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

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