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TQM To err is a human Don Berwick 7 7 5% 2
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ISO 9001 ISO 9001 (1995) ISO9000 25 395-405 4
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ISO9000 ISO9001 1987 1994 2000 1 ISO9001 2 ISO9001 1 3 ISO9001 ISO9001 4 ISO9001 ISO9001 22
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[ ] [1] 1985 [2],,, 2002ISO9000 [2000 ] 5. [1] TO ERR IS HUMAN [2] Williams[3] NHEPNominal Human Error Probability HEARTHuman Error Assessment and Reduction Technique HEART 8 NHEP NHEP NHEP 5-1 1 24
1 1 1 2 [4][5][6][7][8] 42 3 5-2 1 25
[4] 2 1 2 2 1 3 3 2 2 [5] AFPM Assessment for Fool Proofs in Manufacturing 26
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TQM ISO9000 [ ] [1], 2000 [2] 1996 [3]J.C.Williams HEARTa proposed method for assessing and reducing human error (1986)in 9th Advance in Reliability Tech. Symp. Univ. of Bradford [4] 1984 Vol.14 No.2, 128-135 [5] 1985 Vol.15, No.1, 41-50 [6] 1985 1 Vol.15, No.4, 350-359 [7] 1986 2 Vol.16, No.1, 4-13 [8] 2002 Vol.32, No.2, 225-237 [9] 1984 Vol.14, No.2, 128-135 Vol45 1 4 29
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ISO9001 ISO9001 1. 1.1. 1.2. 1.3. ISO90002000 ISO90012000 9001:2000 7.5.1 7.5.5 ISO9001 7 1.4. 1 2 3 4 5 6 1.5. 2. 3. 4 3.1. 6.1 3.1.1. 5.5.16.2.1 3.1.2. 6.3 60
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