哈石化烫伤事故案例.ppt

Contributing Factors促成因素: 1.进行排污、排水后将排污阀门又关闭 Sewage valve was closed after sewage drainage 2.对此作业风险认识不足，没有采取可靠控制措施 Insufficient understanding of the operational risk , no reliable control measures taken . Root Causes根本原因: 1.未在界区管线进户处加设盲板 No blind plate installed at battery limit line inlet 2.对此作业未进行危险识别和控制 Did not conduct hazard identification and control 3.未有技术或管理人员将安全措施经一步复查，未对此种作业进行相应管理 No technician and management person rechecked the safety measures , no appropriate management Corrective Actions采取的措施: 1.立即将受伤员工送至哈市五院住院进行治疗 The injury worker was sent to the NO. 5 Hospital at once 2.