事故调查与根源学案.pptVIP

go to View... Header/Footer to change this text 事故调查与根源分析 Synonyms Definitions 术语和定义 Accident 事故 Incident 一般事故 Event 事件 Loss 损失 Near-miss 险情 Near-hit 损失起因与事故调查模式 现场调查 现场调查工具 急救包 记录表 放大镜 录像带 相机/录像机 胶带 卷尺 便签和铅笔 方格纸 塑料袋 标签 罗盘 数码相机 事故现场管理 与证人面谈interview 收集证据之后 分析技巧Techniques of Analysis 分析技巧Techniques of Analysis 如何确定关键因素 Critical factors 负面的事件的或意料之外的条件，影响事故的发展 如果拿掉可消除或减小事故损失程度 是时间事件中的一个环节 Negative If reduced, can eliminate or reduce severity One BB in the timeline 根源分析 系统原因分析 事故调查的目的在于找出事故的系统/根本原因，以便在管理上采取有效措施，改正缺陷，防止事故再次发生。 分析技巧Techniques of Analysis 最后工作 对每个系统原因列出行动方案 准备正式报告 报告报管理层批准 管理层职责  批准行动 对行动确定日期和人员 获得进展反馈 确保跟进行动程序 检验最后结果 问 题？ There are several pitfalls that should be avoided when seeking the root or system cause(s) of an incident: Personal factors alone do not cause incidents. If a person’s attitude or behaviour appears to cause an incident, some failure in the safety system made it possible for the attitude or behaviour to override the system. The objective is not to find fault or place blame. The system causes are being sought so that faults in the safety systems can be corrected. Do not blame specific individuals as the only root cause. Problems do not come so much from the way people work but from the way they are managed. If people are not working safely, the systems are failing to control the safe actions of workers. It is the supervisor’s responsibility to make sure employees work safely. 1 1 For smaller charts, run on 17x22 paper, reduce to 35%. For larger charts, reduce to 75%, 36x48. The priorities at the incident scene must be as follows; Your Safety – Do not add to the problem Others Safety – Don’t make matters worse Casualties – Treatment of others can now be organised Evidence – Once the above issues are dealt with, we can turn our attention to evidence. Now that we have evidence we must now process it. At the heart of any meaningful investigation is the ability to conduct a fair, ethical and detailed In