事故根源综合分析表 Comprehensive List of Causes

为
因
素
5 5-1
PERSONAL FATORS
行为 Behavior 不合格的操作受到奖赏 Inproper 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 5-3 5-4 没有适当的监督规范 Improper supervisory example 对关键的安全行为没有充分的认识 Inadequate identification of critical safe behaviors 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 stress ·不适当的表现反馈 inadequate performance feedback ·不适当的纪律处置 inadequate disciplinary process 5-5 5-6 5-7 5-8 5-9 过分的急功好进 Inappropriate aggression 使用不适当的方法刺激生产 Improper use of production incentives 监督暗中催促 Sueprvisor implied haste 雇员性急 Employee perceived haste 其他因素 Other 不适用 Not Applicable 7-3 6 技术水平 Skills Level 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 inablity 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 7-2 不能充分回想起训练内容 inadequate recall of training material ·缺乏强化培训 Training not reinforce on thr job ·缺少再培训 inadequate refresher training frequency 培训工作欠缺 inadequate trainig effort ·培训计划设计不当 inadequate training program design ·培训目标不准确 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 qulified for job 没有提供培训 No traning provided ·没有认识到培训的必要性 need for training not identified ·培训记录不对或过期 training records incorrect or out of date ·未经培训就使用新的操作方法 new work methods introdued without traiing ·故意不参加培训 decision made not to train 7-5 其他因素 Other 不适用 Not Applicable 8 8-1 管理 /监督 /员工的领导关系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 assignmnet of responsibility ·授权不清或不妥 improper or insufficient delegation of authority 8-2 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 accoutability ·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 8-3 8-4 8-5 8-6 8-7 8-8 8-9 工地或工作中隐患（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 其他因素 Other 不适用 Not Applicable 9 9-1 9-2 9-3 9-4 9-5 9-6 9-7 承包商的选择和审查 Contractor Selection & Oversight 承包商未进行资格预备审 Lack of contractor pre-qualifications 承包商资格预审欠妥 Inadequate contractor pre-qualifications 承包商选用欠妥 Inadequate contractor selection 雇佣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 其他因素 Other 不适用 Not Applicable 10 10-1 工程 /设计 Engineering/Design 技术设计欠妥 Inadequate technical design ·技术输入陈旧 design input obsolete ·技术输入不正确 design input not correct ·技术输入不可用 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
·Collect Evidence 收集证据
根源分析第2步：找出关键起因 RAC Step 2: Identify Critical Factors
· Analyze Information 分析所收集的信息 · Cause Factor Charting 重建起因事件链
位置 Positions
文件 Paper
4-1 决定欠妥或缺乏判断 Improper decision making or lack of judgement 4-2 注意力分散 Distracted by other concerns 4-3 忽视地面和周围环境 Inattention to footing and surroundings 4-4 嬉闹 Horseplay 4-5 暴力行为 Acts of violence 4-6 未做警告 Failure to warn 4-7 使用药物或酒精 Use of drugs or alcohol 4-8 无思索地进行常规活动 Routine activity without thought 4-9 其他因素 Other
6-1 设备有缺陷 Defective equipment 6-2 设备不足 Inadequate equipment 6-3 设备准备不够 Improperly prepared equipment 6-4 工具缺陷 Defective tools 6-5 工具欠妥 Inadequate tools 6-6 工具准备不妥 Improperly prepared tools 6-7 车辆有缺陷 Defective vehicle 6-8 车型和用途不符 Inadequate prepared vehicle 6-9 车辆准备欠妥 Improperly prepared vehicle 6-10 其他因素 Other
2-1 设备使用欠妥 Impreoper use of equipment 2-2 工具使用不当 Improper use of tools 2-3 使用有缺陷设备（明知） Use of detective equipment(aware) 2-4 使用有缺陷工具（明知） Use of detective tools (Aware) 2-5 工具、设备和材料放置欠妥 Improper placement of tools, equipments and materials 2-6 设备操作速度欠妥 Operation of equipment at a improper speed 2-7 对正在运行的设备进行维修 Servicing of equipment in operation 2-8 其他因素 Other
事故根源综合分析表
事故 INCIDENT
人证 People 解决方案
Solutions
物证 Parts
Comprehensive List of Causes
调查准备 Preparation Investigation 根源分析第一步：收集证据 RCA Step 1: Data Collection
条
件
7
类
CONDITIONS
8 作业场所环境/布置 Work Place Environment / Layout
8-1 拥挤或活动受制 Congestion or restricted motion 8-2 照明不适或光线太强 Inadequate or exxcessive illumination 8-3 通风不宜 Inadequate ventilation 8-4 无保护的高度 Uprotected height 8-5 工作场所布局不妥 Inadequate work place layout · 缺乏控制 controls less than adequate · 安置不妥 display less than adequate · 标示不妥 labels less than adequate · 位置超出可及或势力范围 locations out of reach or sight · 相矛盾的信息 confliciting information is presented 8-6 其他因素 Other
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可能的系统原因 POSSIBLE SYSTEM CAUSES
人
1 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-1 体力 Physical Capbility 视力低下 Vision Deficiency 听力低下 Hearing deficiency 其他感官缺陷 Other sensory deliciency 肺活量下降 Reduced respiratory capacity 其他永久性身体残疾 Other permanent physical dsiablities 暂时残疾 Temporary disability 无力支撑身体姿势 Inability to sustain body position 身体活动范围受限 Restricated range of body body movement 物质过敏症 Substence sensitivities or allergies 2 身体状况 Physical Condition 3 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9 精神状态 Metal State 判断力差 Poor Judgement 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 mechniacal aptitude 理解能力差 Low learning aptitude 受药物影响 Influenced by medication 其他因素 Other 不适用 Not Applicable 4 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9
根源分析第3步：根源分析
可能的直接原因 POSSIBLE SYSTEM CAUSES
行
1 遵守工作程序方面 Following Procedure 2 工具或设备使用 Use of Tools or Equipment
为
类
ACTIONS
4 疏忽/缺乏安全意识 Inattention/ Lack of Awareness 5 保护系统 Protective Systems 6 工具、设备及车辆 Tools- Equipment & Vehicles
7-1 明火和爆炸性物品 Fire or explosion 7-2 噪音 Nosie 7-3 带点系统 Energized electrical systems 7-4 除电力外能源系统 Energized systems, other than electrical 7-5 辐射 Radiation 7-6 极温 Temperature extremes 7-7 化学危险品 Hazardous chemicals 7-8 机械危险物 Mechanical hazards 7-9 凌乱或石屑碎片 Clutter or debris 7-10 风暴或自然现象 Storms or acts of nature 7-11 地面或过道打滑 Slippery floors or walkways 7-12 其他因素 Other
5-1 护罩和保护性装置不够 Inadequate protective guards or protective devices 5-2 护罩和保护性装置缺陷 Defective guards or protective devices 5-3 个人保护用品不适宜 Inadequate personal protective equipment 5-4 个人保护用品缺陷 Defective personal protective equipment 5-5 警示系统不适 Inadequate warning systems 5-6 警示系统缺陷 Defective warning system 5-7 工艺或设备隔离不妥 Inadequate isolation of process or equipment 5-8 安全装置欠妥 Inandequate safety devices 5-9 安全装置有缺陷 Defective safety devices 5-10 其他因素 Other
· Document the type/severity of event 记录事故的类型和严重程度 · Cover the who/what/when/where/how as known as the time包括所涉及的人、事件、时间、地点和目前的进展
·People, Parts, positions and paper 认证、物证、位置和文件
3 保护方法的使用Use of Protective Methods 3-1 缺乏隐患存在意识
Lack of knowledge of hazards present 3-2 未使用个人保护用品 Personal protective equipment not used 3-3 个人保护用品使用不正确 Improper use of proper personal protective equipment 3-4 动力设备维修保养 Servicing of energized equipment 3-5 设备和材料未能固定 Equipment or material not secured 3-6 保护装置、警示系统或安全装置失效 Disabled guards, warning systems or safety devices 3-7 保护装置、警示系统、安全装置拆卸 Removal of guards, warning systems or safety devices 3-8 没有个人保护用品 Personal protective equipment not available 3-9 其他因素
工作暴露 WLeabharlann Baidurk Exposures to
1-1 个人违规 Violation by individual 1-2 集体违规 Violation by group 1-3 监督违规 Violation by supervisor 1-4 未经许可操作设备 Operation of equipment without authority 1-5 工作位置或姿态不正确 Improper position or posture for the task" 1-6 超体能工作 Overexertion of physical capability" 1-7 工作或运载速度不适宜 Work or motion at improper speed" 1-8 吊装欠妥 Improper lifting" 1-9 加载欠妥 Improper loading 1-10 走捷径 Shortcuts 1-11 其他因素 Other