事故根本原因分析的必备工具!!事故根源分析表 Comprehensive List of Causes
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Comprehensive List of Causes
A
DESCRIPTION OF INCIDENT
People Solutions
Parts
TOOL
FOR
ROOT
CAUSE
ANALYSIS
ANALYSIS PHASE: IDENTIFICATION OF CRITICAL FACTORS
ቤተ መጻሕፍቲ ባይዱ
IMPLEMENTATION & RESEARCH PHASES: EVIDENCE GATHERING
CONDITIONS
7. 7-1 7-2 7-3 7-4 7-5 7-6 7-7 7-8 7-9 7-10 7-11 7-12 Work Exposures to Fire or explosion Noise Energized electrical systems Energized systems, other than electrical Radiation Temperature extremes Hazardous chemicals Mechanical hazards Clutter or debris Storms or acts of nature Slippery floors or walkways Other 8. 8-1 8-2 8-3 8-4 8-5 Work Place Environment / Layout Congestion or restricted motion Inadequate or excessive illumination Inadequate ventilation Unprotected height Inadequate work place layout • controls less than adequate • displays less than adequate • labels less than adequate • locations out of reach or sight • conflicting information is presented Other
• Document the type / severity of event • Cover the who / what / when / where / how as known at the time
• Gather relevant evidence • Implementation phase = direct evidence (scene and witnesses) • Research phase = indirect evidence (written sources) • Consider People / Parts / Position / Paper
8-6
POSSIBLE SYSTEM CAUSES
PERSONAL FACTORS
1. 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 Physical Capability Vision deficiency Hearing deficiency Other sensory deficiency Reduced respiratory capacity Other permanent physical disabilities Temporary disabilities Inability to sustain body positions Restricted range of body movement Substance sensitivities or allergies Inadequate size or strength Diminished capacity due to medication 2. 2-1 2-2 Physical Condition Previous injury or illness Fatigue • due to workload • due to lack of rest • due to sensory overload Diminished performance • due to temperature extremes • due to oxygen deficiency • due to atmospheric pressure variation Blood sugar insufficiency Impairment due to drug or alcohol use 3. 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 Mental State Poor judgment Memory failure Poor coordination or reaction time Emotional disturbance Fears or phobias Low mechanical aptitude Low learning aptitude Influenced by medication 4. Mental Stress 4-1 Preoccupation with problems 4-2 Frustration 4-3 Confusing directions / demands 4-4 Conflicting directions / demands 4-5 Meaningless or degrading activities 4-6 Emotional overload 4-7 Extreme judgment / decision demands 4-8 Extreme concentration / perception demands 4-9 Extreme boredom 4-10 Other o Not Applicable 5. Behavior 5-1 Improper performance is rewarded • saves time or effort • avoids discomfort • gains attention 5-2 Improper supervisory example 5-3 Inadequate identification of critical safe behaviors 5-4 Inadequate reinforcement of critical safe behaviors • proper performance is criticized • inappropriate peer pressure • inadequate performance feedback • inadequate disciplinary process 5-5 Inappropriate aggression 5-6 Improper use of production incentives 5-7 Supervisor implied haste 5-8 Employee perceived haste 5-9 Other o Not Applicable 6. Skill Level 7. 6-1 Inadequate assessment of 7-1 required skills 6-2 Inadequate practice of skill 6-3 Infrequent performance of skill 6-4 Lack of coaching on skill 6-5 Insufficient review of instruction to establish skill 7-2 6-6 Other o Not Applicable Training / Knowledge Transfer Inadequate knowledge transfer • inability to comprehend • inadequate instructor qualifications • inadequate training equipment • misunderstood instructions Inadequate recall of training material • training not reinforced on the job • inadequate refresher training frequency 7-3 Inadequate training effort • inadequate training program design • inadequate training goals / objectives • inadequate new employee orientation • inadequate initial training • inadequate means to determine if qualified for job 7-4 No training provided • need for training not identified • training records incorrect or out of date • new work methods introduced without training • decision made not to train 7-5 Other o Not Applicable For each identified critical factor, consider if any of the listed root 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. 8. 8-1 Management / Supervision / Employee Leadership Conflicting roles / responsibilities • unclear reporting relationships • conflicting reporting relationship • unclear assignment of responsibility • conflicting assignment of responsibility • improper or insufficient delegation of authority Inadequate leadership • standards of performance missing or not enforced • inadequate accountability • inadequate or incorrect performance feedback • inadequate work site walk-through • inadequate safety promotion Inadequate correction of prior hazard / incident Inadequate identification of worksite / job hazards Inadequate management of change system Inadequate incident reporting / investigation system Inadequate or lack of safety meetings Inadequate performance measurement & assessment Other 9. Contractor 10. Engineering / Selection & Design Oversight 1010-1 Inadequate technical 9-1 Lack of contractor design pre-qualifications • design input 9-2 Inadequate obsolete contractor pre • design input not qualifications correct 9-3 Inadequate • design input not contractor selection available 9-4 Use of non -approved • design output contractor inadequate 9-5 Lack of job oversight • design input 9-6 Inadequate oversight infeasible • design output 9-7 Other unclear o Not Applicable • design output not correct • design output inconsistent • no independent design review 1010-2 Inadequate standards, specifications, and / or design criteria 1010-3 Inadequate assessment of potential failure 1010-4 Inadequate ergonomic design 1010-5 Inadequate monitoring of construction 1010-6 Inadequate assessment of operational readiness 1010-7 Inadequate monitoring of initial operation 1010-8 Inadequate evaluation and / or documentation of change 10-9 Other o Not Applicable 11. 1111-1 1111-2
ACTIONS
1. 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 FollowingProcedures Violation by individual Violation by group Violation by supervisor Operation of equipment without authority Improper position or posture for the task Overexertion of physical capability Work or motion at improper speed Improper lifting Improper loading Shortcuts Other 2. 2-1 2-2 2-3 2-4 2-5 2-6 2-7 2-8 Use of Tools or Equipment Improper use of equipment Improper use of tools Use of defective equipment (aware) Use of defective tools (aware) Improper placement of tools, equipment or materials Operation of equipment at improper speed Servicing of equipment in operation Other 3. 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9 Use of Protective Methods Lack of knowledge of hazards present Personal protective equipment not used Improper use of proper personal protective equipment Servicing of energized equipment Equipment or materials not secured Disabled guards, warning systems or safety devices Removal of guards, warning systems or safety devices Personal protective equipment not available Other 4. 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 Inattention / Lack of Awareness Improper decision making or lack of judgment Distracted by other concerns Inattention to footing and surroundings Horseplay Acts of violence Failure to warn Use of drugs or alcohol Routine activity without thought Other 5. 5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10 Protective Systems Inadequate guards or protective devices Defective guards or protective devices Inadequate personal protective equipment Defective personal protective equipment Inadequate warning systems Defective warning systems Inadequate isolation of process or equipment Inadequate safety devices Defective safety devices Other 6. 6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10 Tools, Equipment & Vehicles Defective equipment Inadequate equipment Improperly prepared equipment Defective tools Inadequate tools Improperly prepared tools Defective vehicle Inadequate vehicle for the purpose Improperly prepared vehicle Other
• Organise all evidence • Map evidence • Identify critical factors • Use CLC to identify all immediate and root causes
Positions
Paper
POSSIBLE IMMEDIATE CAUSES
A
DESCRIPTION OF INCIDENT
People Solutions
Parts
TOOL
FOR
ROOT
CAUSE
ANALYSIS
ANALYSIS PHASE: IDENTIFICATION OF CRITICAL FACTORS
ቤተ መጻሕፍቲ ባይዱ
IMPLEMENTATION & RESEARCH PHASES: EVIDENCE GATHERING
CONDITIONS
7. 7-1 7-2 7-3 7-4 7-5 7-6 7-7 7-8 7-9 7-10 7-11 7-12 Work Exposures to Fire or explosion Noise Energized electrical systems Energized systems, other than electrical Radiation Temperature extremes Hazardous chemicals Mechanical hazards Clutter or debris Storms or acts of nature Slippery floors or walkways Other 8. 8-1 8-2 8-3 8-4 8-5 Work Place Environment / Layout Congestion or restricted motion Inadequate or excessive illumination Inadequate ventilation Unprotected height Inadequate work place layout • controls less than adequate • displays less than adequate • labels less than adequate • locations out of reach or sight • conflicting information is presented Other
• Document the type / severity of event • Cover the who / what / when / where / how as known at the time
• Gather relevant evidence • Implementation phase = direct evidence (scene and witnesses) • Research phase = indirect evidence (written sources) • Consider People / Parts / Position / Paper
8-6
POSSIBLE SYSTEM CAUSES
PERSONAL FACTORS
1. 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 Physical Capability Vision deficiency Hearing deficiency Other sensory deficiency Reduced respiratory capacity Other permanent physical disabilities Temporary disabilities Inability to sustain body positions Restricted range of body movement Substance sensitivities or allergies Inadequate size or strength Diminished capacity due to medication 2. 2-1 2-2 Physical Condition Previous injury or illness Fatigue • due to workload • due to lack of rest • due to sensory overload Diminished performance • due to temperature extremes • due to oxygen deficiency • due to atmospheric pressure variation Blood sugar insufficiency Impairment due to drug or alcohol use 3. 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 Mental State Poor judgment Memory failure Poor coordination or reaction time Emotional disturbance Fears or phobias Low mechanical aptitude Low learning aptitude Influenced by medication 4. Mental Stress 4-1 Preoccupation with problems 4-2 Frustration 4-3 Confusing directions / demands 4-4 Conflicting directions / demands 4-5 Meaningless or degrading activities 4-6 Emotional overload 4-7 Extreme judgment / decision demands 4-8 Extreme concentration / perception demands 4-9 Extreme boredom 4-10 Other o Not Applicable 5. Behavior 5-1 Improper performance is rewarded • saves time or effort • avoids discomfort • gains attention 5-2 Improper supervisory example 5-3 Inadequate identification of critical safe behaviors 5-4 Inadequate reinforcement of critical safe behaviors • proper performance is criticized • inappropriate peer pressure • inadequate performance feedback • inadequate disciplinary process 5-5 Inappropriate aggression 5-6 Improper use of production incentives 5-7 Supervisor implied haste 5-8 Employee perceived haste 5-9 Other o Not Applicable 6. Skill Level 7. 6-1 Inadequate assessment of 7-1 required skills 6-2 Inadequate practice of skill 6-3 Infrequent performance of skill 6-4 Lack of coaching on skill 6-5 Insufficient review of instruction to establish skill 7-2 6-6 Other o Not Applicable Training / Knowledge Transfer Inadequate knowledge transfer • inability to comprehend • inadequate instructor qualifications • inadequate training equipment • misunderstood instructions Inadequate recall of training material • training not reinforced on the job • inadequate refresher training frequency 7-3 Inadequate training effort • inadequate training program design • inadequate training goals / objectives • inadequate new employee orientation • inadequate initial training • inadequate means to determine if qualified for job 7-4 No training provided • need for training not identified • training records incorrect or out of date • new work methods introduced without training • decision made not to train 7-5 Other o Not Applicable For each identified critical factor, consider if any of the listed root 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. 8. 8-1 Management / Supervision / Employee Leadership Conflicting roles / responsibilities • unclear reporting relationships • conflicting reporting relationship • unclear assignment of responsibility • conflicting assignment of responsibility • improper or insufficient delegation of authority Inadequate leadership • standards of performance missing or not enforced • inadequate accountability • inadequate or incorrect performance feedback • inadequate work site walk-through • inadequate safety promotion Inadequate correction of prior hazard / incident Inadequate identification of worksite / job hazards Inadequate management of change system Inadequate incident reporting / investigation system Inadequate or lack of safety meetings Inadequate performance measurement & assessment Other 9. Contractor 10. Engineering / Selection & Design Oversight 1010-1 Inadequate technical 9-1 Lack of contractor design pre-qualifications • design input 9-2 Inadequate obsolete contractor pre • design input not qualifications correct 9-3 Inadequate • design input not contractor selection available 9-4 Use of non -approved • design output contractor inadequate 9-5 Lack of job oversight • design input 9-6 Inadequate oversight infeasible • design output 9-7 Other unclear o Not Applicable • design output not correct • design output inconsistent • no independent design review 1010-2 Inadequate standards, specifications, and / or design criteria 1010-3 Inadequate assessment of potential failure 1010-4 Inadequate ergonomic design 1010-5 Inadequate monitoring of construction 1010-6 Inadequate assessment of operational readiness 1010-7 Inadequate monitoring of initial operation 1010-8 Inadequate evaluation and / or documentation of change 10-9 Other o Not Applicable 11. 1111-1 1111-2
ACTIONS
1. 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 FollowingProcedures Violation by individual Violation by group Violation by supervisor Operation of equipment without authority Improper position or posture for the task Overexertion of physical capability Work or motion at improper speed Improper lifting Improper loading Shortcuts Other 2. 2-1 2-2 2-3 2-4 2-5 2-6 2-7 2-8 Use of Tools or Equipment Improper use of equipment Improper use of tools Use of defective equipment (aware) Use of defective tools (aware) Improper placement of tools, equipment or materials Operation of equipment at improper speed Servicing of equipment in operation Other 3. 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9 Use of Protective Methods Lack of knowledge of hazards present Personal protective equipment not used Improper use of proper personal protective equipment Servicing of energized equipment Equipment or materials not secured Disabled guards, warning systems or safety devices Removal of guards, warning systems or safety devices Personal protective equipment not available Other 4. 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 Inattention / Lack of Awareness Improper decision making or lack of judgment Distracted by other concerns Inattention to footing and surroundings Horseplay Acts of violence Failure to warn Use of drugs or alcohol Routine activity without thought Other 5. 5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10 Protective Systems Inadequate guards or protective devices Defective guards or protective devices Inadequate personal protective equipment Defective personal protective equipment Inadequate warning systems Defective warning systems Inadequate isolation of process or equipment Inadequate safety devices Defective safety devices Other 6. 6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10 Tools, Equipment & Vehicles Defective equipment Inadequate equipment Improperly prepared equipment Defective tools Inadequate tools Improperly prepared tools Defective vehicle Inadequate vehicle for the purpose Improperly prepared vehicle Other
• Organise all evidence • Map evidence • Identify critical factors • Use CLC to identify all immediate and root causes
Positions
Paper
POSSIBLE IMMEDIATE CAUSES