事故调查-怎样建立事故流程图2014年9月3日剖析.pptVIP

SnapCharT? Guidelines One Action Per Event Events: “Who did What?” “What did What?” Sequence from Left to Right If Assumption/Unverified Fact: - Dashed Box - Dashed Oval Conditions tell what we know about an Event should NOT include action steps Do NOT Use Names SnapCharT? Guidelines ALL items on chart should be: - Factual - Non-Judgmental - Precise Quantified 事故流程图的优点 有利于引导事故调查，组织和整理信息数据； 有利于进行逻辑推理，还原事故真实面貌； 有利于识别事故的关键因素； 有利于事故汇报和事故信息分享； 观看事故录像（交通事故） 每个人做事件流程图 练习事件单元以及状态单元的描述排列 关键因素 A problem or issue that, if corrected, could have prevented an incident from occurring or significantly reduced the incidents consequences. 不期望发生的问题； 可能是一个人为错误，或是一个设备失灵； 如果得到了纠正，便可以预防事故的发生或大大降低事故的造成的后果； Step 3: Define Causal Factors The most general problem some task that was done improperly or some task that was not done or equipment that did not operate as it was expected to operate. Winter SnapCharT?(Management Presentation SnapCharT?) Checklist is required for turbine start up Supervisor told Operator to start up turbine Operator aligns valves for start up Operator heats up turbine with steam Operator rolls turbine with steam to complete warm up Operator places turbine on line Turbine Damaged Operator manually trips turbine Operator does not use procedure About 20 valves must be opened or shut Procedure is checklist Operator opens steam vents Operator throttles steam vents Operator shuts vents puts traps on line Over $100,000 damage discovered Operator does not open one valve on one drain line Noise is water hitting blades Turbine making loud pinging noise Operator cooled down turbine, opened and inspected 观看跌落事故的录像 建立事故流程图 联系找出关键因素 建立事故流程图， 还原事故全貌。 谢谢！ * * * Read slide. * * * * * * * * * * * * 怎样建立事故流程图？ 安全理念： 一切生产作业活动中的事故都是可以预防的！ The Iceberg Relationship Between Accidents, Incidents, Near Misses, Problems Refinery pump seal imp