事故根源综合分析表

8-6
可 能 的 系 统 原 因 POSSIBLE SYSTEM CAUSES 人 为 因 素 PERSONAL FACTORS
1. 1-1 1-2 体力 Physical Capability 视力低下 Vision deficiency 听力低下 Hearing deficiency 1-3 其它感官缺陷 Other sensory deficiency 1-4 肺活量下降 Reduced respiratory capacity 1-5 其它永久性身体残疾 Other permanent physical disabilities 1-6 暂时残疾 Temporary disabilities 1-7 无力支撑身体姿势 Inability to sustain body positions 1-8 身体活动范围受限 Restricted range of body movement 1-9 物质过敏症 Substance sensitivities or allergies 1-10 身高不够或体力不足 Inadequate size or strength 1-11 由于药物疗法造成能力 下降 Diminished capacity due to medication 1-12 其它因素 Other o 不适用 Not Applicable 2. 2-1 2-2 身体状况 Physical Condition 原先受伤或得病 Previous injury or illness 疲劳 Fatigue •由于工作量 due to workload •由于缺乏休息 due to lack of rest •由于感官超载 due to sensory overload 操作能力降低 Diminished performance •由于温度极限 due to temperature extremes •由于缺氧 due to oxygen deficiency •由于大气压变化 due to atmospheric pressure variation 血糖降低 Blood sugar insufficiency 由于使用药物或酒 精而使能力削弱 Impairment due to drug or alcohol use 3. 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9 精神状态 Mental State 判断力差 Poor judgment 记忆力丧失 Memory failure 协调不好或反应时间 长 Poor coordination or reaction time 情绪干扰 Emotional disturbance 恐惧 Fears or phobias 缺乏机械知识 Low mechanical aptitude 理解能力差 Low learning aptitude 受药物影响Influenced by medication 其它因素 Other 4. 4-1 精神压力 Mental Stress 全神贯注于别的问题 Preoccupation with problems 4-2 受到挫折Frustration 4-3 对工作方向及要求模 糊不清 Confusing directions / demands 4-4 目标或要求相冲突 Conflicting directions / demands 4-5 无意义的或品味低的 活动 Meaningless or degrading activities 4-6 情绪超负荷 Emotional overload 4-7 过激的评价/决定要求 Extreme judgment / decision demands 4-8 过度的精力集中 Extreme concentration / perception demands 4-9 极度的乏味 Extreme boredom 4-10 其它因素 Other o 不适用 Not Applicable 5. 行为 Behavior 5-1 不合格的操作受到奖赏 Improper performance is rewarded • 节省时间或努力 saves time or effort • 避免不便 avoids discomfort • 哗众取宠 gains attention 5-2 没有适当的监督示范 Improper supervisory example 5-3 对关键的安全行为没有充 分的认识 Inadequate identification of critical safe behaviors 5-4 没有充分强调关键的安全 行为 Inadequate reinforcement of critical safe behaviors • 正确的行为被指责 proper performance is criticized • 同事的不当压力 inappropriate peer pressure • 不适当的表现反馈 inadequate performance feedback • 不是当的纪律处置 inadequate disciplinary process 5-5 过分的急功好进 Inappropriate aggression 5-6 使用不适当的方法刺激生 产 Improper use of production incentives 5-7 监督暗中催促 Supervisor implied haste 5-8 雇员性急 Employee perceived haste 5-9 其它因素Other o 不适用 Not Applicable 6. 技术水平 Skill Level 6-1 对所需求技术没有充 分评估 Inadequate assessment of required skills 6-2 缺乏技术实践 Inadequate practice of skill 6-3 不经常操作的技术 Infrequent performance of skill 6-4 缺乏技术指导 Lack of coaching on skill 6-5 没有充分温习训练以 巩固技术 Insufficient review of instruction to establish skill 6-6 其它因素 Other o 不适用 Not Applicable 7. 7-1 训练/知识转换 Training / Knowledge Transfer 没有进行充分的知识转换 Inadequate knowledge transfer • 不能领会 inability to comprehend • 导师资格欠缺 inadequate instructor qualifications • 培训设备不够 inadequate training equipment • 误解指令说明 misunderstood instructions 不能充分回想起训练内容 Inadequate recall of training material • 缺乏强化培训 training not reinforced on the job • 缺少再培训 inadequate refresher training frequency 培训工作欠缺 Inadequate training effort • 培训计划设计不当 inadequate training program design • 培训目标不明确 inadequate training goals / objectives • 对新员工缺乏教育 inadequate new employee orientation • 初始培训不妥 inadequate initial training • 无法判定是否合适上岗 inadequate means to determine if qualified for job 没有提供培训 No training provided • 没有认识到培训的必要 性 need for training not identified • 培训记录不对或过期 training records incorrect or out of date • 未经培训就使用新的操 作方法 new work methods introduced without training • 故意不参加培训 decision made not to train 其它因素 Other 8. 管理/监督/员工的领导关系 Management / Supervision / Employee Leadership 角色和职责冲突 Conflicting roles / responsibilities • 报告关系不明确 unclear reporting relationships • 报告关系矛盾 conflicting reporting relationship • 职责分配不清 unclear assignment of responsibility • 职责分配矛盾 conflicting assignment of responsibility • 授权不清或不妥 improper or insufficient delegation of authority 不适宜的领导关系 Inadequate leadership • 业绩标准缺乏或力度不够 standards of performance missing or not enforced • 职责和义务不明 inadequate accountability • 执行情况反馈不够或错误 inadequate or incorrect performance feedback • 缺少现场走访 inadequate work site walk-through • 安全推广不力 inadequate safety promotion 工地和工作中隐患(危险)整改 不力 Inadequate correction of prior hazard / incident 不能明确鉴别工地和工作中危 险隐患 Inadequate identification of worksite / job hazards 不合适的变更管理系统 Inadequate management of change system 事故报告调查机制不完善 Inadequate incident reporting / investigation system 安全会议不足或没有 Inadequate or lack of safety meetings 安全业绩考核和评估不当 Inadequate performance measurement & assessment 其它因素 Other 9. 9-1 9-2 9-3 承包商的选择和审查 Contractor Selection & Oversight 承包商未进行资格预审 Lack of contractor prequalifications 承包商资格预审欠妥 Inadequate contractor prequalifications 承包商选用欠妥 Inadequate contractor selection 雇用未经审核批准的承 包商 Use of non-approved contractor 无工程监管 Lack of job oversight 工程监管欠妥 Inadequate oversight 10. 工程/设计 Engineering / Design 10-1 技术设计欠妥 Inadequate technical design • 设计输入陈旧 design input obsolete • 设计输入不正确 design input not correct • 设计输入不可用 design input not available • 设计输出不妥 design output inadequate • 设计输入不可行 design input infeasible • 设计输出不清 design output unclear • 设计输出不正确 design output not correct • 设计输出不一致 design output inconsistent • 没有独立的设计审查 no independent design review 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 10-3 潜在问题估计不足 Inadequate assessment of potential failure 10-4 人机工程学设计欠妥 Inadequate ergonomic design 10-5 施工监察欠妥 Inadequate monitoring of construction 10-6 操作准备工作评估欠妥 Inadequate assessment of operational readiness 10-7 对最初操作监察不力 Inadequate monitoring of initial operation 10-8 评估欠妥和文档变更管 理欠妥 Inadequate evaluation and / or documentation of change 10-9 其它因素 Other 11-7 o 不适用 Not Applicable 11. 11-1 11-2