事故发生的根源分析.ppt

1、Root Cause Analysis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,Find the ca

2、uses 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

3、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？,.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,3,000 FIRST AID 急救 (Minor 轻伤),30,000 NEAR MISSES 未遂事件 (Unsafe acts-Unsafe conditions 不安全的行为和状态)

4、,1 FATAL 死亡,30 DISABLING 残疾 (Severe 重伤),300 MEDICAL 需要治疗 (Serious 受伤),Because we dont get to pick where we land 因为我们无法预知事情的结果。,?,Why Investigate Incidents and Near misses? 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方向。,Effort 努力方向,Why Investigate Incidents and Near misses? 为什么要调查事故和未遂事件

5、？,3,000 FIRST AID 急救 (Minor 轻伤),30,000 NEAR MISSES 侥幸脱险 (Unsafe acts-Unsafe conditions 不安全的操作和状态),1 FATAL 身亡,30 DISABLING 残疾 (Severe 重伤),300 MEDICAL 疗伤 (Serious 受伤),Group Exercise 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,Responsibil

6、ity 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,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 POINT调查的重点,Do Not

7、 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,Cause 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 Conditio

8、ns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 Sp

9、eed 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,Five “Why”s 五个“为什么”,Why? 为什么？ Why? 为什么？ Why? 为什么？ Why? 为什么？ Why? 为什么？,Why Analysis “为什么”分析,The why questio

10、ns 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”分析,Done after fact-finding has developed the obje

11、ctive 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

12、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,车间滑倒,Incident Investigation Process 事故调查的过程,Follow-Up 后续工作,Corrective Action 改进措施,Response 回应,Fact

13、-Finding 实情调查,Analysis 分析,Notification 通告,Identify 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。 60 seconds till the world ends Multiple 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 s

14、imple, 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 Counterme

15、asures 制定对策,Controls and Countermeasures 控制措施和对策,Identify those persons who are responsible for corrective/preventive actions. 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完成并且行之有效 Share results with similar o

16、perations 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，并用录像演示,Hierarchy of Controls 风险控制措施的优先顺序,Elimination/Substitution- removing or reducing the hazard 消除/替换 消除或降低风险 Engineering Controls workstation design, machine guards, safety controls,

17、 isolation of hazardous areas, monitoring devices, etc. 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 Administrative Controls - procedures, assessments, inspection, records to monitor and ensure safe practices and environments are maintained. 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 Training Controls - initial new

18、hire safety orientation, job specific safety training and periodic refresher training. 培训 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-Up 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 Countermeasures 对策追踪,Complete Incident Investigation Forms with CM, responsible persons, completion date and status. 与CM，负责人一起完成事故调查表格，包括日期和状态 Follow your guidelines 遵循你的指示 Ask Affected Parties 寻问受影响的相关方 Regular Review by Sr. Mana