事故根本原因分析检查表

1、esign or constructionDRoot cause analysis of accidents, incidents andesign or constructionD事故、事件和未遂事故根本原因分析表First Level Root Causes 一级根本原因Second Level Root Causes 二级根本原因Third Level Root Causes三级根本原因Accid.,Incid.& N.M.事故、事件和未遂事故1Task工作安排和执行Risk assessment风险评估No SWR未进行安全工作审核2Handling or loading is not

2、 adequately specified搬运和装卸没有明确的规定3Tools工具Tools in bad condition工具状况不良4Tools not available没有工具5Inadequate or wrong tools for the job作业中使用了不恰当的或错误的工具6Improper gauges计量仪表不合适7PPEPPE in bad conditionPPE状况不良8PPE not available没有PPE9Inadequate PPE for the job使用的PPE不恰当No warning signs没有警示标识11Risk assessment风

3、险评估Risk assessment of the equipment or of the process not done未对设备或工艺进行风险评估Hazard not identified未辨识出危害Inadequate risks controls风险控制不当Equipment badly designed or badly constructed设备的设计或构造有缺陷Standards not applied or inadequate未执行相关标准或采用了不适合的标准Equipment or software cannot support the usage设备或软件不能满足使用的需

4、求Inadequate man/machine interface人机界面不当Improperly programmed machine设备运行程序编制不当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First Level Root Causes 一级根本原因Desi n or constructionSecond LevelDesi n or constructionThird Level Root Causes三级根本原因Accid.,Incid.& N.M.事故、事件和未遂事故Eq

5、uipment/material 设备和物质材料g设计或构造gInadequate reviews (SHE audits, PSSR, )检查不到位 (SHE审核，开车前检查等)20Unavaibility of documentation files没有运行程序的说明文件21Machine without adequate guard设备上无合适的防护装置22Equipment used outside of its capabilities and limitations超能力和超极限使用设备23Controls including emergency stop buttons not

6、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24Maintenance维修No maintenance没有维修25Equipment failure设备故障26Inadequate 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)27Obsolescence of equipment使用报废或超期服役的设备28Safety

7、devices out of order安全设施失效29Software or hardware not updated软件或硬件未更新30Material材料Unavailable Material Safety Data Sheet没有物质安全数据表31Hazardous materials not identified未辨识出有害物质32Presence of gas or fumes存在有毒气体或异味33Improper labelling标签不当34Quality requirements of materials inadequate对材料的质量要求不当35Contaminated

8、 material材料被污染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First Level Root Causes 一级根本原因Second Level Root Causes 二级根本原因Third Level Root Causes三级根本原因Accid.,Incid.& N.M.事故、事件和未遂事故36Material handled improperly (storage, distribution, usage or disposal) 材料的处理不当 (存储、运输、使用或

9、处置)37Inadequate sampling采样不当38Ergonomics人机工程Awkward positions使用不便39Bad design of man/machine interface人机界面有缺陷40Environment环境Local environment当地的环境Process affected by conditions over the course of a day生产工艺经常变换带来影响41Process affected by humidity, vibration, noise, lighting, 生产工艺受到湿度、震动、噪音和光线等的影响。42Too

10、 much noise噪音大43Poor lighting照明不足44Extreme temperatures极端温度45Influence of weather天气的影响46Housekeeping现场整洁Mess脏乱47Slippery floor地面滑48Obstacles有障碍物49Communication沟通Information improperly disseminated信息传递不正确50Forget to communicate忘记沟通51Competency能力Lack of experience of the worker in performing this task

11、执行任务的员工经验不足52No training未接受过培训53Training not understood未理解所培训的内容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Accid.,Incid.& N.M.First Level Root Causes 一级根本原因First Level Root Causes 一级根本原因Second Level Root Causes 二级根本原因事故、事件和未遂事故三级根本原因5455565758595455565758596061626364

12、656667686901对文件的理解有误Mistake 失误Doesnt Mistake 失误没有理解所收到的信息Worker distracted in the workplace工作时注意力不集中Too much judgment required to perform the taskPeople performancePeople performance 员工的行为Too much information at the same time在同一时间内需要了解的信息过多FatigueNot Not fit for duty 不能胜任工作Physically unable for the

13、job身体条件无法胜任工作Alcohol, drugs or medicines酒精、毒品或药品Under stress for work or personal reasons有来自工作或个人方面的压力Horseplay工作时玩闹Use without authorisation擅自使用设备、工具等Defeat safety devices without authorisationBehaviourBehaviour 行为Lack of motivation缺乏积极性Lack of vigilance警惕性不强Deliberate mistake故意出错视了操作程序的部分细节Inatten

14、tion to details of 视了操作程序的部分细节忽Work permit procedure (andLOTO procedures)Not defined, inadequate,Work permit procedure (andLOTO procedures)没有制定制度、制度不完善、制度未颁布实施或未被遵守Standard doesnt exist or not enforced作业许可 (以及挂牌上锁程序作业许可 (以及挂牌上锁程序)作许挂牌锁程序Root cause analysis of accidents, incidents and near-作许挂牌锁程序事故、

15、事件和未遂事故根本原因分析表First Level Root Causes 一级根本原因Second Level Root Causes 二级根本原因Third Level Root Causes三级根本原因Accid.,Incid.& N.M.事故、事件和未遂事故业业 可 (以及 上2Management管理Guidelines for judgment unavailable没有作业情况判别指导书3Management of change 变更管理Not defined, inadequate, not implemented, not complied with没有制定制度、制度不完善、

16、制度未颁布实施或未被遵守4Standard doesnt exist or not enforced没有制定标准规范或未强制实施5Guidelines for judgment unavailable没有制定变更管理的判别指导书6Other procedures其它的规程Not defined, inadequate, not implemented, not complied with没有制定制度、制度不完善、制度未颁布实施或未被遵守7Standard doesnt exist or not enforced没有制定标准规范或未强制实施8Guidelines for judgment una

17、vailable没有作业情况判别指导书9Work instructions are not clearly written作业指导写得不清楚80Work instructions are not complete作业指导不完整81Training培训Proper training to perform the task not administered to the worker 没有针对员工所从事的作业任务提供适当的培训82Workers not trained properly员工培训不到位83Testing performed not significant培训后的测试流于形式，没有发挥

18、功效84No training for wearing PPE没有进行PPE穿戴的培训85No training for using tools没有进行使用工具的培训86Role and accountability 岗位职责Unclear job工作任务不清87Unclear responsibilities职责不清88Performance setting 绩效指标的设定Performance expectations for team or individuals not set未制定团队或个人的绩效目标89Inadequate Policy Setting政策不健全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First Level Root Causes 一级根本原因Second Level Root Causes 二级根本原因Third Level Root Caus