事故根本原因分析检查表

Accid.,Incid.& N.M. 事故、事件和未遂事故
People performance 员工的行为
Not fit for duty 不能胜任工作
Root cause analysis of accidents, incidents and near-misses 事故、事件和未遂事故根本原因分析表 事故、
Accid.,Incid.& N.M. 事故、事件和未遂事故
Equipment/material 设备和物质材料
Maintenance 维修
Root cause analysis of accidents, incidents and near-misses 事故、事件和未遂事故根本原因分析表 事故、
Accid.,Incid.& N.M. 事故、事件和未遂事故
Environment 环境
Root cause analysis of accidents, inຫໍສະໝຸດ Baiduidents and near-misses 事故、事件和未遂事故根本原因分析表 事故、
First Level Root Causes 一级根本原因 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67
First Level Root Causes 一级根本原因 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Material Design or construction 设计或构造
Second Level Root Causes 二级根本原因
Third Level Root Causes 三级根本原因
Accid.,Incid.& N.M. 事故、事件和未遂事故
Risk assessment 风险评估
Task 工作安排和执行
9 10 11 12 13 14 15 16 17
Risk assessment 风险评估
Root cause analysis of accidents, incidents and near-misses 事故、事件和未遂事故根本原因分析表 事故、
Root cause analysis of accidents, incidents and near-misses 事故、事件和未遂事故根本原因分析表 事故、
First Level Root Causes 一级根本原因 1 2 3 4 5 6 7 8
PPE Tools 工具
Second Level Root Causes 二级根本原因
First Level Root Causes 一级根本原因 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Management 管理 Second Level Root Causes 二级根本原因 Third Level Root Causes 三级根本原因 Accid.,Incid.& N.M. 事故、事件和未遂事故
Improperly programmed machine 设备运行程序编制不当 Inadequate reviews (SHE audits, PSSR, …) 检查不到位（SHE审核，开车前检查等） Unavaibility of documentation files 没有运行程序的说明文件 Machine without adequate guard 设备上无合适的防护装置 Equipment used outside of its capabilities and limitations 超能力和超极限使用设备 Controls including emergency stop buttons not clearly labelled or differentiated 包括紧急停止开关在内的各种控制按钮未明确标识或区分 No maintenance 没有维修 Equipment failure 设备故障 Inadequate maintenance (lack of spare parts, lack of scheduled maintenance, lack of preventive maintenance, …) 维修不当（缺乏备件、缺乏定期维修或预防性维修等等） Obsolescence of equipment 使用报废或超期服役的设备 Safety devices out of order 安全设施失效 Software or hardware not updated 软件或硬件未更新 Unavailable Material Safety Data Sheet 没有物质安全数据表 Hazardous materials not identified 未辨识出有害物质 Presence of gas or fumes 存在有毒气体或异味 Improper labelling 标签不当
Behaviour 行为 Mistake 失误 Competency 能力
Second Level Root Causes 二级根本原因
Third Level Root Causes 三级根本原因
Lack of experience of the worker in performing this task 执行任务的员工经验不足 No training 未接受过培训 Training not understood 未理解所培训的内容 Documents improperly interpreted 对文件的理解有误 Doesn’t understand information 没有理解所收到的信息 Worker distracted in the workplace 工作时注意力不集中 Too much judgment required to perform the task 完成工作任务需要做出许多判断 Too much information at the same time 在同一时间内需要了解的信息过多 Fatigue 疲劳 Physically unable for the job 身体条件无法胜任工作 Alcohol, drugs or medicines 酒精、毒品或药品 Under stress for work or personal reasons 有来自工作或个人方面的压力 Horseplay 工作时玩闹 Use without authorisation 擅自使用设备、工具等 Defeat safety devices without authorisation 擅自摘除安全设施 Lack of motivation 缺乏积极性 Lack of vigilance 警惕性不强
Deliberate mistake 故意出错 Inattention to details of procedure 忽视了操作程序的部分细节 Not defined, inadequate, not implemented, not complied with 没有制定制度、制度不完善、制度未颁布实施或未被遵守 Work permit procedure (and Standard doesn’t exist or not enforced LOTO procedures) 没有制定标准规范或未强制实施 作业许可（以及挂牌上锁程序） 作业许可（以及挂牌上锁程序） Guidelines for judgment unavailable 没有作业情况判别指导书 Not defined, inadequate, not implemented, not complied with 没有制定制度、制度不完善、制度未颁布实施或未被遵守 Standard doesn’t exist or not enforced Management of change 没有制定标准规范或未强制实施 变更管理 Guidelines for judgment unavailable 没有制定变更管理的判别指导书 Not defined, inadequate, not implemented, not complied with 没有制定制度、制度不完善、制度未颁布实施或未被遵守 Standard doesn’t exist or not enforced 没有制定标准规范或未强制实施 Guidelines for judgment unavailable Other procedures 没有作业情况判别指导书 其它的规程 Work instructions are not clearly written 作业指导写得不清楚 Work instructions are not complete 作业指导不完整 Proper training to perform the task not administered to the worker 没有针对员工所从事的作业任务提供适当的培训 Workers not trained properly 员工培训不到位 Testing performed not significant Training 培训后的测试流于形式，没有发挥功效 培训 No training for wearing PPE 没有进行PPE穿戴的培训
Third Level Root Causes 三级根本原因
No SWR 未进行安全工作审核 Handling or loading is not adequately specified 搬运和装卸没有明确的规定 Tools in bad condition 工具状况不良 Tools not available 没有工具 Inadequate or wrong tools for the job 作业中使用了不恰当的或错误的工具 Improper gauges 计量仪表不合适 PPE in bad condition PPE状况不良 PPE not available 没有PPE Inadequate PPE for the job 使用的PPE不恰当 No warning signs 没有警示标识 Risk assessment of the equipment or of the process not done 未对设备或工艺进行风险评估 Hazard not identified 未辨识出危害 Inadequate risks controls 风险控制不当 Equipment badly designed or badly constructed 设备的设计或构造有缺陷 Standards not applied or inadequate 未执行相关标准或采用了不适合的标准 Equipment or software cannot support the usage 设备或软件不能满足使用的需求 Inadequate man/machine interface 人机界面不当
First Level Root Causes 一级根本原因 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Communication 沟通 Housekeeping 现场整洁 Local environment 当地的环境 Ergonomics 人机工程
Second Level Root Causes 二级根本原因
材料
Third Level Root Causes 三级根本原因
Quality requirements of materials inadequate 对材料的质量要求不当 Contaminated material 材料被污染 Material handled improperly (storage, distribution, usage or disposal) 材料的处理不当（存储、运输、使用或处置） Inadequate sampling 采样不当 Awkward positions 使用不便 Bad design of man/machine interface 人机界面有缺陷 Process affected by conditions over the course of a day 生产工艺经常变换带来影响 Process affected by humidity, vibration, noise, lighting,… 生产工艺受到湿度、震动、噪音和光线等的影响。 Too much noise 噪音大 Poor lighting 照明不足 Extreme temperatures 极端温度 Influence of weather 天气的影响 Mess 脏乱 Slippery floor 地面滑 Obstacles 有障碍物 Information improperly disseminated 信息传递不正确 Forget to communicate 忘记沟通