事故根本原因分析检查表

Second Level Root Causes
Co二m级m根un本ic原at因ion 沟通
Competency 能力
Mistake 失误
Not fit for duty 不能胜任工作
Third Level Root Causes 三级根本原因
Forget to communicate 忘记沟通 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
Accid.,Incid.& N.M. 事故、事件和未遂事
People performance 员工的行为
First Level Root Causes
一级根本原因 63 64 65 66 67 68 69
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
20
没有运行程序的说明文件
Machine without adequate guard
21
设备上无合适的防护装置
Accid.,Incid.& N.M. 事故、事件和未遂事
22
Equipment used outside of its capabilities and limita百度文库ions
超能力和超极限使用设备
38
39
40
41
42
43
Environment
44
环境
45
46
47
48
49
Material 材料
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
Second Level Root Causes
二级根本原因
Ergonomics 人机工程
Third Level Root Causes 三级根本原因
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
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
Second Level Root Causes
二级根本原因
Behaviour 行为
Third Level Root Causes 三级根本原因
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
23
24
25
Equipment/material 设备和物质材料
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
Accid.,Incid.& N.M. 事故、事件和未遂事
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
First Level Root Causes
一级根本原因
Second Level Root Causes
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
Quality requirements of materials inadequate 对材料的质量要求不当
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
Maintenance 维修
Material 材料
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）
First Level Root Causes
一级根本原因
1
2
3
4
5
Task
工作安排和执行 6
7
8
9
10
11
12 13
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
Second Level Root Causes
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）
First Level Root Causes
一级根本原因 37
16
设备或软件不能满足使用的需求
Inadequate man/machine interface
17
人机界面不当
Improperly programmed machine
18
设备运行程序编制不当
19
Design or construction 设计或构造
Inadequate reviews (SHE audits, PSSR, …) 检查不到位（SHE审核，开车前检查等） Unavaibility of documentation files
71
作业许可（以及挂牌上锁 Standard doesn’t exist or not enforced
程序）
没有制定标准规范或未强制实施
Guidelines for judgment unavailable
72
没有作业情况判别指导书
Not defined, inadequate, not implemented, not complied
73
with
Management of change 没有制定制度、制度不完善、制度未颁布实施或未被遵守
变更管理
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
First Level Root Causes
Equipment failure 设备故障
First Level Root EquipmCaeunst/emsaterial
设一备级和根物本质原材因料
26
27 28 29 30 31 32 33 34 35
36
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
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
Accid.,Incid.& N.M. 事故、事件和未遂事
Not defined, inadequate, not implemented, not complied
70
Work permit procedure with
(and LOTO procedures) 没有制定制度、制度不完善、制度未颁布实施或未被遵守
First Level Root Causes
一级根本原因
50
51
52
53
54
55
56
57
58
59
People performance 员工的行为
60
61
62
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
Accid.,Incid.& N.M. 事故、事件和未遂事
Local environment 当地的环境
Housekeeping 现场整洁
Communication 沟通
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。
二级根本原因
Third Level Root Causes 三级根本原因
Equipment badly designed or badly constructed
14
设备的设计或构造有缺陷
Standards not applied or inadequate
15
未执行相关标准或采用了不适合的标准
Equipment or software cannot support the usage
二级根本原因 Risk assessment
风险评估
Tools 工具
PPE
Risk assessment 风险评估
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
一级根本原因
Second Level Root Causes