事故根源综合分析表(中英文)资料下载.pdf

1、 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,工具、设备及车辆 Tools,Equipment&#VeniresEquipment&#Venires781-12-13-14-15-16-1设备有缺陷 Defective equipment7-18-11-22-23-24-25-26-2设备不足 Inadequate equipment7-28-21-32-3

2、3-34-35-36-3设备准备不够 Improperly prepared7-38-31-42-43-44-45-46-4工具缺陷 Defective tools7-48-41-52-53-54-55-56-5工具欠妥 inadequate tools7-58-51-62-63-64-65-66-6工具准备不妥 Improperly prepared tools7-61-72-73-74-75-76-7车辆有缺陷 Defective Vehicle7-71-82-83-84-85-86-8车型和用途不符 Inadequate vehicle for thepurpose7-81-93-94-

3、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 体力体力 Physical Capability2 身体状况身体状况 Physical condition3 精神状态精神状态 Mental State4 精神压力精神压力 Mental Stress5 行为行为 Behavior6 技术水平技术水平 Skill Level7训练训练/知识转换知识转换 Training/Knowledgetransfer8管

4、理管理/监督监督/员工的领导关系员工的领导关系Management/supervision/Employee9承包商的选择和审查承包商的选择和审查contractor selection&#oversight10 工程工程/设计设计Engineering/Design11 工作计划工作计划 Work Planning12采购、材料处理及材料控制采购、材料处理及材料控制Purchasing,Material handing&#Material13 工具和设备工具和设备 Tools&#Equipment14工作规程工作规程/政策政策/标准标准/程序（程序（PSP）WorkRules/Policie

5、s/Standards/Procedures（PSP）15 沟通沟通 Communication1-1 视力低下 Vision deficiency2-1原先受伤或得病Previousinjury or illness3-1 判断力差 Poor judgment4-1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 isrewarded6-1对所需求技术没有充分评估 Inadequate assessment ofrequired skills7-1没有进行充分的知识转换 inadequateknowl

6、edge transfer8-1角色和职责冲突 Conflicting roles/responsibilities9-1承包商未进行资格预审 Lack ofcontractor pre-qualifications10-1技术设计欠妥 inadequate technicaldesign11-1 工作计划欠妥 Inadequate work planning12-1收货项目与订购项目不符 Incorrect itemreceived13-1需求和风险评估欠妥 Inadequate assessmentof needs and risks14-1 执行任务缺乏PSP Lack of PSP f

7、or the task15-1在同伴间水平沟通不完善 Inadequatehorizontal communication between peers1-2 听力低下 Hearing deficiency2-2 疲劳 Fatigue3-2 记忆力丧失 Memory failure4-2 受到挫折 Frustration节省时间努力 saves timeor effort6-2缺乏技术实践 Inadequatepractice of skill不能领会 inability to comprehend报告关系不明确 unclear reportingrelation ship9-2承包商资格预审欠

8、妥 inadequatecontractor per-qualifications设计输入陈旧 design input obsolete11-2预防性保养欠妥 Inadequate preventivemaintenance给供应商的规范不正确 Inadequatespecification to vendor13-2人的因素及人机控制考虑欠缺 Inadequatehuman factors/ergonomics considerations缺乏PSP的详细职责 lack of definedresponsibility for PSP15-2上下级间垂直沟通不完善 Inadequate v

9、erticalcommunication between supervisor and person1-3基它感觉缺陷 Other SensoryDeficiency由于工作量 Due to workload3-3协调不好或反应时间长 Poorcoordination or reaction time4-3对工作方向及要求模糊不清 Contusing Directions/demands避免不便 avoids discomfort6-3不经常操作的技术Infrequent performance of skill导师资格欠缺 inadequate instructorqualification

10、s报告关系矛盾 conflicting reportingrelation ship9-3承包商选用欠妥 inadequatecontractor selection设计输入不正确 design input notcorrect维护需求评估 assessment of needs订购书上的规范不明确 inadequatespecification on requisition13-3标准和堆满不合适 Inadequate standards orspecifications缺乏作业安全分析 lack of job safety analysis15-3不同机构间沟通不完善 Inadequate

11、communication between different organizations1-4肺活量下降 ReducedRespiratory Capacity由于缺乏休息 due to lack ofrest3-4 情绪干扰 Emotional disturbance4-4目标或要求相冲突Conflicting directions哗众取宠 gains attention6-4缺乏技术指导 Lack ofcoaching on skill培训设备不够 Inadequate trainingequipment职责分配不清 unclear assignment ofresponsibility

12、9-4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 notavailable润滑/维修 lubrication/servicing对订单修改控制不当 inadequate controlon changes to orders13-4 不适当的可用性 Inadequate availability作业安全分析不当 inadequate job safetyanalysis15-4工作组之间沟通不完善 Inadequatecommunication between work groups1-5其它良久性身体残疾 Ot

13、herPermanent Physical disabilities由于感官超载 due to sensoryoverload3-5 恐惧 Fears or phobias4-5无意义的或品味低的活动 Meaningless ordegrading activities5-2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 misunderstoodinstructions职责分配矛盾 conflicting assignment ofresponsibility9

14、-5 无工程监管 Lack of job oversight设计输入不妥 design outputinadequate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 Inadequateadjustment/repair/maintenance14-2PSP工作展开不力 Inadequate development ofPSP15-5班组之间沟通不完善 Inadequatecommunication between shifts1-6暂时残疾 Temporarydisabilitie

15、s2-3操作能力降低 Diminishedperformance3-6缺乏机械知识 Low mechanicalaptitude4-6情绪超负荷 Emotionaloverload5-3对关键的安全行为没有充分的认识 inadequateidentification of critical safe6-6 其它因素 Other7-2不能充分回想起训练内容 inadequaterecall of training material授权不清或不妥 improper or insufficientdelegation of authority9-6工程监管欠妥 inadequateoversight

16、设计输入不可行 design inputinfeasible清洁/涂层 deaning/resurfacing产品验收不完善 inadequate productacceptance 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 inadequatecoordination with process/equipment design15-6沟通方法不完善 inadequate communicationmethods1-7无力支撑身体姿势 Inability tosustain body positions由于温度极限 due totemperature extremes3-7 理解能力差 Low learning aptitude4-7过渡的评价/决定要求Extreme judgment/decisiondemands5-4没有充分强调养分的安全行为 inadequate rein forcement critical safe behaviors 不适用 Not Applicable缺