事故发生的根源分析(英文版)(ppt 50页)

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安全事故根源分析图中英文

条分缕析前车可鉴To make a root cause analysis, to learn lessons from the past 根源分析第2步：找出关键起因 PCA Step 2: identify critical factors 分析收集的信息 Analyze information 重建起因事件链 Causal factor charting 识别事故关键起因 Identify critical causal factors
可能的间接原因Possible indirect causes 个人因素Personal factors 1.行为诱因 behavior driver 1.1省时间save time 1.2嫌麻烦avoid 1.3 雇员性急 employee perceived haste 1.4同事催促 peer pressure 1.5监督催促 Supervisor implied haste 1.6不适当的行为反馈 Inadequate performance feedback 1.7不适当的激励机制 Inadequate incentive system 1.8不适当的处罚 Inadequate punishment 1.9其它因素other 不适用not applicable 2. 工作压力 Working pressure 2.1 工作量过大 work overload 2.2 焦虑或挫折 preoccupation with problems or frustration 2.3 精神负担过重 emotional overload 2.4决策或责任压力大 Extreme judgment/decision demands 2.5对工作方向及要求模糊不清 Confusing directions/demands 2.6过度的精力集中 Extreme concentration 2.7极度的乏味 Extreme boredom 2.8其它因素other 不适用 not applicable 3.心理素质 Mental capability 3.1情绪干扰emotional disturbance 3.2害怕或恐惧 fears or phobias 3.3性格问题personality 3.4 动手能力差 low mechanical aptitude 3.5理解能力差 Low learning aptitude 3.6记忆能力差 Memory failure 3.7协调或反应能力差 Poor coordination or reaction time 3.8判断力差 Poor judgment 3.9其它因素other 不适用 Not applicable 4.体能素质 Physical capability 4.1疲劳Fatigue/tiredness 4.2视力低下 vision deficiency 4.3听力低下 hearing deficiency 4.4感到体力虚弱 felt weak 4.5身高不够 inadequate size 4.6速度不当 inadequate speed 4.7物质过敏症 substance 4.8旧伤旧病复发 previous injury or illness 4.9其它感官缺陷 other sensory deficiency 4.10其它身体永久伤残 other permanent physical disabilities 4.11其它因素other 不适用not applicable 5.技能素质skill level 5.1对所需求技术没有充分评估 inadequate assessment of required skills 5.2缺少培训或证书 Lack of training or certificates 5.3故意不参加培训 Decision made not to train 5.4缺乏技术实践/练习 Lack of practice of skill 5.5缺乏技术指导 Lack of coaching on skill 5.6不经常操作的技术 Infrequent performance of skill 5.7没有查看指南以明确技术要求 not review of instruction to establish skill requirements 5.8缺乏隐患存在意识 Lack of knowledge of hazards present 5.9其它因素other 不适用not applicable

事故发生的根源分析(英文版)(ppt 50页)

受伤都是意外的，不是自觉的…
...Working Safely Is!
但工作安全是可以自觉控制的!
Why Investigate Incidents and Near misses? 为什么要调查事故和未遂事件？
Because we don’t get to pick where we land…
尽可能快当场面谈
• Put at ease 营造轻松的气氛
– fact finding, not fault finding 调查事故情况，不是调查当事人的过失
– start with easily answered questions (conditions, etc.) 以容易回答的问题开始提问（受访者身份等）
Why Investigate Incidents and Near misses? 为什么要调查事故和未遂事件？
But we can pick where we focus…
但是我们能选择努力的方向。
1 FATAL 身亡
30 DISABLING 残疾
(Severe 重伤)
300 MEDICAL 疗伤
Secondary 首要和其次问题
Leading 引导性
vs. Neutral 公正性
Individual 个人
vs. Group 小组
During the Interview 在面谈中
What techniques can you use for more effective interviews? 有效的面谈可采用哪些技巧？ • As soon as possible and at the scene
Fact Finding: Interview Questions 事件调查：面谈的问题

事故根源综合分析表(中英文)

••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 causes123456工具、设备及车辆 Tools,Equipment & Venires781-12-13-14-15-16-1设备有缺陷 Defective equipment 7-18-11-22-23-24-25-26-2设备不足 Inadequate equipment 7-28-21-32-33-34-35-36-3设备准备不够 Improperly prepared 7-38-31-42-43-44-45-46-4工具缺陷 Defective tools 7-48-41-52-53-54-55-56-5工具欠妥 inadequate tools7-58-51-62-63-64-65-66-6工具准备不妥 Improperly prepared tools 7-61-72-73-74-75-76-7车辆有缺陷 Defective Vehicle7-71-82-83-84-85-86-8车型和用途不符 Inadequate vehicle for the purpose7-81-93-94-95-96-9车辆准备欠妥 Improperly prepared vehicle 7-91-105-106-10其它因素 Others7-101-117-118-67-12可能的系统原因 Possible system causes1体力 Physical Capability 2身体状况 Physical condition 3精神状态 Mental State4精神压力 Mental Stress5行为 Behavior6技术水平 Skill Level7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 Work Planning12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/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 illness3-1判断力差 Poor judgment 4-1全神贯注于别的问题Preoccupation with problems5-1不合格的操作近观到奖赏Improper performance is rewarded6-1对所需求技术没有充分评估 Inadequate assessment ofrequired skills 7-1没有进行充分的知识转换 inadequate knowledge transfer8-1角色和职责冲突 Conflicting roles/responsibilities9-1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 design11-1工作计划欠妥 Inadequate work planning12-1收货项目与订购项目不符 Incorrect item received13-1需求和风险评估欠妥 Inadequate assessment of needs and risks14-1执行任务缺乏PSP Lack of PSP for the task15-1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 Fatigue3-2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 Inadequatepractice of skill•不能领会 inability to comprehend •报告关系不明确 unclear reporting relation ship9-2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•给供应商的规范不正确 Inadequate specification to vendor13-2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 PSP15-2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 ship9-3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 requisition13-3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 Inadequatecommunication between different organizations 1-4肺活量下降 Reduced Respiratory Capacity •由于缺乏休息 due to lack of rest3-4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 ofcoaching on skill •培训设备不够 Inadequate training equipment•职责分配不清 unclear assignment of responsibility9-4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 orders13-4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 overload3-5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 example6-5没有充分温习训练以巩固技术 Instruction to establishskill•误解指令说明 misunderstood instructions •职责分配矛盾 conflicting assignment of responsibility9-5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 substitution13-5调节、修理、保养欠妥 Inadequate adjustment/ repair /maintenance 14-2PSP 工作展开不力 Inadequate development of PSP15-5班组之间沟通不完善 Inadequate communication between shifts1-6暂时残疾 Temporary disabilities2-3操作能力降低 Diminished performance3-6缺乏机械知识 Low mechanical aptitude 4-6情绪超负荷 Emotional overload5-3对关键的安全行为没有充分的认识 inadequate identification of critical safe6-6其它因素 Other7-2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 authority9-6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 requirements13-6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 methods1-7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 demands5-4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 job8-2不适宜的领导关系 Inadequate lead ship9-7其它因素 Other •设计输出不清 design output nuclear11-3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 Inadequateremoval/ 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 available1-8身体活动范围受限 Restricted range of body movement •由于缺氧 due to oxygen deficiency3-8受药物影响 Infected by medication 4-8过度的精力集中 Extremeconcentration /perceptiondemands•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 repair12-2对材料和研究不足 Inadequate research onmaterials/ equipment13-8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 instructions1-9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 pressure7-3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 shipment13-9设备记录档案不完备 Inadequate equipment record history14-3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 Inadequatecommunication due to job turnover1-10身高不够或体力不足Inadequate size or strength2-4血糖降低 Blood sugar insufficiency□不适用 Not Applicable4-10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 parts12-4材料处理欠妥 Improper handling of materials13-10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、规章制度或指导准则没有很好沟通 Inadequate communication ofsafety and health data, regulations or guidelines 1-11由于药物疗法造成能力下降Diminished capacity due tomedication 2-5由于使用药物或酒精而使能力削弱 Impairment due to drugor 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-through10-2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 substitution12-5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 used1-12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 promotion10-3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 tear12-6材料包装不妥 Inadequate material packaging•每一步超过一个行为 more than one action per step15-12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 Applicable5-6使用不适当的方法刺激生产 Improper use of productionincentives•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/incident10-4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 provided15-13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 steps15-14讲话干扰 Speech interference 5-8雇员性急 Employee perceived haste7-4没有提供培训 No training provided8-5不合适的变更管理系统 inadequate management of change system10-6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 identified8-6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 people12-10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 data8-7安全会议不足或没有 inadequate or lack of safety meetings10-8评估欠妥和文档变更管理欠妥inadequate evaluation and /ordocumentation 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& assessment10-9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 train8-9其它因素 Other □不适用 Not Applicable11-6审核/检查/监视欠缺 Inadequate audit/inspection / monitoring 14-4PSP 强化措施不力 Inadequate enforcement of PSP7-5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 identified14-5PSP 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 training11-8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 use14-6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 systemDocument 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 hazardsPreparing 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 andothers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。

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

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

事故发生的根源分析英文版

– set an example by following safety rules/policies 以身作则了？
– provided adequate resources and support 是否提供了足够的资源和支持使别人能遵守纪律
Before You Discipline (5 Questions) 在你开始严肃纪律前（问自己5个问题）
Things that make you go Hmmm… 解决问题的策略
Cause & Corrective Action: 原因&整改措施
Employee failed to notice protrusion of table in line of path…
员工未能注意到桌子挡住了行走区域 Discipline employee to be aware of walking path
Protect company interests 维护公司的利益（表明公司对员工生命安全的高度重视）
– Every Imerys employee is a valuable asset.
每个Imerys的员工都是公司的重要财富
Getting hurt is not generally a conscious decision...
(Serious 受伤)
3,000 FIRST AID 急救
(Minor 轻伤) 30,000 NEAR MISSES
侥幸脱险 (Unsafe acts-Unsafe conditions 不安全的操作和状态)
Effort 努力方向
Group Exercise 分组练习
• Discuss other reasons we should investigate near misses and close calls 讨论我们调查未遂事件的其他原因

事故根源分析方法-Root Cause Analysis (RCA)

International Isocyanate Institute
9 设备
•
• • • • • • • • • • •
设备
购买/后勤不足 • 说明书或通知单不完全 • 对原料/设备的研究不充分 • 卖主的说明书不完全 • 装运方式或路线不当 • 接收,检查和承诺不当 • 安全和健康数据的沟通 • 不充分 • 原料处理不当原料储存不当原料运输不当危险品的鉴别不充分磨损和消耗使用计划编制不充分工作寿命范围的不当检查和/或监控不当装载不当或超标准装载维护不当由没有资格或未经培训的人使用使用频度超过指定限制
那里为什么会有一个原子?
International Isocyanate Institute
为什么不能生产出合格的零件?
原料材质不合格不合格零件设计不合理不合适的生产工具工艺过程出错 • 除了你个人所能知道的原因之外，要把所有有可能的影响条件、因素都尽量考虑进去，在这个阶段“头脑风暴”是一个很有用的方法。 •“头脑风暴”（Brain Storming - BS）： 9一种通过集思广益、发挥团体智慧，从各种不同角度找出问题所有原因或构成要素的会议方法。 9BS几大原则：严禁批评、思维自由奔放、结果多多益善。
• 这种分类方法是根据引起事故的主要原因来分类，设备材料、程序、人员是完成任何工作的基本要素，设计和培训工作则决定了人机协调工作的质量和有效性。
International Isocyanate Institute
物
设计不合理物料放置不当设备有缺陷休息不好违章
人
未戴防护用品未穿劳保服装经验不足侥幸心理
International Isocyanate Institute

事故WHYTREE分析方法ppt课件

人
核实假设的技巧
缺点事件
觀察現象 #1
觀察現象 #2
觀察現象 #3
觀察現象 #4
細化成假设干個問題(例) ：引擎卡死了沒有點火壓縮不充分空氣燃料混合不充分
假设該假設是真，那麼缘由是什麼？
引擎有問題
中間缘由
中間缘由
中間缘由
假设下一層的缘由中的一個是真，那麼上面的假設也是真。
中間缘由
中間缘由
• 留意：只在完成一个循环的“脑力风暴〞
六、核实
• 每一项假设都应核实。在没有核实前，运用虚线框起。
• 核实的方法 • 测试- 油样分析，发动机动力测试 • 丈量- 振动，超音波，红外线 • 察看 - 摄像，照相 • 实验、实验 - 统计分析 (Six Sigma
Methodologies)
假设核实查表
他要问几次WHY?
• 阅历证明他要找到营运系统的根本缘由的
话，最起码他要问五次。
缺点事件
物理的缘由
為什麼？為什麼？
人的缘由
為什麼？為什麼？
系統的根本缘由
為什麼？
根本缘由
什么时候停顿问WHY？
•当他在营运系统的层面上发现根本缘由时(处理方案经常显而易见)。
•当他无法控制或影响处理方案时：面对他无法控制也无法影响的问题时，忘了它，或找适宜的人来对付它。
素被忽略。应该思索一切能够的缘由。
五、假设问题的思索:
• 变化 (CHANGE) • 一种改动行为或改动环境要素。可以用动词来
引导。举例如下：
• 为什么？由于操作员启动了送料泵 • 为什么？由于原料从阀门走漏 • 条件 (CONDITION) • 条件是一种被动的要素，事物的形状或继续的

事故形成的原因分析通用版

解决方案编号：YTO-FS-PD572事故形成的原因分析通用版The Problems, Defects, Requirements, Etc. That Have Been Reflected Or Can Be Expected, And A Solution Proposed T o Solve The Overall Problem Can Ensure The Rapid And Effective Implementation.标准/ 权威/ 规范/ 实用Authoritative And Practical Standards事故形成的原因分析通用版使用提示：本解决方案文件可用于已经体现出的，或者可以预期的问题、不足、缺陷、需求等等，所提出的一个解决整体问题的方案（建议书、计划表），同时能够确保加以快速有效的执行。

文件下载后可定制修改，请根据实际需要进行调整和使用。

《安全生产法》规定，生产经营单位应当对从业人员进行安全生产教育和培训，并向从业人员如实告知作业场所和工作岗位存在的危险因素、防范措施以及事故应急措施。

分析研究事故的特点及其形成过程，有助于对作业场所和工作岗位危险因素的分析预控，便于对从业人员进行有针对性的教育和培训，也能够增强从业人员在作业过程中对危险因素的辨识能力，提高自我保护意识。

1 事故的主要特征事故的主要特征表现在3个方面。

(1) 危害性任何事故都会在一定程度上给个人、集体和社会带来身体、经济、社会效益方面的损失和危害，乃至夺去人的生命、威胁企业的生存和社会的稳定。

(2) 意外性从主观愿望上来说，人们都不愿意发生事故，而事故往往发生在人们意想不到的地点和时刻。

意外性有3种表现：其一是有些事故在它首次发生之前人们还未能了解它；其二是不少事故的发生具有随机性，尽管人们努力去探索其发生的概率和规律，但是无法揭示出何时何地会发生何种事故；其三是人们的主观失误造成的意外，或称之为"人为意外"，这往往是由于作业人员缺乏专业知识、存有侥幸心理、工作马虎和有章不循等造成的。

(全景展示)交通事故发生的因素及防范方案英文版

(全景展示)交通事故发生的因素及防范方案英文版Document Title: Factors and Prevention Measures of Traffic Accidents (A Comprehensive Overview)IntroductionIn this document, we will explore the various factors contributing to traffic accidents and propose prevention measures to mitigate the risks involved.Factors Leading to Traffic Accidents1. Human Factors- Driver fatigue- Distracted driving- Speeding- Reckless driving behavior2. Environmental Factors- Poor weather conditions (rain, snow, fog)- Road construction- Lack of proper lighting on roads3. Vehicle Factors- Mechanical failures- Lack of maintenance- Defective parts4. Infrastructure Factors- Poor road design- Lack of traffic signs and signals- Inadequate road maintenancePrevention Measures1. Education and Awareness- Conduct driver education programs- Spread awareness about the dangers of distracted driving - Promote safe driving practices through campaigns2. Enforcement of Traffic Laws- Strict enforcement of speed limits- Crackdown on drunk driving- Implementing penalties for reckless driving behavior3. Infrastructure Improvements- Regular maintenance of roads and bridges- Installation of proper signage and signals- Implementing road safety audits4. Technology Integration- Use of advanced safety features in vehicles- Implementing speed detection devices- Utilizing traffic monitoring systems5. Emergency Response- Enhance emergency response systems for quick assistance- Provide training for first responders to handle traffic accident situations effectively- Establishing designated trauma centers for accident victimsConclusionBy addressing the various factors contributing to traffic accidents and implementing preventive measures, we can work towards reducing the number of accidents on our roads. It is crucial for all stakeholders, including government agencies, law enforcement, drivers, and the community, to collaborate in creating a safer environment for everyone.。

Safety Lesson 14 Accidents Happen课件(共26张PPT)

• 1.in time • 2.jump out • 3.run after • 4.be hit by • 5.in an/the accident • 6.at 15 Park Road • 7.in a hurry • 8.stop ······fromdoing • 9.on their way to • 1o.shout to sb.
______ ____________
Discussion
.Check your answers with your classmates. • 2.Read the text.
Show time(8:18-8:27)(10:38-10:47)
Read and match the actions with the right person
Thinking
• Task 1: ★ P36Read the passage aloud and underline the words you cant’t read.
• Task 2: ★ P36Listen to the passage and check the pronunciation of the words and underline the phrases
Explaination
3.Doctors say that she can expect to return to school in a
about a week. 注；
(1)except to do sth.期望做某事。
(2)expect sb. to do sth.盼望某人做某事。
(3)expect + that 从句期待，期望···（
4）expect+sth. 盼望或期待某事。 Eg. 1) All their parents expect their children __B___ at

《Accidents Happen》Safety PPT课件

C
讲解来自《点拨》
知识点
6
until /ən'tɪl/ conj. & prep. 直到……为止
until conj.直到……为止，引导时间状语从句。(1)当主句是肯定句时，其谓语动词必须
是延续性动词，表示这一动作或状态
一直延续到until后所表示的时间。 eg:I worked until all the workmates left last night. 昨晚我一直工作到所有的同事都走了。
讲解来自《点拨》
知识点
1
thirteenyearold 13岁的
thirteenyearold是一个合成词，结构为“数词＋连字符＋量词(单数)＋连字符＋形容词”，在句中只能作定语，修饰名词。eg：He is a thirteenyearold boy. 他是一个13 岁的男孩。
sth. happen(s)＋地点/时间
某地/某时发生了某事
An accident happened in that street last Monday. 上周一在那条街上发生了一起事故。
sb. happen(s) to do sth.
某人碰巧做某事
I happened to see Jenny in my school.我碰巧在我的学校看见了詹妮。
考向一
不及物动词，意为“发生”，不能用于被动语态，为短暂性动词，不能与表示一段时间的时间状语连用，用法如下：
魔法记忆
讲解来自《点拨》
用法
意义
例句
sth.happen(s) to sb./sth.
某人/某物发生某事
What happened to your coat? It's all ripped. 你的外套怎么了？都扯破了。

why tree 事故分析

事故/事件树分析法
WHY Tree Analysis
所有事故与伤害都是可以避免的
气候
速度
安全装备
训练
事实
为什么调查事故/事件 ?
01 03
展示对安全的承诺(有感领导) 提高员工对安全工作的信心
查找安全管理系统的缺陷(隐患) 发现可能引起其它事故的条件
02
避免再次发生类似事故/事件(举一反三) 沟通学习到的教训
14事故所见事证所见事证所见事证所见事证所见事证已证实因素已证实因素已证实因素已证实因素系統因素人為因素具體因素已证实因素人為因素管理因素直接因素摔断腿地上有油踩在油渍上不会锁螺栓不对没检查新员工没培训没有规定有规定未执行振动腐蚀没锁紧垫片问题工具不当没有规定有规定未执行法兰漏油有人泼洒或溢出踩在油渍上没看到没有警示故意的没警示边走边聊天没有规定有规定没执行管理层的责任向所有可能受益人员传达事件的教训及经验落实跟踪以预防事件再发生事故分析應避免
4 用头脑风暴广泛思考各种可能, 因素有可能不只一项.
5 若可能因素不只一项, 可用逻辑符号表示其相互关系.
6
以事实证明该项可能因素为不相关后终止.
7 重复三/四/五/六步骤. 直到找出直接/人為/管理因素
8
相关管理因素可以不只一项.
9
若有须要, 可以依据危害等级安排执行顺序.
分析树
事故所见事证所见事证所见事证所见事证所见事证
工艺危害分析
PHA
溢出容器
液位异常升高
LV 15 故障关
泵故障
故障树分析 Fault-Tree Analysis
出口堵塞到LV15的信号虚高
LC 15 故障输出虚
高
LC15设定点过高