事故调查与根源探究.pptVIP

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