct regular evaluations of nuclear plants and assess training programs, is widely credited with improving plant safety and performance.

"You can invest in safety now, or you can pay for failure later," Mr. Reilly says in the speech. "An oil spill of national significance may now put the very survival of any but the largest company in peril."

It's unclear how the industry will respond to Mr. Reilly's message. At a recent commission hearing, Nancy Kete, the commission's senior adviser on corporate safety, acknowledged the oil industry's structure was "much more complicated" than the nuclear industry's, with more service providers and more types of technology.

"There's a small number of very large companies and then a large number of smaller companies, and so the cost of something like this and the influence of something like this will be more complicated," Ms. Kete said. "I don't think we can design it for them, but I think that they can handle that."

Write to Stephen Power at stephen.power@wsj.com

Clarence Irving Lewis, "Mind and the World Order"

事实、虚构和预测 　
(我在許多方面都受益於 C. I. Lewis 的著作 感謝他是天經地義的 甚至不必處處提起

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W. Edwards Deming《轉危為安》四處提到 C. I. Lewis

舉兩例

"不論我們信念多強，必須隨時記得經驗數據是永遠無法十全十美的。(7)"--

(7)參考Clarence Irving Lewis, "Mind and the World Order"(Scribner's, 1929; Dover, 1956)，第6-9章。

沒有理論基礎的經驗，是無用的。事實上，除非有一些理論，否則經驗甚至不能加以記錄。雖然有時理論是粗糙的，但它能引導出一假設及系統，使人得以據此將觀察分類（5）。有時候靠預感，不管它是對或錯，便足以導向有效觀察的充分理論。

什麼是（經營 ）系統？（What is the system? ）對管理人員而言，其系統包含

（5）參考C. I. Lewis, Mind and the World Order（Scribner, 1929；Dover, 1956）, p.195.

Vanguard News 月刊– December 2010

Vanguard News – December 2010

In this issue:

The Leaders Summit

Owen Buckwell wins leadership prize

Health will get going in 2011

Consultation limited to doing the wrong thing righter

But commissioning is a problem

Councils have been ‘set free’

When ‘set free’ means sacked

One review you must send evidence to

If it looks like a duck...

NHS inquiry looking into systemic issues

D-I-Y Fundamentals

Two events for the New Year

Other Vanguard Events

***

The Leaders Summit

We had a huge turnout for the Leaders Summit last week – over 400 people came and by all accounts it was a great day. Portsmouth City Council and Plymouth NHS Trust were like bookends on the day’s presentations, the former has improved housing services and halved the cost, the latter stroke care... and halved the cost. If the same were done across all housing and health services we’d be wondering why we worried about the crunch.

Leaders from financial services (BNP Paribas Fortis and Aviva) showed how they had dismantled scale designs and achieved incredible economics through flow, leaders of local authorities talked about the amazing results they have achieved through applying the method to their services and, in particular, how ‘place’ is better understood and designed on the basis of demand. And Advice UK gave a powerful illustration of the way in which they have re-designed advice services to make them work for people in need (as well as it being pointed out for the umpteenth time that hundreds of millions is being spent mopping up failure demand from HMRC and DWP, why doesn’t that bother ministers?).

What was interesting is that while these organisations had applied the Vanguard Method across very different services, all found the same counterintuitive truths. They were stunning presentations, there were lots of questions, plenty of chat and lots friends and new people to meet; a great day. If you missed it Simon Caulkin is writing a summary of the day, it will be posted on the web site in a week or so.

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Owen Buckwell wins leadership prize

Gary Hamel has created something called the Management Innovation Exchange (MIX), a site arguing for the need to re-think management. We posted Owen Buckwell’s story (‘Forget your people, act on the system’) in the Leadership category and it won! Read more here:

http://www.managementexchange.com/blog/m-prize/announcing-m-prize-winners-audacity-imagination-experimentation

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Health will get going in 2011

My prediction for the New Year is that health will get started on systems thinking. The results in Plymouth will stimulate interest as stroke is a major concern for many Trusts. We are also receiving many enquiries about what the Vanguard Method could do in health and the current change of regime provides an opportunity to do the right thing. The work in Plymouth showed how stable demand is; it is a profound revelation and means there is fantastic scope for improving services as costs are driven out. I am looking forward to it.

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But commissioning is a problem

I gave evidence to the Health Select Committee a couple of days ago. I went to explain why commissioning as currently practised (and labelled World Class!) drives costs up. The committee was concerned about whether moving commissioning to GPs is going to work. It is interesting, there is a general consensus that it didn’t work too well when done in PCTs but, as ever, instead of learning about why, much of the evidence focused on peoples’ views and prejudices surrounding the impending move. It is, as Deming taught, a mistake to treat experience as knowledge. What we need is a better health system, not a move of a bad system.

I got the opportunity to explain how commissioning creates costs through its failure to absorb variety. The limited evidence we have currently suggest it may be inflating costs by as much as 100%. But the evidence so far is growing and it parallels the finding in housing where the schedule of rates does the same, and for the same reasons.

Will the committee pursue this issue? I doubt it, but at least the evidence is on the record. I know we’ll be pursuing it next year. We’ll have to if we want to design a system that will work.

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Consultation limited to doing the wrong thing righter

The Cabinet Office and Treasury are conducting a consultation for the up-coming White Paper on public sector reform. Their call for evidence says, “In particular, if you would like to contribute your views, suggestions and expert knowledge on where these reforms could improve a specific public service based on your experience of running or managing a service, the Government wants to hear from you!”. Hurray! A great opportunity for systems thinkers to put forward their evidence?

But hold your horses and read on... “The Secretariat will delete from its records any responses that are ....not directly relevant to the questions being considered”. And the questions being considered? They are about the independent provision of public services, employee run services, external investment, ‘innovative’ payment by results commissioning (sic) and so on. Nothing asking whether these are the right things to do. Nothing asking for knowledge of what works.

They are asking for evidence to support their prejudices, it can only lead to doing the wrong thing righter. If systems thinkers respond with evidence of true public service reform, or evidence of how adherence to these models is driving up costs and worsening services their responses will be deleted.

That’s how the centre ‘listens’.

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Councils have been ‘set free’

In a recent speech, the housing minister told councils they have been set free. No longer are they subject to tick-box targets. But the minister expressed his concerns about council managers exhibiting ‘Stockholm Syndrome’, the psychological attachment of the abused to their abuser. But in truth I think the current syndrome is more like schizophrenia, for while this minister issues no targets, he has ignored the evidence on some other major causes of costs, for example Choice-Based-Lettings, and continues to advocate it. In families with parents who say one thing and do another we find higher incidence of schizophrenia. You’re free unless, of course, you are not.

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When ‘set free’ means sacked

Local authority managers who run the housing benefits service have been told by the Department of Work and Pensions that their local benefits service will be no more when the new universal single benefit comes into effect in 2017. The idea is that the new benefit will be available on-line and via one national call centre. Local offices not required.

Systems thinkers who have developed extremely efficient and fast benefits services, saving millions, are up in arms. They not only provide a fast service, they provide a whole service, sorting out other things that need sorting, like bus-passes, school meals and housing issues, at the same time. They know that problems are not service-shaped but person-shaped. They also know that specialisation, back-offices and call centres merely create more demand with the benefits service.

I know some people have written to the minister to explain that the plans for the universal benefit are wrong-headed and will drive up costs. Will they get a good listening to or will they get the sack? If you know about benefits processing please add your voice by writing to the minister driving all this, Lord Freud. Get your lead members to understand what is going on, politicians talk to each other. We have to stop them wasting yet more of our money on these ideological and wrong-headed schemes.

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One review you must send evidence to

The demise of the Audit Commission is raising concerns in some quarters (not here!). The Communities and Local Government Select Committee is conducting an inquiry into audit and inspection of local authorities.

I am submitting evidence on the following lines: Audit is not without value judgement. The idea of ‘best practice’ should be abandoned. The ‘value for money’ methodology used by the Audit Commission has little to do with value for money. ‘Better’ is a more constructive lodestar. Responsibility for innovation must be with the innovator. Inspection of performance should be limited to one question (I think you know the question) and citizen redress should be given teeth.

I think it would be helpful if people in the know sent evidence of the unreliability and lack of validity in Audit Commission inspections, how inspection has forced people to do things that make performance worse and evidence of how better services have been improved by not following Audit Commission / DCLG prescriptions.

My fear is that the committee will think re-inventing performance audit in some fashion will be a good idea. It is a very bad idea. You can find out how to submit evidence here:

http://www.parliament.uk/business/committees/committees-a-z/commons-select/communities-and-local-government-committee/inquiries/audit--com/

Please do so. It can only help.

***

If it looks like a duck...

“If it looks like a duck and quacks like a duck, then we have to consider the possibility that it is a duck”

So they say with the re-introduction of targets (as ‘not targets’) in health. The Department of Health wants unscheduled admissions down by 20%, A and E attendances down by 10% and length of stay in hospitals down by 25%. But, as usual, no idea about method. You can read the article here:

http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4127836&c=2

And the DoH wants call centres to deal with GP appointments. Imagine how much failure demand and cost they will create. How much is commissioning contributing to extended stays in hospital? Quite a lot. How much cost do the DoH initiatives and directives create?

It’s a duck for sure. A goal without a method. We should shoot it. Before it causes havoc.

***

NHS inquiry looking into systemic issues

The inquiry into the Staffordshire disaster is moving into the ways in which regulation has been central to the problems. It is one to watch. Go to:

http://nhslocal.nhs.uk/story/inside-nhs/cure-nhs-says-too-much-regulation-undermines-health-care

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D-I-Y Fundamentals

Something NEW from Vanguard, exclusively for local authorities

To respond to increasing interest in the Vanguard Method amongst local authorities and to help local authority managers respond to the current financial challenges, we have developed a do-it-yourself Systems Fundamentals programme.

This three-day programme is an introduction to the Vanguard Method. It won’t give you all the help you may need to make significant changes to your services but it does serve as a powerful introduction and it works as a self-scoping exercise, participants will see the value they could get if they were to pursue the method. Some do so, on their own, and they do well; the only advantages in getting help from an expert are speed, less mistakes, and, generally, a bigger improvement. We advise avoiding help from pretenders, we have created a market for systems thinking, you’d be amazed at those who say they can do it.

The Fundamentals programme is an action-learning programme, participants get to follow the Model for Check for transactional services (like benefits, care services etc). Everything you need is provided; you just need to find a place to run it, the means to show a DVD which is the basis for most of the teaching content and a service that you want to study as part of the programme. It has been tested with a number of local authorities; hence we are confident that it works without the need for an expert in the room.

We are offering the Fundamentals D-I-Y programme for an introductory price of £1,500 plus VAT. It is designed for a group of up to 12 participants. Should you wish to re-use the programme we will charge you £100 plus VAT per delegate trained. These and other details of the programme logistics will be sent to you for you to understand more fully what is required to run the programme successfully.

We are planning to make further low-cost help available to local authorities next year.

If you would like to purchase the Fundamentals D-I-Y programme please nominate one person who will be responsible for delivering it and ask that person to get in touch with Maria Brunning (office@vanguardconsult.co.uk), who will forward a detailed explanation and agreement.

***

Two events for the New Year

Inquiries into police services and care services have taken notice of systems thinkers’ evidence. It is a good time to make available to others how you study these services as systems, what you learn when you do and the principles for better service design. If they interest you, watch out for news of the events in the New Year.

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Process Mapping and Analysis for Performance Improvement

Vanguard’s most popular event

Thursday 3rd February 2011 - Belfast

Wednesday 9th February 2011 – Buckingham

Tuesday 15th February 2011 - Newcastle

Wednesday 2nd March 2011 - Manchester

Wednesday 23rd March 2011 - Buckingham

Thursday 28th April 2011 - Buckingham

Thursday 5th May 2011 - Bridgend

Wednesday 25th May 2011 - Buckingham

Thursday 30th June 2011 - Buckingham
For information and bookings: office@vanguardconsult.co.uk

***

Systems Thinking in the Public Sector: Profound Results, Profound Challenges

Thursday 17th February 2011 - London

Thursday 17th March 2011 - Newcastle

Thursday 14th April 2011 - Exeter

Thursday 19th May 2011 - Cambridge

Thursday 16th June 2011 - Cardiff

Thursday 21st July 2011 - Birmingham

For information and bookings: pr@vanguardconsult.co.uk

***

Systems Thinking: Delivering efficiency beyond imagination in your organisation

A four-day action-learning programme, based in Bridgend, Wales.
Day 1 - 3rd February 2011
Day 2 – 10th February 2011
Day 3 – 17th February 2011
Day 4 – 24th February 2011
For information and bookings: info@vanguardconsult.co.uk

Thanks for reading!

John Seddon

john@vanguardconsult.co.uk

Author: "Systems Thinking in the Public Sector”, available from Triarchy Press: www.triarchypress.com and “Freedom from command and control: a better way to make the work work" available from Vanguard (www.systemsthinking.co.uk).. “Freedom from command and control” is also available in the US from: http://www.productivitypress.com/productdetails.cfm?SKU=3276

For independent evidence of the benefits of systems thinking in the public sector see the case studies: http://www.triarchypress.com/pages/Systems_Thinking_Case_Studies.htm

Vanguard Consulting: Developers of the Vanguard Method, helping organisations change from a command and control to a systems design. Beware of imitators, as Vanguard has developed solutions for sectors others claim to be able to provide the same service. If providers are not accredited to the Vanguard Method you should not expect a Vanguard service.

www.thesystemsthinkingreview.co.uk A web-site devoted to Systems Thinking in the public sector.

Systems Thinking People – a service helping systems thinkers find suitable work and helping organisations fund suitable systems thinkers. www.systemsthinkingpeople.com

Vanguard Capchart – simple-to-use tool for creating capability measures. http://www.vanguardcapchart.com/

Other Vanguard sites around the world:

Ireland: www.vanguard-ireland.com

Scotland: www.vanguardscotland.co.uk

Netherlands: www.vanguardnederland.nl

Denmark: www.vanguard-consult.dk

Sweden: www.vanguard-consult.se

USA: www.newsystemsthinking.com

Croatia: www.vanguard-savjetovanje.hr

Belgium: http://www.vanguardbelgium.com/