E-Journal of Advanced Maintenance Vol.2 (2010) 135-148
Japan Society of Maintenology

An activity theory-based approach for industrial trouble analysis and its
application to similarity evaluation beyond the superficial resemblance
Hiroshi NARAZAKI1,*, Takashi FUKUSHIMA1 and Tetsuo SAWARAGI2
1

Production Systems laboratory, Kobe Steel, Ltd., 5-5 Takatsukadai 1-chome, Nishi-ku, Kobe,
651-2271 Japan
2
Dept. of Mechanical Engineering and Science, Graduate School of Kyoto University, Yoshida
Honmachi, Sakyo, Kyoto, 606-8501 Japan
ABSTRACT
Many industrial organizations are interested in using the past failure experiences for the educational purposes
for the prevention of future troubles and accidents as well as the improvement of the quality of their products
and services. The education often employs the style of drawing lessons from similar experiences in the past, and,concerning the similarity, it is important to look at the background causes and tacit factors such as theorganizational culture and value systems rather than the superficial phenomena such as wrong operations.
However, the analysis of such background factors tends to depend on human subjective judgments and personal
impressions. Aware of such problem, this paper discusses an approach to establish a framework to give theguideline for the analysis. Referring to Y. Engestroem’s activity theory, our framework describes a dynamical
process where a small seed of a problem propagates and grows to an explicit problem such as a trouble or an
accident. The analysis is a process of interpreting the facts in terms of the activity structure, and this enables thegeneralization and similarity evaluation of an individual case in terms of the activity structure, beyond thesuperficial and domain-specific descriptions. Using a example of a quality defect trouble in a manufacturing
process, we explain our approach and shows how an accident in a different domain can be drawn as a similarcase by looking at the inner activity structure.
KEYWORDS

ARTICLE INFORMATION

failure analysis, trouble database, accident database, activity theory,
Similarity evaluation, knowledge management

Article history:
Received 1 October 2010
Accepted 22 November 2010

1.

Introduction

Facing the increasing demands toward the assurance of quality as well as the maintenance ofsafety, the industrial organizations are paying efforts to reduce the risks for possible troubles andaccidents. One major approach for that purpose is to enhance the education that improves the skills torecognize and deal with the inherent risks for preventing possible troubles and accidents. For sucheducation, drawing lessons from past experiences is a popular style where the trainees are asked toenumerate the causes together with preventive measures. This type of training is expected to sharpen
the sensitivity to the risks and the ability of handling them. In that training, the interpreting andunderstanding the phenomena at the deep level beyond the superficial happening is essentiallyrequired to extract the general knowledge that can be applied to a situation in a different domain andcontext.
For the use of past experiences, many companies are building databases that store and share theinformation concerning troubles and accidents. From the standpoint of the information technology
tools, knowledge management systems [1][2] provide the infrastructure to build, share, and growknowledge base among the organizational members. For the effective use of the collected information,
the text mining methods [3][4] attract attentions for the efficient extraction of the information thatmeets the needs of the users' viewpoints. There are also works on the decision-support systems [5][6]that provide necessary information to those who should properly deal with the risks and crisis. Many*

Corresponding author, E-mail: narazaki.hiroshi@kobelco.com

ISSN-1883-9894/10 © 2010 – JSM and the authors. All rights reserved.

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H. Narazaki, et al./ An activity theory-based approach
for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblanceworks such as above are mainly interested in improving the efficiency in extracting and organizing theinformation to assist the users.
In this paper, in contrast to the technologies that help manage the information, we are moreinterested in the interpretation and understanding of the information collected.
The interpretation of the past experience also plays important roles in drawing lessons from theexperiences to prevent future troubles and accidents as stated above. However, it is basically in arealm of human mental process and depends on personal subjectivity and skills. We believe that it is
an important problem to establish a methodological framework for the interpretation andunderstanding process.
Hatamura's failure analysis approach [7] is a well-known approach in Japan along the above
mentioned direction. For details, see the WEB site dedicated to the theory and examples to Hatamuras failure analysis [8].
It presents the guideline for the identification of failure causes, widening the scope to theinherent factors such as the human, organizational, and environmental factors beyond the superficial
and explicit causes such as human errors. Even if the direct cause of an accident is a simple erroneous
operation by an operator, it argues that it is only accidental and the true cause lies in the backgroundfactors such as the organizational tradition and culture that has caused the erroneous operation. For
the future prevention, superficial measures such as revising manuals and strengthening rules andmonitoring are not sufficient, and the actions that eliminate the true and deep problems are necessary.
"Failure mandalas" in [8] summarizes the viewpoints that categorize the failure causes at the deep andbackground level as well as the superficial level. In practice, the analysis can proceed by checking
which of the keywords given in the failure mandalas are to be applicable. Those keywords concerning
the background factors are also useful to categorize the failure examples in a domain-independent
manner.
Our work is also along the same direction in that main concern is in the analysis of the
background factors behind the superficial phenomena. However, more interest is in supporting aprocess of understanding and interpretation. We present a framework to model a dynamical process inwhich a small seed grows and eventually becomes apparent as a failure or an accident through theinteractions among various entities. The failure mandala keywords in Hatamura's failure analysis
correspond to the snapshot descriptions during the course of such dynamical process. The analysis
from the dynamical process perspective gives us more insight on why and how a failure has occurredrather than what and what kind of failure has occurred.
Our approach is based on the notions and concepts presented in the activity theory [9]. The
activity theory offers a framework to abstract various activities using the diagram as shown in Fig. 1.
Our method describes a course of process development in terms of the entities in Fig. 1 and theinteractions among them. In [10], a criticality accident is analyzed based on the activity theory, and it
is shown that the activity theory can effectively explain the process that leads to an accident from theviewpoint of the interactions between the individuals and the organizations. This work generalizes theresult so that our approach can be applied to a wider range of industrial problems.
toolA

subject

C
rule

B

F

D
community

object→resultE
division of labor

Fig.1. A diagram that describes an activity structure136

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

Concerning the understanding and generalization of a case to an abstract structure, anotherrelated field is the natural language understanding [11] in which the generalized description of eventsare expressed by a formal language called a script language. The texts describing events are translated
to abstract descriptions by a script language by replacing the words with appropriate category labels
and variables, yielding a set of generalized and abstract patterns of events. When new textual
information is input, similar scripts are retrieved and instantiated by filling concrete words to categorynames and variables. This is effective to extract or predict implicit or missing information in the input
texts, and it is also useful to retrieve information based on the similarity. However, the similarity
remains in the superficial resemblance, and hence, it is often pointed out that it is too narrowly
defined. Our approach defines similarity in terms of the activity structure that is beyond thesuperficial and domain-specific layer, achieving a wider applicability. However, the script language isuseful to formally describe the event to avoid the ambiguity and inconsistency in the input
information. As shown later, we also use the script language as a method to describe the event.

2.

An Example Scenario

We make discussion using an example scenario as shown in Fig.2. This example is fictitious,
though based on an actual incident. In Table 1, we also show keywords that correspond to thecategories in the failure mandala. The keywords are selected subjectively by the authors.
Using the failure mandala keywords, we can search troubles that are in a different domains but
similar in the background factors, e.g., "Search the accidents caused by the insufficient information
sharing." At this moment, the choice of keywords is totally left for the subjective judgment of ananalyst. In the later discussion, we show that our approach is also used for the keyword selection
based on the analysis results based on the activity theory.
Our approach consists of the following steps:
First, ｗe translate the natural language-based descriptions of a trouble in Fig.2 using a script
language called CNM (Causal Network Model). This is done for identification of "core"
information in the texts describing the events.
Secondly, we construct the diagrams of the activity structure based on the obtained CNM
description of the trouble. This is done based on the core subjects and activities identified in theprevious step.
Thirdly, we interweave the observed facts with the interactions among the entities andsubsequent change of activity structure. Templates for analysis are given.
Lastly, we extract the scenario based on the analysis results obtained. We also show that the
failure mandala keywords that characterize the background factors are extracted from the generated
scenario.
In the following section, we explain the above steps using the example shown in Fig.2.
A claim concerning the quality defect was reported by a customer.
The investigation identified the manufacturing process that is responsible for the defect.
The quality defect was observed during the manufacturing process. However, the process operator
inappropriately judged that the defect was minor and could be repaired by a repair action on the product.
The defect was superficially removed and could not be detected using the conventional testing procedure in
the subsequent inspection process.
According to the rule, it was mandatory for the operator to report the quality problem to the management toinitiate the alert level monitoring and handling procedure.
It can be said that the judgment that the problem was classified as minor was lenient. It put higher priority
to spare the labor and cost that might have been incurred if the defect was reported to the management than
the avoidance of the more damaging quality problem.
If the discard and remake action had been applied, or at least, if the operator had notified the subsequent
inspection process of possible quality problem asking for more thorough inspection than usual as apreventive measure for quality problem, then the defect might have been detected, and the claim might havebeen avoided.
Fig. 2. A fictitious example

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance
Table 1 Features selected from the failure mandala in relation with the example in Fig.2
Category

FeatureExplanation

PersonalfactorInsufficientknowledge
Insufficient
communication

The limited effect of repair actions for repairing the quality defectwas not well understood.
The problem and possible risk was not informed to the subsequent
inspection process, resulting in the failure to apply the preventive
actions to avoid quality problem.
The optimistic judgment that the quality problem could be avoided
by repair actions turned out to be wrong.
The advantage that was close to the manufacturing process was moreweighed than the more serious damage that would be eventually
incurred.
The judgment that the quality problem was minor and repairable waspartly due to the lack of responsibility in the quality issue.

Misjudgment
Narrow outlook
Organization
al factor

Poor
organizational
culture3. Model of Manufacturing Activity based on Activity Theory
3.1.

Description of an event using a script language CNM (Causal Network Model)

Trouble reports are usually written in the natural language. Developing software that can“understand” natural language is technically quite difficult. A more realistic approach is the use of ascript language with clearly defined syntax and semantic rules to avoid the ambiguity of the meaning.
One of the most well-known script languages is the one proposed in Shank’s Conceptual Dependency
theory [11]. It classifies the predicate verbs into eleven categories such as the transfer of physicalobjects and that of messages, together with the slots to be filled by words that are the parameters tomake the description complete. We use our version of the script language called Causal Network
Model (CNM) [12]. Web use CNM because it is suitable for describing a decision-making process andsocial interactions among subjects and events. The CNM involves the descriptors such as “Motivate”
and “Satisfy” that connect an event with the psychological effects to a human being. For example, the“Motivate” link explicated that a subject is motivated to trigger a sequence of events by the result ofsome other events. The “Satisfy” link denotes the psychological satisfaction with an event. The
insufficient satisfaction may cause a subject to be motivated to trigger other events. Referring to thelinks labeled as “Motivate” and “Satisfy”, we can identify the range of subjects and actions that
constitute the crucial sequence of events.
Using the CNM script language, the example scenario in Fig.2 is summarized to the five events
labeled from E1 to E5 in Table 2. In Table 2, an each event is described by a triplet [Subject, Action
category, Content of action] in the column of “CNM description of events.” An action category
specifies the type of action such as “Perceive” and “Do,” and the parameters for the action. In thecolumn of “Relation,” the effect and temporal order of events are shown. Sequential events areconnected by “Sequence” link. The “Sequence” and “Motivate” links both specify the temporal orderamong events, but they are different in that the “Motivate” link is related to the psychological effect tothe subject and his/her decision-making while the “Sequence” link just arrays the events in thetemporal order. “Sequence(E2,E3)” denotes that E2 occurs after E2 while “Motivate(E1, operator,E2)” denotes that the event E1 has motivated the operator to cause the event E2. The operator, thesecond argument of “Motivate,” is the subject of the event E2, the third argument. “Satisfy(E2,Inspector)” denotes that the inspection operator is satisfactory with the test result described in E2.
There may be other peripheral events and subjects that appear in the trouble report, but, basically, theabove five events constitute the crucial elements. The identification of such crucial events is the majoradvantage of using the CNM script language.
A byproduct of using the CNM script language is the enhanced search capability based on theevent pattern specification such as “claims caused by the overlook of the quality defects.” This can bedone by extracting the cases that include the CNM description patterns such as [ _inspector, Not138

H. Narazaki, et al./ An activity theory-based approach
for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

Perceive, Quality defect] and [ _customer, Perceive, Quality defect] where “_inspector” and“_customer” are the variables for the unidentified quality inspector and customer. Considering that
there are various ways of expression such as “After the shipment, the claim of quality defect wasreceived” and “Though no problem had been detected at the inspection stage, the customer expressed
the complaints on the quality,” this enhanced search capability drastically decreases the labour incomparison with the case where one should read through all the reports and manually extract thecases.
Table 2 CNM (Causal Network Model) description of an example scenario

3.2.

Event

CNM description of events

RelationshipThe operator in the
manufacturing process perceives
the quality defect.
The operator in the
manufacturing process repairs
the quality defect.
The operator in the inspection
process finds no quality
problem.
The quality problem is found in
the manufacturing process of thecustomer.

E1:[Operator, Perceive, Quality
defect]Motivate(E1,Operator, E2)
Satisfy(E2,Operator)
Sequence(E2,E3)

E2:[Operator, Do, Repair action]
E3:[Inspector, not Perceive,
Quality defect]

Satisfy(E3,Inspector)
Sequence(E3,E4)

E4:[Customer, Do, Process
received product]
E5:[Customer Perceive, Quality
defect]Sequence(E4,E5)
Not Satisfy(E5,Customer)

Description of manufacturing activities in the framework of the activity theory

The activity theory describes the activity structure using the following six kinds of nodes andlinks that connect them as shown in Fig.1;
1. the subject who performs an action,
2. the object of the actions and the result of the action,
3. the tool used in the action, which can be either tangible such as machines or intangible such as
knowledge and skill,
4. the community to which the subject belongs,
5. the rules that explicitly or implicitly governs the behaviors of the subject in the community, and6. the division of labor among the members of the community.
In Fig.3 the activity structure for the example scenario in Fig.2 is shown. Three activities are involvedin this example; the manufacturing activity that yields the product, the inspection activity that tests the
product quality, and the customer’s activity that produces the final product from the supplied product.
The descriptions by the CNM in Table 2 are superimposed on the diagram. Explanations about
the activities in Fig. 3 are given below:
Concerning the manufacturing activity, the subject is the operator who yields the product using
the tool. The tool can be either a tangible one such as a machine or an intangible one such as
knowledge and skill required for the operation. The community is the organizational unit to which theoperator belongs and is responsible for producing high quality products. The rule includes theoperation standards as well as the tacit code of behaviors such as the values system shared by thecommunity members. The division of labor brings about the cooperative activity by the members toefficiently and effectively achieve the goal of the unit, i.e., the production of high quality product.
Concerning the inspection activity, the subject is the inspector, and the tool is the tools and skills
used for the inspection. The community and the division of labor are similar to those in the
manufacturing activity.
Concerning the customer’s activity, the subject is assumed to be a manufacturer that uses theshipped product as a resource. In this example, the customer failed to produce a product ofsatisfactory quality due to the defect of the supplied product.

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance
Manufacturing activity

CNM descriptions
E1:[Operator,Perceive,
Quality defect]
E2:[Operator,Do,repair]
Motivate(E1,operator, E2)
Satisfy(E2,Operator)

Subject

Tool

Manufacturing skills andequipments

A

B

F

Object→Result

Manufacturing
operator

Supply of products

Product

Tool
Sequence(E2,E3)C
Rule

D
Community

E
Divisionof laborA

Manufacturing unit

operation
standards

Subject

Subject

Inspection machineand skills

CNM descriptions
E3:[Inspector, Not Perceive,
Quality defect]
Satisfy(E3,Inspector)

F

Object→Result

A
C
Rule
B

F

Object→Result
Product

C
Rule

B

Tool

Inspector

Operation
rules

Manufacturing
activity ofa customer

D
Community
Inspection
unit

E

D
Community
CNM descriptions
E4[Customer,Do,Process]E5:[Customer, Perceive,
Quality defect]
Sequence(E4,E5)
Not Satisfy(E4,Customor)

E
Divisionof labor

Division of labor
Inspection activity

Sequence(E2,E4)

Fig. 3. An activity structure for the example scenario in Fig.2

Those three activities are connected by the links as shown by the dotted line in Fig. 3. There canbe other peripheral activities such as the training activity that outputs the skilled operator for the
manufacturing and inspection activities and the research and development activity that outputs thetools of the manufacturing and inspection activities. However, these are beyond the scope of thecurrent analysis the scope of which is defined by the CNM descriptions in Table 2.
When a problem arises at some point in the activity structure, however small it may be, it may
propagate to other elements, growing to the extent that it ends up with a damage that ruins the whole
activities. The activity theory enlists the following four types of contradiction as the source of suchproblem;
1. the contradiction of the first type that appears within a node in the diagram,2. the contradiction of the second type that appears between the neighboring nodes in the diagram,
3. the contradiction of the third type that appears during the transition phase in an activity, and4. the contradiction of the fourth type that appears between the nodes of different activities.
The process leading to a trouble is explained in terms of the above four types of contradiction,and the changes in the activity structure to resolve them.
3.3.

Activity-based analysis of a process

The activity theory discusses that the contradiction of the first type is generated by the gap
between the utility and exchange values of an entity in the activity structure. Consider a doctor as asimple example. A doctor is a medical expert who should cure the patients, but at the same time,he/she is a professional to earn money to sustain his/her life. If he/she finds that the payment is not
sufficient to continue the medical service, the contradiction of the first type becomes apparent.

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

See Fig.4a for an illustration. Consider a case where a subject performs an action for a recipient,i.e., an object. From the viewpoint of the recipient, the utility value of the subject is expressed by thequality of his/her action. Then, the utility value recognized by the recipient is expressed by theexchange value in the form of the reward such as payment. Suppose that the subject’s action is not somuch useful for the recipient as the subject believes to be. In other words, if the usefulness does notmeet the standard expected by the recipient, then this gap recognized by the recipient is expressed in
the reward that turns out to be less than the value expected by the subject. This gap of the rewards
makes apparent the gap of the utility values between the subject and the recipient apparent. In thiscase, the contradiction of the first type is recognized at the subject. Following the convention of theactivity theory, this recognized contradiction is written as “The utility value that the subject currently
has vs. the utility value that the subject is expected to have.” From the viewpoint of the exchange
value, this can be rephrased as “The reward that the subject thinks appropriate vs. the reward that therecipient offers,”
The scenarios to level the gap are twofold as shown in Fig.4b. In the first case, the subject who
has recognized the gap is motivated to acquire higher skills, improving the quality of work to meet theutility value expected by the recipient. In other words, the actual utility value is improved to the
expected level, and this in turn leads to the increase of the reward. Then the gap is filled and thecontradiction is resolved both at the subject and the recipient. This is the case along the path (1), (2),and (3A) in Fig. 4b. On the contrary, there may be the case where the recognized gap at the subject
causes the loss of motivation to continue the work or the decrease of work quality. In this case, theutility value recognized by the recipient further decreases and widens the gap at the recipient. This
may finally result in a catastrophic situation such as the withdrawal or the firing of the subject. It
should be noted that, in the first scenario, the contradiction of the first type is propagated to the tool,i.e. the current skill vs. the skill that should be acquired to meet the demands of the recipient. In
contrast, in the latter scenario, the contradiction is held within the subject until it reaches to anunsustainable point.
The viewpoint of the subject

Exchange value
expressing the usefulness

The expected utility value believed by the subject

Work quality

The viewpoint of the recipient

The expected utility value entertained by the recipient

Recognition of gap

Recognition of gap

The actual utility value appreciated the recipients

RewardThe actual utility value observed by the recipient

Fig. 4a Gap between the expected and actual utility values(3A) Improvement of skill that contributes to theimprovement of(3B) Loss of motivation for maintaining the work
quality that may further lower the actual utility
value appreciated by the recipient

The viewpoint of the subject(1)The work quality does not meet the
expected standard of the recipient.

Exchange value
expressing the usefulness

The expected utility value believed by the subject

Work quality

Recognition of gap

The actual utility value appreciated the recipients

The viewpoint of the recipient

The expected utility value entertained by the recipient

Recognition of gap
RewardThe actual utility value observed by the recipient(2)Recognition of actual utility value throughthe exchange value expression

Fig. 4b Two possible scenarios to cope with the recognized contradiction

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

Table 3 lists the keywords that characterize the contradiction of the first type for each element in
the activity structure. In general, the contradiction of the first in Table 3 is related to a question: “Isthere any gap between the expected level and the actual, realized, or recognized level?” For example,
from the viewpoint of functional capability and effectiveness in Table 3, the contradiction can bestated as “The functional capability that is currently realized vs. the functional capability that should
be realized.” In the natural language expression, various expressions are possible for describing thecontradiction, but we insist that the contradiction can be categorized into one of the classes listed inTable 3. These categories are defined mainly considering industrial applications. We have no intention
to insist that the categories in Table 3 are universal. A different application may result in a different setof categories.
Element

Expected vs. Actual
Performance quality- efficiency- quality
Capability- skill and knowledge
subject- decision-making and judgment
Attitude- motivaton- sincerity and earnestness
Functional capability- effectiveness- efficiency- reliability
Usabilitytool- easy to use- easy to introduce and deploy- easy for maintenance
Optimality- smaller redundancy and waste
Validness- correctness- precisenessrule- completeness
Practicality- operability- publicity
Effectiveness as a community- cooperative performance- solidarity- information and value sharing
Soundness
community- mission and vision- compliance- governance
Adaptability- autonomous adaptability- self transform
Effectiveness- rationality
division of labor- efficiency- flexibility
attibutes to be achieved- quality- safety
object- quantity- cost- competetive advantage

Table 3 List of keywords that characterize contradiction142

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

The contradiction of the second type occurs between the neighboring nodes. The contradiction of
the first type propagates to the neighboring node, giving rise to the contradiction in the second type.
The contradiction of the second type is the source of changing the activity structure. For example,
suppose that the operator finds the gap between the utility value from the self viewpoint and that fromthe others’ viewpoint. The gap can be filled by letting the contradiction propagate to the contradiction
at the tool such as “the expected effectiveness vs. the actual effectiveness.” Then, the contradiction of
the second type becomes appear between the tool and the subject, arousing the motivation forimproving the tool capability, and the method of using the tool. In contrast, if the contradiction at the
subject is left unsolved until it reaches to the unsustainable point, a catastrophic result such as theoperator quitting the job, or some accident triggered by a simple mistake may occur.
The contradiction of the third type is the transition of the structure within an activity. The
springboard that resolved the contradiction of the second type is implemented by a small group, and it
may cause a tension between the older activity and the newer activity. Soon the new activity structure
may be widely accepted to replace the old activity. It should be noted that, when considering a trouble
case, the change is not always in the positive direction. For example, the contradiction of the second
type between the subject and rule may be resolved by the negligence of the rule and it may become
prevalent among the members of the community.
The contradiction of the fourth type is that between the nodes in different activities. In the above
example in Fig.2, the contradiction of the object in the manufacturing activity such as the quality
defect is propagated to the object of the customer’s activity.
3.4.

Analysis of an example in Fig.2

The application of the above mentioned approach to the trouble case in Fig.2 is shown in Fig.5.
In white balloons, the contradictions of the first type are shown with the category label selectedfrom Table 3 and the case specific description in the form of “A vs. B” with the selected option
underlined. The contradiction of the first type propagates to the neighboring nodes, causing thecontradiction of the second type. The behaviors selected to resolve them are written in the rectangles
on the links. There are cases where the new behavior is acquired by the innovation that brings about aprogress, but in many trouble cases, a selected behavior tends to be superficially effective in the shortterm but risky and more harmful in the long term. Even in the case where such behavior is recognized
as a temporal emergency escape, it often becomes customary under the lack of compliance andgovernance. This transition is caused by the contradiction of the third type, i.e. the contradiction
between the two different activity patterns in the same activity structure. Depending on the cases, thetransition may be either in the positive direction that leads to a progress or in the negative directionthat leads to a trouble or an accident. The contradiction of the fourth type becomes apparent between
the neighboring activities that are connected by the dotted lines. Dark balloons associated with the
behaviors written on the links show the failure mandala keywords, indicating the relevance toHatamura’s failure analysis.
The causes of overlooking the quality defects are twofold at the manufacturing activity as
indicated in the two behaviors written in the rectangles on the links. First, instead of selecting thecostly but thorough repair action that can completely remove the quality defect, the operator has
chosen the easier but incomplete operation. Secondly, there is the organizational culture, labeled as“incomplete compliance,” that allows an easy but risky behavior to be selected. In this case, the above
two behaviors are rooted in the contradictions of the first type between the subject and tool, andbetween the subject and the community, respectively. The insufficient risk assessment of the operator
was the cause for the inappropriate judgment, and this comes from the contradiction of the first typedescribed as “optimistic and lenient vs. careful and thorough” in the category “Capability:
decision-making and judgment” in Table 3. Similarly the tool and the community are associated withthe contradictions categorized as “Functional capability: effectiveness” and “Soundness: governance,”
respectively, with more detailed description in the form “A vs. B.”. Though detailed descriptions in
the form "A vs. B" may be dependent on individual cases, the categories are defined so that theyshould be domain-independent to make them useful for drawing the similarity at the activity structurelevel in a cross-domain manner.

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

Fig. 5. An activity-theory based analysis of a trouble case in Fig. 2.

The quality defect generated at the manufacturing unit failed to be detected by the usual testingprocedure at the inspection unit. The background for this failure is also two fold. First, the lack of
information sharing has made difficult for the inspector to apply a preventive tool such as a severer
testing procedure. Secondly, if the preventive measure had been autonomously applied based on therisk assessment, the quality defect might have been blocked. The inspection unit determines the levelof testing precision considering the balance between the cost and the effect. There is always adecision-making problem what cost needs to be accepted to optimize the balance. This leads to thecontradiction of the first type at the subject such as “Capability: decision-making and judgment”
concerning the risk assessment. This contradiction may well initiate the activity that improves the tool
for more effective quality defect detection, or the activity that revises the information sharing rule.
These new activities lead to the progress, and the perspectives for designing new activities can belearned through the analysis at the activity structure level as discussed here. Connecting the failure
analysis to the design of new activities for progress is important and necessary. This is our major
future work, but at this moment, we continue our discussions, focusing on the analysis.
By extracting the behaviors in the rectangles, we obtain a scenario for the trouble as shown in
Fig.6. Fig. 6 is a chronological and logical sequence of what has happened, and in general terms, canbe regarded as a fact-based scenario of a trouble. As explained above, our analysis is more concernedwith the factors why they have happened in terms of the contradictions and their resolutions in theactivity structure.

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for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance
Manufacturing activity
Between the subject and the tool
Application of simple but unreliable operation
to remove the quality defect

Between the subject and the tool
Incomplete compliance to avoid the preventive and careful
actions such as the report to the inspection process

Between the manufacturing activity and the inspection activity
Lack of the information concerning the possible quality defectInspection activity
Between the subject and the tool
Application of insufficient testing method that
may overlook the inherent quality defect
Between the inspection activity and the customer’s manufacturing activity
Supply of product having quality defectA customer’s manufacturing activity
Between the subject and the object
Quality defect detected

Fig. 6. A fact-based scenario for a trouble case in Fig.2

3.5.

Summary of our approach
We summarize our approach stated in the above explanations as follows:

Step 1: Identify the crucial part of the trouble by describing the phenomena using the CNM script
language.
Step 2: Construct the diagram of activity structure based on the CNM description. Identify thecontradiction of the first type at each node referring to the list in Table 3.
Step 3: Identify the contradictions of the second type between the neighboring nodes. Write theselected behaviors that have been taken to solve the contradiction.
Step 4: Write the effects that have happened between the neighboring activities.
Step 5: Construct a scenario for the trouble by extracting the selected behaviors and the effects
between the neighboring activities in the steps 3 and 4.
Step 6: Associate failure mandala keywords with the selected behaviors.
The steps 5 and 6 are introduced to relate our approach with the conventional fact-based scenario
construction and the categorization based on the background failure causes. The scenario describes
what has happened in the chronological order. For each event, a category label in the failure mandala
can be assigned. As seen here, the failure mandala is the categorization and characterization of theevents happened while our approach is the description of the process concerning why and how theevents have happened. Said differently, the failure mandala describes what has happened and ourapproach describes how it has happened.
In the next section, this approach can draw a similarity at the activity structure level in a crossdomain manner.

4. Similarity over Different Domains
The purpose of this section is how the activity structure level analysis can draw the similarity
with a case in a different domain beyond the superficial resemblance characterized by keywords andlinguistic expressions. Using a criticality accident at JCO plant for an example, we show how ourapproach can draw similarity with the trouble example in Fig. 2 at the activity structure level. The
outline of the JCO accident is shown in Fig. 7. See Figures 8 and 9 for the activity theory-based
analysis and the extracted scenario that describes the chronological sequence of events.

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H. Narazaki, et al./ An activity theory-based approach
for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance…….A criticality accident occurred at a uranium fuel processing facility. ….. The facility was used to process
the low-enriched uranium of the uranium 235 with the density from 3 to 5%. Several times in a year, thefacility was asked to process the high-enriched uranium of the uran 235 with the density 18.8%. The facility
for low-enriched uranium was used for the convenience of the operation. The accident occurred at the lasthomogenization process. When several batches of uranyl nitrate solutions were poured into the container, thestate suddenly turned into the criticality state, emitting a large amount of neutron rays.…….. In a word, thecause of the accident was nothing but the fact that they used the settling tank that was used for a different
purpose and hence was not designed to meet the requirement to prevent the criticality state. Furthermore,they poured into the tank the uranyl nitrate solution that was more than the criticality mass. The containerthat should have been used for this purpose was not used for the convenience of work. This decision did not
go through the necessary permission process by the authority , and on that day, they changed it to a different
container without any appropriate permission.…
Fig.7. Abbreviated extraction concerning the criticality accident shown in
http://shippai.jst.go.jp/fkd/Detail?fn=0&id=CC0300004&
Op eration activity

Insufficient knowledge
Inappropriate judgment

Capability; Risk assessment
and decision -making:complicated but legitimate vs.
simple but illegal

Functional Capability:
effectiveness: easy to use b ut
unstab le vs. laborious but stableTool
A
Use of simp le but illegal
operation metho d

Subject
Poor organizational
cultu reRule C

B

ck
La

of

m
co

p

e
nc
li a

F

Safety: low-risk vs. high-risk
Object→Result

Overlook of danger
for critical accident

DE

Co mmunity

Divisiono f labor

Operation activity

Tool
ASoundness: Gov ern ance; weak vs. strict

Accident

Functional capability :Effectiveness; easy vs. precise

Managemen t activity

AC

Overlook o f an
inapprop riate operation method
Subject

B

B

F

Rule

Object→Result

Inappropriate
jud gment

Safety; low-risk v s. high-risk

C
Ru le

D
Commun ity

F

Object→Rule

Lack of in formation
concern in g the risk

Tool

Capability; Risk assessment
and decision ; careful and risksensitive vs. q uick and easy

Su bjectD
Community

E
Divisionof lab or

Capability; Risk assessment anddecision: wron g operation vs. riskpreventive operation

E
Divisiono f labor

Fig.8. An analysis of a criticality accident

We briefly describe the analysis process of this criticality accident case.
The seed of the accident was generated in the operation process where the simple but dangerous
operation method had been in use. This was the result of the conflict between the operator that wanted
to maximize the efficiency and the operation rule that required rigorous and authorized methods. The
insufficient risk assessment led to the wrong decision that the operator selected a simple but illegal
operation method. This situation had been overlooked due to the insufficient information sharing
between the operation unit and the technical management unit. However, if the management hadexerted sufficient control actions based on the proper risk awareness and the governance principles,
then the illegal operation might have been removed. As a result of the continuation of the high-risksituation, a criticality accident occurred triggered by a wrong operation.
The scenario is summarized in Fig.9.

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H. Narazaki, et al./ An activity theory-based approach
for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

Fig. 9. A scenario extracted from the activity theory-based analysis

Comparing figures 6 and 9, the similarity between the quality defect trouble and the criticality
accident is rather clear. The criticality accident is similar to the quality defect example in that theyshare the features such as the inappropriate judgment and the poor organizational culture. In otherwords, the two cases share the same characteristics in their causes from the viewpoint of failure
mandala. From the viewpoint of the process, they share the similarity in the following two points:
First, Insufficient knowledge and lack of awareness about the risk have led the operator to thedecision in favor of simpler operation method that is useful in the narrow scope.
Secondly, the lack of awareness about the possibility that a more dangerous situation might
happen, the management or the inspection activities had failed to take preventive actions.
In terms of the schematic diagram of activity structures, the similarity is apparent in thefollowing respects: The contradiction between the subject and tool, and the contradiction between thesubject and community in the first activity propagate to the second activity. The contradiction between
the subject and tool in the second activity propagates to the third activity. Finally, in the third activity,
the trouble has become apparent. This structural similarity can be easily seen in Figures 5 and 8. Thissimilarity is also reflected to the fact-based scenarios in Figs.6 and 9, which naturally leads to thesimilarity in terms of the failure mandala keywords associated with the scenarios.
Though superficially quite different, we find that these two cases share the similarity in its process
and characterization of the events by analyzing the cases from the viewpoint of the activity structure.
This can be a basis for drawing lessons from preceding cases.

5. Conclusion
When we talk about the failure analysis, the main interest tends to be in the physical causal
analysis of the phenomena or the direct triggering cause such as machine failure and human errors.
Admitting the importance of such analysis, we also weigh the importance of identifying the deep
background factors such as knowledge, decision-making, attitudes and organizational culture. The
importance of identifying background factors has been already recognized and there already exist
works as stated in the introduction. We proposed an approach for the analysis of deep factors based on
the activity theory, and this contributes to establishing the methodology that analysis why and how afailure has occurred beyond merely stating subjective impressions. Using a quality defect trouble case,we showed how to carry out the activity theory-based analysis, and how to derive the scenario and147

H. Narazaki, et al./ An activity theory-based approach
for industrial trouble analysis and its application to similarity evaluation
beyond the superficial resemblance

keywords that categorize and characterize them in a domain independent manner. Further we showedthat we can draw similarity between two superficially different examples in different domains using
the above mentioned quality defect trouble and the criticality accident. This is expected to be useful indrawing lessons from the experiences for the educational purposes. This can also be useful todesigning new activities that lead to the progress, by focusing on the resolution of the contradiction
extracted.
Another important direction of our future work is concerned with the remedial actions. Our
analysis suggests that the remedial actions should be also beyond the superficial level such as revisingmanuals and reinforcing education. As we showed, the trouble occurs when the contradiction is
confined within an entity to the unbearable level, collapsing to the negative resolution. In contrast, by
propagating the contradiction to other entities, a new activity or a change in the activity structure maytrigger the progress to resolve the contradiction in the positive direction. For example, thecontradiction at the operator such as “current skill vs. desired skill” should be propagated to the tool
as “current tool vs. more effective tool,” motivating a new activity to find better method for
production. Thus, the remedial actions should be discussed from the viewpoint of designing and/orchanging the activity structure.
Though we believe in various possibilities and usefulness of our novel approach, we admit that
our work needs more refinement and verification, including the discussions for remedial actions. Our
future efforts are directed toward that direction.

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