事故根源综合分析表

• • Collect Evidence 收集证据 • • • People, Parts, Positions and Paper 人证、 物证、位置和文件 • • • Preserve Evidence 保护证据 • 可能的直接原因 Possible immediate causes 1 2 3 4 5 6 工具、设备及车辆 Tools, Equipment & Venires 7 8 1-1 2-1 3-1 4-1 5-1 6-1 设备有缺陷 Defective equipment 7-1 8-1 1-2 2-2 3-2 4-2 5-2 6-2 设备不足 Inadequate equipment 7-2 8-2 1-3 2-3 3-3 4-3 5-3 6-3 设备准备不够 Improperly prepared 7-3 8-3 1-4 2-4 3-4 4-4 5-4 6-4 工具缺陷 Defective tools 7-4 8-4 1-5 2-5 3-5 4-5 5-5 6-5 工具欠妥 inadequate tools 7-5 8-5 1-6 2-6 3-6 4-6 5-6 6-6 工具准备不妥 Improperly prepared tools 7-6 1-7 2-7 3-7 4-7 5-7 6-7 车辆有缺陷 Defective Vehicle 7-7 1-8 2-8 3-8 4-8 5-8 6-8 车型和用途不符 Inadequate vehicle for the purpose 7-8 1-9 3-9 4-9 5-9 6-9 车辆准备欠妥 Improperly prepared vehicle 7-9 1-10 5-10 6-10 其它因素 Others 7-10 1-11 7-11 8-6 7-12 可能的系统原因 Possible system causes 1 体力 Physical Capability 2 身体状况 Physical condition 3 精神状态 Mental State 4 精神压力 Mental Stress 5 行为 Behavior 6 技术水平 Skill Level 7 训练/知识转换 Training/ Knowledge transfer 8 管理/监督/员工的领导关系 Management/ supervision/ Employee 9 承包商的选择和审查 contractor selection & oversight 10 工程/设计Engineering/ Design 11 工作 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 Work Planning 12 采购、材料处理及材料控制 Purchasing, Material handing & Material 13 工具和设备 Tools & Equipment 14 工作规程/政策/ 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 /程序（PSP） Work Rules/ Policies /Standards /Procedures(PSP) 15 沟通 Communication 1-1 视力低下 Vision deficiency 2-1 原先受伤或得病Previous injury or illness 3-1 判断力差 Poor judgment 4-1 全神贯注于别的问题 Preoccupation with problems 5-1 不合格的操作近观到奖赏 Improper performance is rewarded 6-1 对所需求技术没有充分评 估 Inadequate assessment of required skills 7-1 没有进行充分的知识转换 inadequate knowledge transfer 8-1 角色和职责冲突 Conflicting roles/ responsibilities 9-1 承包商未进行资格预审 Lack of contractor pre-qualifications 10-1 技术设计欠妥 inadequate technical design 11-1 工作计划欠妥 Inadequate work planning 12-1 收货项目与订购项目不符 Incorrect item received 13-1 需求和风险评估欠妥 Inadequate assessment of needs and risks 14-1 执行任务缺乏PSP Lack of PSP for the task 15-1 在同伴间水平沟通不完善 Inadequate horizontal communication between peers 1-2 听力低下 Hearing deficiency 2-2 疲劳 Fatigue 3-2 记忆力丧失 Memory failure 4-2 受到挫折 Frustration •节省时间努力 saves time or effort 6-2 缺乏技术实践 Inadequate practice of skill •不能领会 inability to comprehend •报告关系不明确 unclear reporting relation ship 9-2 承包商资格预审欠妥 inadequate contractor per-qualifications •设计输入陈旧 design input obsolete 11-2 预防性保养欠妥 Inadequate preventive maintenance •给供应商的 规范 编程规范下载gsp规范下载钢格栅规范下载警徽规范下载建设厅规范下载 不正确 Inadequate specification to vendor 13-2 人的因素及人机控制考虑欠缺 Inadequate human factors/ ergonomics considerations •缺乏PSP的详细职责 lack of defined responsibility for PSP 15-2 上下级间垂直沟通不完善 Inadequate vertical communication between supervisor and person 1-3 基它感觉缺陷 Other Sensory Deficiency •由于工作量 Due to workload 3-3 协调不好或反应时间长 Poor coordination or reaction time 4-3 对工作方向及要求模糊 不清 Contusing Directions /demands •避免不便 avoids discomfort 6-3 不经常操作的技术 Infrequent performance of skill •导师资格欠缺 inadequate instructor qualifications •报告关系矛盾 conflicting reporting relation ship 9-3 承包商选用欠妥 inadequate contractor selection •设计输入不正确 design input not correct •维护需求评估 assessment of needs •订购书上的规范不明确 inadequate specification on requisition 13-3 标准和堆满不合适 Inadequate standards or specifications •缺乏作业安全分析 lack of job safety analysis 15-3 不同机构间沟通不完善 Inadequate communication between different organizations 1-4 肺活量下降 Reduced Respiratory Capacity •由于缺乏休息 due to lack of rest 3-4 情绪干扰 Emotional disturbance 4-4 目标或要求相冲突 Conflicting directions •哗众取宠 gains attention 6-4 缺乏技术指导 Lack of coaching on skill •培训设备不够 Inadequate training equipment •职责分配不清 unclear assignment of responsibility 9-4 雇用未经审核批准的承包商 use of non-approved contractor •设计输入不可用 design input not available •润滑/维修 lubrication/ servicing •对订单修改控制不当 inadequate control on changes to orders 13-4 不适当的可用性 Inadequate availability •作业安全分析不当 inadequate job safety analysis 15-4 工作组之间沟通不完善 Inadequate communication between work groups 1-5 其它良久性身体残疾 Other Permanent Physical disabilities •由于感官超载 due to sensory overload 3-5 恐惧 Fears or phobias 4-5 无意义的或品味低的活 动 Meaningless or degrading activities 5-2 没有适当的监督示范 improper supervisory example 6-5 没有充分温习训练以巩固 技术 Instruction to establish skill •误解指令说明 misunderstood instructions •职责分配矛盾 conflicting assignment of responsibility 9-5 无工程监管 Lack of job oversight •设计输入不妥 design output inadequate •调整/装配 adjustment/ assembly •供应商未经批准擅自更换替代品 unauthorized substitution 13-5 调节、修理、保养欠妥 Inadequate adjustment/ repair /maintenance 14-2 PSP工作展开不力 Inadequate development of PSP 15-5 班组之间沟通不完善 Inadequate communication between shifts 1-6 暂时残疾 Temporary disabilities 2-3 操作能力降低 Diminished performance 3-6 缺乏机械知识 Low mechanical aptitude 4-6 情绪超负荷 Emotional overload 5-3 对关键的安全行为没有充 分的认识 inadequate identification of critical safe 6-6 其它因素 Other 7-2 不能充分回想起训练内容 inadequate recall of training material •授权不清或不妥 improper or insufficient delegation of authority 9-6 工程监管欠妥 inadequate oversight •设计输入不可行 design input infeasible •清洁/涂层 deaning/ resurfacing •产品验收不完善 inadequate product acceptance requirements 13-6 废旧物品和再次利用物资处理不妥 Inadequate salvage and reclamation •程序和设备设计不相一致 inadequate coordination with process /equipment design 15-6 沟通方法不完善 inadequate communication methods 1-7 无力支撑身体姿势 Inability to sustain body positions •由于温度极限 due to temperature extremes 3-7 理解能力差 Low learning aptitude 4-7 过渡的评价/决定要求 Extreme judgment/ decision demands 5-4 没有充分强调养分的安全 行为 inadequate rein for cement critical safe behaviors □ 不适用 Not Applicable •缺乏强化培训 Training not reinforced on the job 8-2 不适宜的领导关系 Inadequate lead ship 9-7 其它因素 Other •设计输出不清 design output nuclear 11-3 维护性保养欠缺 Inadequate repair •未进行产品验收 no acceptance verification performance 13-7 不合适部件白拆卸和更换欠妥 Inadequate removal/ replacement of unsuitable items •员工参与PSP制定安排不当 Inadequate employee involvement in the development 15-7 沟通手段缺乏 No communication method available 1-8 身体活动范围受限 Restricted range of body movement •由于缺氧 due to oxygen deficiency 3-8 受药物影响 Infected by medication 4-8 过度的精力集中 Extreme concentration /perception demands •正确的行为被指责 proper performance is criticized •缺乏再培训 inadequate refresher training frequency •业绩标准缺乏或力度不够 standards of performance missing or not enforced □ 不适用 Not Applicable •设计输出不正确 design output not correct •维修需求信息沟通 communication of needed repair 12-2 对材料和研究不足 Inadequate research on materials/ equipment 13-8 无记录档案 No equipment record history •纠正行为的详细说明不充分 inadequate definition of corrective action format for easy use 15-8 指令不准确 Incorrect instructions 1-9 物质过敏症 Substance sensitivities or allergies •由于大气压变化 due to atmospheric pressure variation 3-9 其它因素 Other 4-9 极度的乏味 Extreme boredom •同事的不当压力 inappropriate peer pressure 7-3 培训工作欠缺 Inadequate training effort •职责和底图不明 inadequate accountability •设计输出不一致 design output inconsistent •工作计划安排 scheduling of work 12-3 产品运输方式线路欠妥 Inadequate mode or route of shipment 13-9 设备记录档案不完备 Inadequate equipment record history 14-3 由于内容不完善，PSP执行不力 Inadequate implementation of PSP, due to deficiencies 15-9 工作更换没有很好沟通 Inadequate communication due to job turnover 1-10 身高不够或体力不足 Inadequate size or strength 2-4 血糖降低 Blood sugar insufficiency □ 不适用 Not Applicable 4-10 其它因素 Other •不适当的表现反馈 inadequate performance feedback 培训计划设计不当 inadequate training program design •执行情况反馈不够或错误 inadequate or incorrect performance feedback •没有独立的设计审查 no independent design review •部件检查 examination of parts 12-4 材料处理欠妥 Improper handling of materials 13- 10 其它因素 Other •自相矛盾的要求 contradictory requirements 15- 10 安全和健康保护资料、规章 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 或指导准 则没有很好沟通 Inadequate communication of safety and health data, regulations or guidelines 1-11 由于药物疗法造成能力下降 Diminished capacity due to medication 2-5 由于使用药物或酒精而使能 力削弱 Impairment due to drug or alcohol use □ 不适用 Not Applicable •不适当的纪律处置 inadequate disciplinary process •培训目标不明确 inadequate training goats/ objectives •缺少现场走访 inadequate work site walk- through 10-2 所采用标准、规范和设计指导思 想欠妥 inadequate standards, specifications, and /or design criteria •部件更换 parts substitution 12-5 材料或零件保管不妥 Improper storage of materials or spare parts □ 不适用 Not Applicable •混乱含糊的格式 confusing format 15- 11 没有使用标准术语 Standard terminology not used 1-12 其它因素 Other 2-6 其它因素 Other 5-5 过分的急功好进 Inappropriate aggression •对新员工缺乏教育 inadequate new employee orientation •安全推广不力 inadequate safety promotion 10-3 潜在问题估计不足 inadequate assessment of potential failure 11-4 过度磨损和撕裂 Excessive wear and tear 12-6 材料包装不妥 Inadequate material packaging •每一步超过一个行为 more than one action per step 15- 12 没有使用查证和重复技术 Verification /repeat back techniques not used □ 不适用 Not Applicable □ 不适用 Not Applicable 5-6 使用不适当的方法刺激生 产 Improper use of production incentives •初始培训不妥 inadequate initial training 8-3 工地和工作中隐患（危险）整改不力 inadequate correction of prior hazard/ incident 10-4 人机工程学设计欠妥 inadequate ergonomic design •使用计划不当 inadequate planning for use 12-7 材料存放超期 material shelf lift exceeded •程序中无确认步骤 no check-off spaces provided 15- 13 口信过长 Messages too long 5-7 监督暗中催促 Supervisor implied haste •无法判断是否合适上岗 inadequate means to determine if qualified for job 8-4 不能明确鉴别工地和工作中危险隐患 inadequate identification of worksite /job 10-5 施工监察欠妥 inadequate monitoring of construction •超期服役 extension of service life 12-8 危险品不能正确鉴别 Improper identification of hazardous materials •不准确的步骤顺序 inaccurate sequence of steps 15- 14 讲话干扰 Speech interference 5-8 雇员性急 Employee perceived haste 7-4 没有提供培训 No training provided 8-5 不合适的变更管理系统 inadequate management of change system 10-6 操作准备工作评估欠妥 inadequate assessment of operational •装载不当 improper loading 12-9 使用不当或废弃材料处理 improper salvage and /or waste disposal •混乱模糊的指令 confusing instructions 15- 15 其它因素 Other 5-9 其它因素 Other •没有认识到培训的必要性 need for training not identified 8-6 事故报告调查机制不完善 inadequate incident reporting/ investigation system 10-7 对最初操作监察不力 inadequate monitoring of initial operation •未经训练的人使用 use by untrained people 12- 10 健康安全资料使用不当 Inadequate use of safety and health data •技术性错误 technical error /missing steps □ 不适用 Not Applicable □ 不适用 Not Applicable •培训记录不对或过期 training records incorrect or out of data 8-7 安全会议不足或没有 inadequate or lack of safety meetings 10-8 评估欠妥和文档变更管理欠妥 inadequate evaluation and /or documentation of change •使用意图错误 use for wrong purpose 12- 11 其它因素 Other •过多的说明 excessive references •未经培训就使用新的操作方法 new work methods introduced without training 8-8 安全业绩考核和评估不当inadequate performance measurement& assessment 10-9 其它因素 Other 11-5 有关参考资料或文献资料不足 Inadequate reference materials or □ 不适用 Not Applicable •潜在的情形没有覆盖 potential situations not covered •故意不参加培训 decision made not to train 8-9 其它因素 Other □ 不适用 Not Applicable 11-6 审核/检查/监视欠缺 Inadequate audit/ inspection / monitoring 14-4 PSP强化措施不力 Inadequate enforcement of PSP 7-5 其它因素 Other □ 不适用 Not Applicable •无文件 no documentation •对工作缺乏监察 inadequate monitoring of □ 不适用 Not Applicable •未明确整改责任 no correction responsibility assigned •监督知识不足 inadequate supervisory knowledge •整改措施不落实 no accountability for corrective action •强化不充分 inadequate reinforcement 11-7 工作安排欠妥 Inadequate job placement •没有纠正不符合 non-compliance not •没有确定合适的人选 appropriate personnel not identified 14-5 PSP沟通传达不力 Inadequate communication of PSP •没有可用的合适人选 appropriate personnel not available •给工作组分发不完全 incomplete distribution to work groups •没有提供合适的人选 appropriate personnel not provided •培训整合不完善 incomplete integration with training 11-8 其它因素 Other •不妥的翻译 inadequate translation to appropriate languages □ 不适用 Not Applicable •已过时的PSP仍在使用 Out of data revisions still in use 14-6 其它因素 Other □ 不适用 Not Applicable •缺乏控制 controls less than adequate •安置不妥 displays less than adequate •标示不妥 labels less than adequate •位置超出可及或视力范围 location out of reach or sight •相矛盾的信息 conflicting information is presented 其它因素 Others 作业场所环境/布置 Work place Environment/ Layout 拥护或活动受制 Congestion or restricted motion 照明不适或光线太强 Inadequate or excessive illumination 通风不宜 Inadequate ventilation 无保护的高度 unprotected height 工作场所布局不妥 Inadequate work place layout幅射 Radiation 极湿 Temperature extremes 凌乱或石屑碎片 Clutter or debris 风暴或自然现象 Storms or acts of nature 地面或过道打滑 Slippery floors or walkways 其它因素 Other 工具使用不当 Improper use of tools 使用有缺陷设备(明知) Use of defective equipment (aware) 加载欠妥 Improper loading 走捷径 Shortcuts 其它因素 Others 工作暴露 Work Exposures to 明火和爆炸物品 Fire or explosion 噪音 Noise 带电系统 Energized electrical systems 除电力外能源系统 Energized system, other than electrical 保护装置、警示系统或安全装置失效 Disabled guards, 保护装置、警示系统、安全装置失效 Disabled guards, 其它因素 Other 集体违规 Violation by group 监督违规 Violation by supervisor 未经许可操作设备 Operation of equipment without authority 工作位置或姿态不正确 Improper position or posture for the task 超体能工作 Overexertion of physical capability 工作或运载速度不适宜 Work or motion at improper speed 吊装欠妥 Improper lifting 没有个人保护用品 Personal protective equipment not available 其它因素 Others 无思索地进行常规活动 Routine activity without thought 其它因素 Others 保护方法的使用 Use of Protective Methods工具或设备使用 Use of Tools or Equipment 使用有缺陷工具(明知) Use of defective tools (aware) 工具、设备和材料放置欠妥 Improper placement of tools, 设备操作速度欠妥 Operation of equipment at improper speed 对正在运行的设备进行维修 Servicing of equipment in operation 未作警告 Failure to warn 使用药物或酒精 Use of drugs or alcohol 遵守工作程序方面 Following Procedures 个人违规 Violation by individual 设备使用欠妥 Improper use of equipment 缺乏隐患存在意识 Lack of knowledge of Hazards present 未使用个人保护用品 Personal protective equipment not used 个人保护用品使用不正确 Improper use of proper personal 动力设备维修保养 Servicing of energized equipment 设备和材料未能固定 Equipment of materials not secured 个人保护用品不适宜 Inadequate warning systems 个人保护用品缺陷 Defective personal protective equipment 安全装置欠妥 Inadequate safety devices 安全装置有缺陷 Defective safety devices 其它因素 Others 决定欠妥或缺乏判断 Improper decision making or lack of judgment 注意力分散 Distracted by other concerns 忽视地面和周围环境 inattention to footing and surrounding 嬉闹 Horseplay 暴力行为 Acts of violence 警示系统不适 Inadequate warning systems 警示系统缺陷 Defective warning systems 工艺或设备隔离不妥 Inadequate iodation of process or equipment 化学危险品 Hazardous chemicals 行为类 Actions 条件类 Conditions 保护系统 Protective systems疏忽/缺乏安全意识 Inattention/ Lack of Awareness 护罩和保护性装置不够 Inadequate guards or protective devices 护罩或保护性装置有缺陷 Defective guards or protective devices RCA Step 2: Identify Critical Factors Identify Critical Cause Factors 识别事故关键起因 Analyze information 分析所收集的信息 Causal Factor Charting 重建起因事件链 管理体系要素 Managerment system Document the type /Severity of event 记录事故的类型和严重程 Cover the who /what / when / where / how as know at the time 包括 所涉及的人、事件、时间、地点和目前的进展 Investigation team establishment 成立事故调查小组 机械危险物 Mechanical hazards Preparing Investigation 人为因素 Job factors 工作因素 Job factors 调查准备 根源分析第1步：收集证据 RCA Step 1: Data Collection 根源分析第2步：找出关键起因 领导及职责 Leadership and Accountability 风险评估和管理 Risk Assessment and Management 人员、培训和行为 People, Training and Behaviors 与承包商和其它方合作 Working with Contractors and others 装置设计和安装 Facilities Design and Construction 实施和运行 Implementation and Operation 变更管理 Management of change 信息和文档 Information and Documentation 客户和产品 Customers and Products 社区和相关方意识 Community and stakeholder Awareness 危机和应急管理 Crisis and Emergency Management 事故分析和预防 Incidents Analysis and Prevention 评估、保障和改进 Assessment Assurance & Improvement 事故 For each identified critical factor, consider if any of the listed rort cause categories apply. if 'yes', circle the specific root cause. If none of the root causes in the category apply, then check the 'not applicable' box at the bottom of the column. 针对每个关键起因，逐个分析所列的事故根源是否适用。 如果适用的话，选定具体的根源编号和说明。如果找不到 相应的根源起因，则可选定每栏下面的‘不适用’项。 损失 LOSS People, property, 事故 INCIDENT Contact with energy or substance 直接起因 IMMEDIATE CAUSES Unsafe acts and conditions 系统原因 BASIC CAUSES Inaderquate programme or comliance 缺乏控制 LACK OF CONTROL Inadequate management system 引 发 C A U S A T IO N 调 查 IN V E S T A G A T IO N 物证 parts 文件 Paper 位置 Position 人证 People 解决 方案 气瓶 现场处置方案 .pdf气瓶 现场处置方案 .doc见习基地管理方案.doc关于群访事件的化解方案建筑工地扬尘治理专项方案下载 Solution BB BB BB BB BB BB BB BB BB BB Cause Analysis May 1 May 2 Prepare Report Share Key Learnings Incident Receive Alert Notification Activate Team Develop Team Plan Analyze and Interpret Identify Immediate & System Cause(s) Develop Proposals for Corrective Actions Implement Corrective Actions & Follow-up Secure Evidence Critique Process for Continuous Improvement IncidentIncident InvestigationInvestigation Flow ChartFlow Chart Amoco Corporation, 6/97 Pre-Planning Team Selection Collect Evidence Research Additional Evidence Preparation PhasePreparation Phase Implementation PhaseImplementation Phase Research PhaseResearch Phase Corrective PhaseCorrective Phase Analysis PhaseAnalysis Phase uu Set objectives.Set objectives. uu Develop procedures.Develop procedures. uu Select & train investigators.Select & train investigators. uu Prepare investigator’s kit.Prepare investigator’s kit. uu Execute notifications.Execute notifications. uu Preserve evidence at scene.Preserve evidence at scene. uu Interview witnesses.Interview witnesses. uu Follow 4Ps technique.Follow 4Ps technique. uu Initiate data mapping.Initiate data mapping. uu Review documentation.Review documentation. uu Conduct tests or re-creations.Conduct tests or re-creations. uu Perform calculations.Perform calculations. uu Complete critical factors chart.Complete critical factors chart. uu Identify immediate causes.Identify immediate causes. uu Identify system causes.Identify system causes. uu Write report.Write report. uu Develop proposals for correctiveDevelop proposals for corrective action.action. uu Share information and learnings.Share information and learnings.