原因分析综合表

原因分析综合表Comprehensive List of Causes原因根源分析工具A TOOL FOR ROOT CAUSE ANALYSIS事故描述DESCRIPT ION OF INCIDENT

人证People事故起因分析ANALYSI S PHASE: IDENT IFICAT ION OF CRIT ICAL FACT ORS

物证Parts

收集证据IMPLEMENT ATION & RESEARCH PHASE S: EVIDENCE GAT HERING

解决方案Solutions

事故类型和严重程度 Document the type / severity of event 有关的人员、时间、地点、如何发生、发 生什么Cover th e who / what / when / where / how as known at the time

收集相关证据

Gathe r relevant evidence Implementation phase = direct evidence (scene and witnesses)

综合所有相关证据 Organise all evidence 分析证据之间的联系 Map evidence 识别关键因素 Identify critical factors 利用 CLC 找出触发原因和系统原因 Use CLC to identify all immediate and root causes

直接证据(现场和目击证人) 人员、岗位、程序等

相对位置Positions

文件Paper

间接证据(有关的材料) Research phase = indirect evidence (written sources)Consider People / Parts / Position / Paper

可能的直接原因POSSIBLE IMM EDIATE CAUSES 行为类 ACTIONS1.1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11

条件类 CONDITIONS3.3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9

遵守工作程序方面 Following Procedures个人违规Violation by individual 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Imp roper position or posture fo r the task 超体能工作Overex ertion of physical capability 工作或运载速度不适宜Work o r motion at improper speed 提升欠妥Improper lifting 加载欠妥Improper loading 走捷径Shortcuts 其他项Other

2.2-1 2-2 2-3 2-4 2-5 2-6 2-7 2-8

工具或设备使用 Use of Tools or Equipm ent设备使用欠妥Imprope r use of equipment 工具使用不妥Imprope r use of tools 使用有缺陷设备(明知) Use of defective equipment(aware)

保护方法的使用 Use of Protective Methods缺乏隐患存在意识Lack of knowledge of hazards present 个人保护设备尚未使用Personal protective equipment notused

4.4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9

疏忽 /意识缺乏 Inattention / Lack of Awareness决定欠妥或缺乏判断 Imp roper decision making or lack ofjudgment

5.5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10

保护系统 Protective System s护罩和保护性装置不够 Inadequate guards or p rotective devices 护罩或保护性装置有缺陷 Defective guards or protective devices 个人保护设备不适宜 Inadequate p ersonal protective equipment 个人保护设备有缺陷 Defective personal protective equipment 警示系统不适Inadequate warning systems 警示系统缺陷Defective warning systems 工艺或隔离设备不妥 Inadequate isolation of process or equipment 安全装置欠妥Inadequate safety devices 安全装置有

缺陷Defective safety devices 其他项Other

6.6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10

工具、设备及车辆 Tools, Equipm ent &Vehicles 设备有缺陷Defective equipment 设备不足Inadequate equipment 设备准备不够Imprope rly prepared equipment 工具缺陷Defective tools 工具欠妥Inadequate tools 工具准备不妥Imprope rly prepared tools 车辆有缺陷Defective vehicle 用车目的不符Inadequate vehicle for the purpose 车辆准备欠妥Imprope rly prepared vehicle 其他项Other

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

工作暴露 Work Exposures to明火和爆炸性物品Fire or ex plosion 噪音Noise 带电的电力系统Energized electrical systems 除电力外能源系统Energized systems, other than electrical 辐射Radiation 极温Temperature ex tremes 化学危险品Hazardous chemicals 机械危险物Mechanical hazards 凌乱或石屑碎片Clutter o r debris 风暴或自然现象Storms or acts of natu re 地面或过道过滑Slippery floors or walkways 其他项Other

8.8-1 8-2 8-3 8-4 8-5

工作地危险 Work Place Environm ent / Layout拥挤或活动受限Congestion or restricted motion 照明不适或过度 Inadequate or ex cessive 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 控制不妥controls less than adequate 显示器不妥displays less than adequate 标签不妥labels less than adequate 位置超出可及或视力范围 locations out ofreach or sight

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 I mproper placement oftools, equipment or materials 设备操作速度欠妥Operation of equipment at imp roper speed 对正在运行的设备进行维修 Se rvicing of equipment in operation 其他项Other

个人保护设备使用不正确 Imp roper use of p roper personal protective equipment 动力设备维修保养Servicing of energized equipment 设备和材料未能固定Equipment or materials not secured 保护装置、警示系统或安全装置失效 Disabledguards, warning systems or safety devices guards, warning systems or safety devices available

保护装置、警示系统、安全装置拆卸 Removal of 没有个人保护设备Personal protective equipment not 其他项Other

注意力分散Distracted by other concerns 忽视地面和周围环境 Inattention to footing and surroundings 嬉闹Horseplay 暴力行为Acts of violence 未作警告Failure to warn 使用药物或酒精Use of drugs or alcohol 无意识地进行常规活动 Rou tine activity without thought 其他项Other

8-6

相矛盾的信息conflicting information is presented 其他项 Other

可能的系统原因POSSIBLE SYSTEM CAUSES 人为因素 PERSONAL FACTORS1.1-1 1-2 1-3 1-4 1-5

工作因素 JOB FACTORS5.5-1

体力 PhysicalCapability 视力低下Visiondeficiency

2.2-1

身体状况Physical Condition 原先受伤或得 病Pr

evious injury orillness

3.3-1 3-2 3-3

精神状态 MentalState 判断力差Poor judgment 记忆力丧失Memoryfailure

4.4-1

精神压力 MentalStress 全神贯注于别的问 题Preoccupation withproblems

行为 Behavior不合格的操作受到奖 赏 Improper perfo rmance isrewarded

6.6-1

技术水平 SkillLevel 对所需求技术 没有充分评估Inadequate assessment of required skills

7.7-1

训练 / 知识转换Training / Knowledge Transfer 没有进行充分的知识 转换Inadequate knowledgetransfer

8.

管理、 监视和对雇员 9. 的领导关系 Managem ent /Supervision / Employee Leadership 角色和职责冲突Conflictingroles / responsibilities 9-1

承包商的选择和 审查 ContractorSelection & Oversight 承包商未进行资格 预审Lack of contractor pre qualifications

10.1010-1

工程 / 设计Engineering / Design 技术设计欠妥Inadequatetechnical design

11.1111-1 1111-2

工作计划 Work Planning工作计划欠妥Inadequate workplanning

12.

采购、材料处理及 材料控制Purchasing, Material Handling & Material Control 收货项目与订购项目 不符Incorrect item received 给销售商的产品 规范标准不正确inadequate specifications to vendor

13.1313-1

工具和设备 Tools &Equipm ent 需求和风险评估欠妥Inadequate assessment of needs and risks

14.

工作规程 / 政策 / 标准 / 程 序 (PSP) Work Rules / Policies /Standards / Procedures (PSP) 执行任务缺乏PSP Lack of PSP forthe task

15.1515-1

沟通 Communication在同伴间水平沟通 不完善Inadequatehorizontal communication between peers

预防性保养欠缺 Inadequatepreventive maintenance

1414-1

听力低下Hearingdeficiency

节省时间或努力saves time or effort

其它感官缺陷Othersensory deficiency

2-2

肺活量下降Reducedrespiratory capacity

疲劳Fatigue 由于工作量due to workload 3-4 3-5 3-6 3-7 3-8 3-9

协调不好或反应时 间长Poor coordination orreaction time

4-2 4-3

情绪干扰Emotionaldisturbance 恐惧Fears or phobias 缺乏机械知识Low mechanical aptitude 理解能力差Low learning aptitude 4-4

受到挫折Frustration 对工作方向及要求 模糊不清Confusingdirections / demands

8-1

设计输入陈旧designinput obsolete

避免不便之处 5-2 5-3 avoids discomfort 哗众取宠gains attention 6-2

必需的评估assessment ofneeds

缺乏技术实践Inadequate practice of skill

不能领会inability tocomprehend

报告关系不明确unclearreporting relationships

9-2

导师资格不够inadequate instructor qualifications

其它永久性身体残 疾Other permanentphysical disabilities 暂时残疾Temporary disabilities

由于缺乏休 息due to lack ofrest

报告关系相矛盾conflicting reporting relationship

承包商资格预审欠 妥Inadequate contractorpre-qualifications

设计输入不正确design input not correct

1212-1

1313-2

润滑/维修lubrication /servicing

人的因素及人机控制 考虑欠妥Inadequatehuman factors / ergonomics considerations

设计输入不可用design input not available

目标或要求相冲突Conflicting directions / demands

没有适当的监督示范Improper supervisory ex ample

6-3

不经常操作的 技术Infrequentperformance of skill

1-6 1-7

由于感官超 载due to sensoryoverload 2-3

4-5

无意义的或品味低 的活动Meaningless ordegrading activities

对关键的安全行为没 有充分的认识Inadequate identification of critical safe behaviors

培训设备不足inadequate training equipment

职责分配不清unclearassignment of responsibility

9-3

承包商选用欠妥Inadequate contractor selection

调节/装配adjustment /assembly

1313-3

标准和规范不合适Inadequate standards or specifications 1414-2

设计输出不妥designoutput inadequate

清洗/涂层cleaning /resurfacing 1111-3

6-4

缺乏技术指导Lack of coaching on skill

职责分配相矛盾conflicting assignment of responsibility 授权不清或不妥improper or insufficient delegation of authority 8-2

9-4

不理解使用说明书misunderstood instructions 7-2

雇佣未经审核批准 的承包商Use of nonapproved contractor 无工程监管Lack of job oversight

涉计输入不可行design input infeasible output unclear

维修性保养欠缺 Inadequaterepair

订购书上资料不 精确或有误inadequate specifications on requisition

1313-4 1313-5

无现实可取性Inadequate availability

缺乏PSP的详细职责lack of defined responsibility for PSP 缺乏安全工作分析lack of job safety analysis 安全工作分析不足inadequate job safety analysis PSP工作展开不力Inadequate development of PSP 程序和设备设计不相一致inadequate coordination with process / equipment design

1515-2

上下级间垂直沟通 不完善Inadequate verticalcommunication between supervisor and person

1515-3

不同机构间沟通不 完善Inadequatecommunication between different organizations

1515-4

设计输出不清design 设计输出不正确design output not correct

无力支撑身体姿势Inability to sustain body positions

操作能力降低Diminished performance

受药物影响Influencedby medication

4-6 4-7

情绪超负荷Emotionaloverload

5-4

1-8

身体活动范围受限Restricted range of body movement 物质过敏症Substance sensitivities or allergies

由于温度极 限due totemperature ex tremes

其它因素Other

□ 不适用Not Applicable4-8

过激的评价 / 决定 要求Ex treme judgment /decision demands

没有充分强调关键的 安全行为Inadequatereinforcement of critical safe behaviors

6-5

没有充分温习 训练以巩固技 术Insufficient reviewof instruction to establish skill

不能充分回想起训练 内容Inadequate recall oftraining material

9-5 9-6 9-7

需要修理的信息传达communication of needed repair

1-9 1-10

过度的精力集中Ex treme concentration / perception demands 极度的乏味Ex treme boredom

正确的行为被责 备proper performance iscriticized

培训没有加固 trainingnot reinforced on the job

不适宜的领导关系Inadequate leadership

工程监管欠妥Inadequate oversight

设计输出不一致

工作计划安排schedulingof work parts

对可修改订单不 能完全控制inadequate control on changes to orders

调节、修理、保养欠 妥Inadequate adjustment /repair / maintenance

工作组之间沟通不 完善Inadequatecommunication between work groups

员工与发展所需不相适应inadequate employee involvement in the development

1313-6

废旧物品和再次利用 物资处理不妥Inadequate salvage and reclamation

1515-5

身高不够或体力不 足Inadequate size orstrength

由于缺氧dueto oxygen deficiency 4-9 4-10

6-6

其它因素OtherApplicable 7-3

再培训的频率不够inadequate refresher training frequency 培训工作欠缺Inadequate training effort

业绩的考核标准缺乏 强制性standards ofperformance missing or not enforced inadequate accountability

其它因素Other1010-2

design output inconsistent independent design review 1111-4

设计评论不独立no 所采用标准、规范和 设计指导思想欠妥Inadequate standards, specifications, and / or design criteria 1010-3

部件检查ex amination of 部件更换parts substitution 过度磨损和撕裂Ex cessivewear and tear

□ 不适用Not Applicable

销售商未经有关 部门批准擅自更 换替代品unauthorizedsubstitution

纠正行为的详细说明不充 分inadequate definition of correctiveactions

班组倒班沟通不完 善Inadequate communicationbetween shifts

1515-6

通讯方法不完善Inadequate communication methods 通讯手段缺乏 No communication method available

1313-7

不适当的同事压 力inappropriate peerpressure

□ 不适用Not

不合适部件拆卸和更 换欠妥Inadequate removal /replacement of unsuitable items 无设备记录档案No equipment record history 1414-3

安排不妥使PSP难以使用inadequate format for easy use

1515-7

责任和义务不明 执行情况反馈不充分 或错误inadequate orincorrect performance feedback

使用计划不当inadequate planning for use 超期服役ex tension of service life 装载不当improper loading by untrained people

产品验收不完善inadequate product acceptance requirements 1313-8 1313-9

1-11

由于药物治疗造成 能力下降Diminishedcapacity due to medication

由于大气压 变化due to atmospheric pressure variation 血糖降低Blood sugar insufficiency 由于使用药物 或酒精而使能 力削弱Impairmentdue to drug or alcohol use 2-6

由于内容不完善，PSP执行不 力Inadequate implementation of PSP, duet

o deficiencies

其它因素Other

□ 不适用Not Applicable

不适当的行为反 应inadequateperformance feedback

培训计划设计欠缺 培训目标 / 目的欠 缺inadequate training goals/ objectives inadequate training program design

1515-8 1515-9

指令不准确Incorrectinstructions

潜在问题估计不足Inadequate assessment of potential failure

1-12

其他因素Other

2-4 2-5

□不适用Not Applicable

不适当的纪律处 置inadequate disciplinaryprocess 5-5 5-6

对工地环境不了解inadequate work site walk through

1010-4 1010-5 1010-6

人机工程学设计欠妥Inadequate ergonomic design

未经训练的人使用 use

产品与收条不相 符或未进行验收noacceptance verification performed 1212-2

设备记录档案不完备Inadequate equipment record history

自相矛盾的要求contradictoryrequirements

混乱含糊的格式confusingformat

工作更换没有很好 沟通 Inadequatecommunication due to job turnover

过分的急功好利Inappropriate aggression

对新员工的定位不 适当inadequate newemployee orientation

对安全工作开展推广 不足inadequate safetypromotion 8-3

施工监视欠妥Inadequate monitoring of construction 操作准备工作评估欠 妥Inadequate assessment ofoperational readiness

使用错误use for wrongpurpose 1111-5

对材料和设备研究不 足Inadequate research onmaterials / equipment

13-10

其它因素Other

每一步超过一个行为 morethan one action per step

□ 不适用Not Applicable

1515-10

使用不适当的方法刺 激生产Improper use ofproduction incentives

初始培训不当inadequate initial training

其它因素Other

□不适用Not Applicable

5-7 5-8

监督暗中催促Supervisor implied haste 雇员性急Employee perceived haste 7-4

没有有效手段确认 学生是否掌握inadequate means to determine if qualified for job

工地和工作中隐患(危 险)整改不力Inadequate 不能鉴别工地和工作中 危险隐患Inadequate

有关参考资料或文献资料 不足Inadequate refe rence materialsor publications

程序中无确认步骤no check -offspaces provided

1212-3

correction of prior hazard / incident 8-4

1010-7

对最初操作监视不力Inadequate monitoring of initial operation

1111-6

审核 / 检查 / 监视欠缺Inadequate audit / inspection / monitoring 1212-4 1212-5

产品运输方式或线路 不妥Inadequate mode orroute of shipment

不准确的步骤顺序inaccuratesequence of steps instructions

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 communicationof safety and health data, regulations or guidelines

混乱模糊的指令confusing 技术性错误technical error /missing steps

材料处理欠妥Imprope rhandling of materials

1515-11

没有使用标准术语Standard terminology not used

5-9

其它因素Other

没有提供培

训No trainingprovided

8-5 8-6

identification of worksite / job hazards 变更管理不善Inadequate management of change system

1010-8

评估欠妥和文档变更 管理欠妥Inadequateevaluation and / or documentation of change

无文件no documentation 未明确整改责任nocorrection responsibility assigned

材料或零部件保管不 妥Improper storage o fmaterials or spare parts

过多的说明ex cessive references 潜在的情形没有覆盖 potential1414-4

1515-12

没有使用查证和重 复技术Verification /repeat back techniques not used 口信过长Messages too long 讲话干扰Speech interference

□ 不适用Not Applicable

没有认识到培训的 必要性need for t rainingnot identified

事故报告调查机制不完 善Inadequate incident reporting /investigation system

10-9

其它因素Other1111-7

整改措施不落实noaccountability for corrective action

1212-6 1212-7 1212-8

材料包装不妥Inadequate material packaging 材料存放超期Material shelf life exceeded

PSP强化措施不力Inadequateenforcement of PSP

situations not covered

1515-13 1515-14 15-15

依靠已过时或不准 确的培训记录trainingrecords incorrect or out of date

8-7 8-8

安全会议不足或没有Inadequate or lack of safety meetings

□ 不适用 Not Applicable

工作安置欠妥 Inadequate jobplacement

对工作没有充分监测inadequate monitoring of work

危险品不能正确鉴别Improper identification of hazardous materials

工作方法已变化而 未培训new workmethods introduced without training

安全业绩考核和评估欠 妥Inadequate performancemeasurement & assessment

没有确定合适的人选appropriate personnel not identified 1212-9

监督知识不足inadequatesupervisory knowledge reinforcement

其它因素 Other

没有可用的合适人选appropriate personnel not available

使用不当或废弃材料 处置欠妥Impropersalvage and / or waste disposal 1414-5

强化不充分 inadequate 没有修正不符合non-compliance PSP沟通传达不力Inadequatecommunication of PSP not corrected

□ 不适用Not Applicable

8-9

其它因素Other

故意不参加培训decision made not to train 7-5

□ 不适用Not Applicable

没有提供合适的人选appropriate personnel not provided 11-8

1212-10

健康安全资料使用不 当Inadequate use of safetyand health data

给工作组分发不完全incomplete distribution to work groups 语言困难inadequate translation to appropriate languages

其它因素Other

以上所列引发事故的根源，考虑了每一个安全识别的临界因 素。如果“ 是”,在相应的因素上画圈，如果不是以上所列因 素，则检查栏目底部的“ 不适用”项。 For each identified critical factor,consider if any of the listed root cause categories apply. If 'y es,' circle the specific root cause. If none of the root causes in the

category apply, then ch eck the 'not applicable' box at the bottom of the column.

□ 不适用Not Applicable

其它因素Other

12-11

其它因素Other

□ 不适用Not Applicable

□不适用Not Applicable

综合培训不充分incompleteintegration with training

已过时的PSP仍在使用out o fdate revisions still in use 14-6

其它因素Other

□ 不适用Not Applicable

纠正阶段: 纠正措施的建议CORRECTIVE PHASE: PROPOSA LS FOR CORRECTIVE ACTION 与 安全管理体系的要素相一致

安全管理体系的要素 ELEMENTS OF GETTING HS E RIGHT领导重视并负责Leadership and Accountability

风险评估和管理Risk Assessm ent and Managem ent

人员、培训和行为

与承包商和其他方合作

装置设计和安装

运行和维修Operations and Maintenance

变更的管理Managem ent of Change

信息和资料Information and Docum entation

用户和产品Custom ers and Products

社区和相关各方的意识Community and Stakeholder Awareness

危机和应急管理Crisis and Emergency Managem ent

事故分析和预防Incidents Analysi s and Prevention

评估、保障和改进Assessment, Assurance and Improvement

People, Training and Behaviours Working with Contractors and Others Facilities Design and Construction

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