事故发生的根源分析(英文版)85093.pptx

Root Cause AnalysisRoot Cause Analysis事故根源分析事故根源分析Best Practice techniques for conducting effective root cause analysis 分析事故根源时常用的有效技巧Identifying Countermeasures,Hierarchy of Control 确定相应的对策并实施有层次的控制手段Examples of how techniques can be applied to incidents and near misses.举例说明如何利用技巧分析事故和未遂事件的原因Objectives 目标目标 Find the causes 找出事故原因There will typically be several causes to an incident.一般来说事故是由多方面的原因造成的 Prevent similar incidents 避免类似事故的发生Performing an incident investigation,and communicating the results,will prevent similar incidents.开展事故调查并传达事故调查的结果以可以避免类似事故的发生 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Why Investigate Incidents?为什么要进行事故调查？为什么要进行事故调查？.Working Safely Is!但工作安全是可以自觉控制的!Getting hurt is not generally a conscious decision.受伤都是意外的，不是自觉的受伤都是意外的，不是自觉的3,000 FIRST AID急救急救(Minor 轻伤轻伤)30,000 NEAR MISSES 未遂事件未遂事件(Unsafe acts-Unsafe conditions 不安全的行为和状态不安全的行为和状态)1 FATAL 死亡死亡30 DISABLING 残疾残疾(Severe 重伤重伤)300 MEDICAL 需要治疗需要治疗 (Serious 受伤受伤)Because we dont get to pick where we land因为我们无法预知事情因为我们无法预知事情的结果。的结果。?Why Investigate Incidents and Near misses?为什么要调查事故和未遂事件？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但是我们能选择努力的方向方向。Effort 努力方向努力方向 Why Investigate Incidents and Near misses?为什么要调查事故和未遂事件？为什么要调查事故和未遂事件？3,000 FIRST AID急救急救(Minor 轻伤轻伤)30,000 NEAR MISSES 侥幸脱险侥幸脱险(Unsafe acts-Unsafe conditions 不安全的操作和状态不安全的操作和状态)1 FATAL 身亡身亡30 DISABLING 残疾残疾(Severe 重伤重伤)300 MEDICAL 疗伤疗伤 (Serious 受伤受伤)Group Exercise 分组练习分组练习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5 minutes 5分钟时间Responsibility 职责职责Ensure employees understand what an accident is.确保员工明白什么是事故。Ensure that all associates understand why they must report accidents.确保所有人员理解为什么一定要报告事故。Responsibility 职责职责Investigate every accident!调查每次事故的原因Major 重大事故Minor 小事故Property 财产损失Near Miss 未遂事件KEY INVESTIGATION POINTKEY INVESTIGATION POINT调查的重点调查的重点调查的重点调查的重点Do Not Look for Someone to Blame!调查不是为了追究责任！Things that make you go Hmmm解决问题的策略解决问题的策略Cause&Corrective Action:原因原因&整改措施整改措施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员工未能注意到桌子挡住了行走区域Discipline employee to be aware of walking path训练员工注意行走训练员工注意行走区域区域Before You Discipline(5 Questions)在你开始严肃纪律前在你开始严肃纪律前（问自己（问自己5个问题）个问题）Leadership requires discipline when justified!即使理由充分，领导也需要严肃纪律！Before you discipline ask yourself“Have I”:在你开始推行纪律前，问问你自己“我是否”：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provided adequate training 是否提供了足够的培训insisted on compliance by enforcing safety rules in the past 在过去是否坚持遵守安全法规provided adequate supervision by identifying and correcting hazards before someone got hurt 在发生事故之前就安排足够的监管力量，发现和消除事故隐患Before You Discipline(5 Questions)在你开始严肃纪律前在你开始严肃纪律前（问自己（问自己5个问题）个问题）Incident Investigation Process事故调查过程Follow-Up整改跟进Corrective Action改进措施Response回应Fact-Finding实情调查Analysis分析事故原因Notification通告Before the InterviewBefore the Interview在面谈之前在面谈之前在面谈之前在面谈之前Preparation 准备Who should do the interview?谁应当负责面谈工作？Interviewer should have credibility with the interviewee 面谈组织者应当得到受访者的信任Interviewer should be aware of group dynamics 面谈组织者应当认识到可能对所涉及到的组织的影响Have prepared questions,just in case 事先准备好一些问题，以防万一Meet on interviewees turf or neutral location 站在被访者的或中立的立场上考虑问题Preferably were the incident occurred 面谈最好仅针对刚发生的事件（“就事论事”）Before the InterviewBefore the Interview在面谈之前在面谈之前在面谈之前在面谈之前Who Should be Interviewed?Who Should be Interviewed?哪些人应该受访？哪些人应该受访？哪些人应该受访？哪些人应该受访？Injured and others directly involved 受伤者及其他直接当事人Witnesses 目击证人Others who do the same job 其他相同工作人员Maintenance personnel 设备维护人员Engineering 工程人员Those who set up the equipment 设备装配人员Other experts 其他专家Fact Finding:The InterviewFact Finding:The Interview实情调查：面谈实情调查：面谈实情调查：面谈实情调查：面谈Interview Tips(put the interviewee at ease)面谈技巧（使受访人处于轻松的状态）（使受访人处于轻松的状态）Create a positive environment 营造一个积极的面谈环境Ask questions without being aggressive 在较为平和的气氛下提出问题Be patient,do not talk too much 保持耐心，不要说过多的话Show interest in the interviewee 对受访者的回答表现出兴趣Avoid criticism 避免批评受访者You are investigating the incident/accident,not the person 你是在调查事故，不是在调查人你是在调查事故，不是在调查人Interview Questions 面谈问题面谈问题OpenOpen开放性开放性开放性开放性 vs.vs.ClosedClosed封闭性封闭性封闭性封闭性PrimaryPrimaryandandSecondarySecondary首要和其次问题首要和其次问题首要和其次问题首要和其次问题LeadingLeading引导性引导性引导性引导性vs.vs.NeutralNeutral公正性公正性公正性公正性IndividualIndividual个人个人个人个人vs.vs.GroupGroup小组小组小组小组What techniques can you use for more effective interviews?有效的面谈可采用哪些技巧？During the InterviewDuring the Interview在面谈中在面谈中在面谈中在面谈中As soon as possible and at the scene 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）seek privacy 面谈情况应保密ask for prevention ideas 寻问预防安全事故的建议During the InterviewDuring the Interview在面谈中在面谈中在面谈中在面谈中Ask open questions(what,when,where)询问开放性的问题（发生什么事情，何时，在哪里）One-on-One and One at a time 每次面谈时采用一对一的方式Fact Finding:Interview QuestionsFact Finding:Interview Questions事件调查：面谈的问题事件调查：面谈的问题事件调查：面谈的问题事件调查：面谈的问题Ask open ended questions(not yes/no)提开放性的问题（不要只提用（不要只提用是是/否否就可以回答的问题）就可以回答的问题）No 避免问Have you received safety training?你接受过安全培训吗？Yes 应该问What safety training have you received?你接受过哪些安全培训？Dont ask leading questions 别提对答案有诱导性的问题No 避免Does your supervisor discuss safety with you?你们的主管与你们讨论安全生产的问题吗？Yes 应该Who discusses safety with you?谁与你们讨论安全生产问题？Fact Finding:Interview QuestionsFact Finding:Interview Questions事件调查：面谈的问题事件调查：面谈的问题事件调查：面谈的问题事件调查：面谈的问题During the InterviewDuring the Interview面谈过程中面谈过程中面谈过程中面谈过程中Phrases to remember 记住适用下列用语“Please help me understand what happened”“请帮我弄明白到底发生了些什么”“Go on”“说下去”“What does that mean to you”“那对你来说意味着什么”“Can you explain that further”“你能进一步解释一下吗”“dead air”“dead air”Interview Quiz 面谈中的小测试面谈中的小测试Is this a good question?这个问题问的是否正确？In which direction was the John running when he tripped on the pallet?当John摔倒在货盘上时，他在朝哪个方向跑？Leading question that assumes:诱导性的问题：John was running John在跑John fell on a pallet John摔倒在货盘上 What would be a better question?怎样更好的提问？What was John doing before he fell?John在摔倒之前在干什么?Why do you think John was fell down?你认为John摔倒的原因是什么?Interview Quiz 面谈中的小测试面谈中的小测试Is this a good question?这个问题问的好不好?Did you see Jane reach past the guard and stick her hand inside the machine?你看到Jane越过警戒线并把手放进机器里了吗？Leading question that assumes:引导性的问题这里有：Jane did reach past the guard Jane确实越过了警戒线 What would be a better question?怎样更好的提问？What did you see the operator do?你看到这个工人当时如何做呢?Interview Quiz 面谈中的小测试面谈中的小测试Is this a good question?这个问题问的好不好?Did you realize that Ed was angry before he got the fork truck?你注意到 Ed在得到叉车前很生气吗?Leading question that assumes:引导性的问题这里有：Ed was angry Ed很生气What would be a better question?怎样更好的提问？How would you describe Eds behavior before he got the fork truck?你能描述一下Ed在得到叉车前的表现吗?Bucket of Bricks桶装砖事故桶装砖事故A Series of Unfortunate Events一连串的不幸事件一连串的不幸事件THE BUCKET OF BRICKS STORY(Interviewing Technique Reinforcer)The following letter is a reprint of an actual letter sent by an employee to the Petrolane-Utah Gas Service.I am writing in response to your request for additional information.In the accident reporting form,I put“trying to do the job alone”as the cause of the accident.You said in your letter that I should explain more fully and I trust that the following information will be sufficient.I am a bricklayer by trade.On the date of the accident,I was working alone on the roof of a new six story building.When I completed my work,I discovered that I had about 500 pounds of bricks left over.Rather than carry the bricks by hand,I decided to lower them in a barrel by using a pulley which fortunately was attached to the side of the building at the sixth floor.Securing the rope at ground level,I went up to the roof,swung the barrel out and loaded the bricks into it.Then I went back to the ground and untied the rope,holding it tightly to ensure a slow descent of the 500 pounds of brick.You will note in the accident report that I weigh 165 pounds.Due to my surprise at being jerked off the ground so suddenly,I lost my present state of mind and forgot to let go of the rope.Needless to say,I proceeded at a rather rapid rate up the side of the building.In the vicinity of the third floor,I met the barrel coming down.This explains the fractured skull and broken collarbone.Slowed only slightly,I continued my rapid ascent,not stopping until the fingers of my right hand were two knuckles deep into the pulley.Fortunately,by this time,I had regained my present state of mind and was able to hold tightly to the rope in spite of my pain.At approximately the same time,however,the barrel of bricks hit the ground and the bottom fell out of the barrel.Devoid of the weight of the bricks,the barrel now weighed approximately 50 pounds.I refer you again to my weight.As you might imagine,I began a rapid descent of the building.In the vicinity of the third floor,I met the barrel coming up.This accounts for the two fractured ankles and the lacerations of my legs and lower body.The encounter with the barrel slowed me enough to lessen my injuries when I fell on the pile of bricks.Fortunately,only three vertebrae were cracked.I am sorry to report,however,that as I lay there on the bricks in pain,unable to stand,and watching the empty barrel six stories above me,I again lost my present state of mind and let go of the rope.The empty barrel weighed more than the rope,so it came back down.And that accounts for my two broken legs.I hope I have furnished the information you required as to how the accident occurred.Sincerely,Joe Schmoe桶装砖事故桶装砖事故（免谈技巧强化）（免谈技巧强化）下面这封信是一名Petrolane-Utah Gas Service的员工的真实来信。应您的要求，我向您写这封信，想让您了解更多关于事故的真实情况。在事故报告书中，我写的事故原因是“设法自己独立完成工作”。您在信中提到要我将当天事故发生的经过描述的更详细些，所以我给您写来这封信，告诉您更多当时的情况。我是一名搬砖工。出事那天，我当时正一个人沿着一幢新建六层楼房的房顶走。当我干完活后，我发现还有大约500磅重的砖块要搬。这时我正巧在六楼一角落处发现一个滑轮一辆皮带轮的拖车，我就想把砖块装入一个桶中再通过滑轮放到地面上放在拖车上搬走。在底层在桶上系好绳索安全带后，我爬到屋顶上拿出桶，并往里面放砖块。然后，我回到地面解开安全带，紧紧握住绳索，试图将这500磅的砖块慢慢降下来。您在事故报告中就已经知道我的体重是165磅。我突然之间就被一股猛力拉离了地面，由于当时感到紧张和害怕，我失去了意识并忘了放掉手中的绳索。接下来显而易见，我被这股猛力迅速地拉向楼顶。就在我大概被拉到三楼的时候，碰撞到了正从上往下降的运砖桶。这次碰撞造成我头骨裂开，锁骨断裂。仅是停顿了一会，我又继续快速被往上拉，一直到我右手指的两个关节插入到滑轮拖车中才停下来。幸运的是，那时我恢复了意识，尽管当时非常疼痛，但我仍旧紧紧拉住绳索。大约就在那时，落下去的桶跌落到地上，砖块全都摔到了桶外边。这只空桶的重量大约是50磅。我再次提醒您我的体重。您可能能够想像，我又开始快速地往下降。大概落到三楼附近，我再次碰撞到了从下面升上来的空桶。这次碰撞又造成我两根踝骨断裂，腿和下半身都撞破。幸运的是这次碰撞减慢了我下落的速度，使我在跌到那堆砖上时只摔断了三根椎骨。我很遗憾地告诉您，当我摔到那堆砖上之后，由于疼痛我站不起身来，只能眼睁睁地看着那只吊在六层楼高的空桶。那时我又失去了知觉，手松开了绳索。空桶再次掉了下来，这次又造成我两条腿被砸伤。我希望这次向您提供的事故情况能够满足您的要求。真诚地Joe SchmoeA Series of Unfortunate Events一连串的不幸事件一连串的不幸事件The InterviewThe Interview面谈面谈面谈面谈You have 5 minutes to:你有5分钟：Create an non controversial atmosphere 营造一种和谐的谈话氛围Gather additional facts 收集更多资料Ask open ended questions 提开放的问题Actively listen 仔细聆听Ask Primary and Secondary Questions寻问首要和其次的问题Incident Investigation Process事故调查过程Follow-Up整改跟进Corrective Action改进措施Response回应Fact-Finding实情调查AnalysisAnalysis分析事故原因分析事故原因分析事故原因分析事故原因Notification通告AnalyseAnalyse Data Data分析数据分析数据 Concentrate on the underlying causes,the Root Causes,not the symptoms.关注于事故的根本原因，并不关注事故表象 Accidents rarely result from a single cause,but occur because of a network of Multiple Causes.事故很少由单一的原因而造成，而是由多种原因的综合作用而造成。Direct causes(energy sources;hazardous materials)直接原因（能源；危险品）Indirect causes(unsafe acts and conditions)间接原因（不符合安全规范的操作行为和生产状态）Basic causes(management policies;personal or environmental factors)基本原因（安全管理措施；人为或环境要素）Unsafe Acts and Conditions不安全行为和作业条件不安全行为和作业条件Unsafe acts 不符合安全规范的操作行为Operating Procedure Deviation 偏离操作规程的要求Running-Horse Play 赶工By-passing safety devices 操作时忽略安全装置Not using protective equipment 不使用保护装置Under influence of drugs or alcohol 服药后或酒后操作Unsafe conditions 不符合安全规范的作业条件Defective Tools/Equipment 使用有安全隐患的工具或设备Line Speed 生产线速度设定不合理Inadequate guard barrier 不恰当的警戒线设置Illumination 照明问题Inadequate/Improper PPE 不充分或不合理的个人防护用品Inadequate machine guarding 不恰当的机械防护Multiple Root Cause Analysis Technique多重根本原因分析的方法多重根本原因分析的方法Five“Why”s 五个“为什么”Why?为什么？为什么？Why?为什么？为什么？Why?为什么？为什么？Why?为什么？为什么？Why?为什么？为什么？Why AnalysisWhy Analysis “为什么为什么为什么为什么”分析分析分析分析The why questions drive to the system root causes.Identify root causes through simple,precise,objective,statements that describe why the factors identified in the discrepancy analyses exist.这些“为什么”问题有助于建立系统以分析事故的根本原因。通过简单、准确、客观的问题来找出真实的根本原因。Why Analysis“为什么为什么”分析分析Done after fact-finding has developed the objective information on events,conditions and contributing factors.事件调查的工作完成后，您已经得到事件、生产状态和有用的因素等方面的信息。State the occurrence simple,precise,and objective terms to describe what happened without stating,or implying,why it happened 以简单、准确、客观的形式来说明事故，而不是陈述或暗示为什么发生Then ask WHY to identify why these conditions,factors and discrepancies exist.然后问“为什么”，确定这些状态、因素和差异存在的原因。Repeat the WHY to drive back to real the system issues that are at the source.重复问“为什么”知道系统里的根本问题 为什么？为什么？为什么？为什么？为什么？5个为什么个为什么车间滑倒Incident Investigation Process 事故调查的过程Follow-Up后续工作Corrective Corrective ActionAction改进措施改进措施改进措施改进措施Response回应Fact-Finding实情调查Analysis分析Notification 通告nIdentify and address multiple root causes-not just the indirect,apparent causes.识别多种根本原因，而不是间接的，表面的原因。n60 seconds till the world endsnMultiple root causes will need multiple controls so dont focus on a single solution.多种根本原因需要多种控制措施以避免着重一个解决方案。Develop simple,precise,objective,statements of what could be done to remove the root causes 制定简单，精确，客观的解决根本原因的方案This list should be as comprehensive as possible 这个方案要尽可能全面Brainstorming will be an effective technique 集体讨论将会是很好的方法Address all identified multiple root causes.公布所有的根部原因Developing Countermeasures 制定对策制定对策Controls and Countermeasures 控制措施控制措施和对策和对策Identify those persons who are responsible for corrective/preventive actions.指定负责整改的人员指定负责整改的人员Set corrective/preventive action target dates,and follow up to ensure action is completed and effective.确定整改的目标和期限，后续工作要保证整改确定整改的目标和期限，后续工作要保证整改完成并且行之有效完成并且行之有效Share results with similar operations within plant and across plants.Video Reenactment excellent tool to accomplish this.将整改的结果告知给相似的部门和整个公司，并用录像演将整改的结果告知给相似的部门和整个公司，并用录像演示示Hierarchy of Controls Hierarchy of Controls 风险风险风险风险控制措施的优先顺序控制措施的优先顺序控制措施的优先顺序控制措施的优先顺序Elimination/Substitution-removing or reducing the hazard消除消除/替换替换 消除或降低风险消除或降低风险Engineering Controls workstation design,machine guards,safety controls,isolation of hazardous areas,monitoring devices,etc.工程技术措施工程技术措施 工位设计，机械防护，安全措施，隔离危险措施，监控设备等工位设计，机械防护，安全措施，隔离危险措施，监控设备等Administrative Controls-procedures,assessments,inspection,records to monitor and ensure safe practices and environments are maintained.行政控制措施行政控制措施 通过步骤，评估，检查，记录等行政措施来确保工作环境的安全通过步骤，评估，检查，记录等行政措施来确保工作环境的安全Training Controls-initial new hire safety orientation,job specific safety training and periodic refresher training.培训培训 新员工的安全培训，岗位的安全培训和定期复训新员工的安全培训，岗位的安全培训和定期复训Personal Protective Equipment个人防护用品Accident Investigation Process事故调查的过程Follow-UpFollow-Up后续工作后续工作后续工作后续工作Corrective Action改进措施Response回应Fact-Finding实情调查Analysis分析Notification通告Track CountermeasuresTrack Countermeasures 对策追踪对策追踪对策追踪对策追踪Complete Incident Investigation Forms with CM,responsible persons,comp