事故根本原因分析检查表

Root cause analysis of accidents, incidents and near-misses,事故、事件和未遂事故根本原因分析表,First Level Root Causes,一级根本原因Second Level Root Causes,二级根本原因Third Level Root Causes,三级根本原因Accid.,Incid.& N.M.,事故、事件和未遂事故,1.0Task,工作安排和执行Risk assessment,风险评估No SWR ,未进行安全工作审核,2.0Handling or loading is not adequately specified,搬运和装卸没有明确的规定,3.0Tools,工具Tools in bad condition,工具状况不良,4.0Tools not available,没有工具,5.0Inadequate or wrong tools for the job,作业中使用了不恰当的或错误的工具,6.0Improper gauges ,计量仪表不合适,7.0PPEPPE in bad condition,PPE状况不良,8.0PPE not available,没有PPE,9.0Inadequate PPE for the job,使用的PPE不恰当,10.0No warning signs,没有警示标识,11.0Equipment/material,设备和物质材料Risk assessment,风险评估Risk assessment of the equipment or of the process not done,未对设备或工艺进行风险评估,12.0Hazard not identified,未辨识出危害,13.0Inadequate risks controls,风险控制不当,14.0Design or construction,设计或构造Equipment badly designed or badly constructed,设备的设计或构造有缺陷,15.0Standards not applied or inadequate,未执行相关标准或采用了不适合的标准,16.0Equipment or software cannot support the usage,设备或软件不能满足使用的需求,17.0Inadequate man/machine interface ,人机界面不当,18.0Improperly programmed machine,设备运行程序编制不当,19.0Inadequate reviews (SHE audits, PSSR, …),检查不到位（SHE审核，开车前检查等）,20.0Unavaibility of documentation files,没有运行程序的说明文件,21.0Machine without adequate guard,设备上无合适的防护装置,22.0Equipment used outside of its capabilities and limitations,超能力和超极限使用设备,23.0Controls including emergency stop buttons not clearly labelled or differentiated,包括紧急停止开关在内的各种控制按钮未明确标识或区分,24.0Maintenance,维修No maintenance,没有维修,25.0Equipment failure,设备故障,26.0Inadequate maintenance (lack of spare parts, lack of scheduled maintenance, lack of preventive maintenance, …),维修不当（缺乏备件、缺乏定期维修或预防性维修等等）,27.0Obsolescence of equipment,使用报废或超期服役的设备,28.0Safety devices out of order,安全设施失效,29.0Software or hardware not updated ,软件或硬件未更新,30.0Material,材料Unavailable Material Safety Data Sheet,没有物质安全数据表,31.0Hazardous materials not identified,未辨识出有害物质,32.0Presence of gas or fumes,存在有毒气体或异味,33.0Improper labelling ,标签不当,34.0Quality requirements of materials inadequate ,对材料的质量要求不当,35.0Contaminated material,材料被污染,36.0Material handled improperly (storage, distribution, usage or disposal),材料的处理不当（存储、运输、使用或处置）,37.0Inadequate sampling,采样不当,38.0Ergonomics,人机工程Awkward positions,使用不便,39.0Bad design of man/machine interface,人机界面有缺陷,40.0Environment,环境Local environment,当地的环境Process affected by conditions over the course of a day ,生产工艺经常变换带来影响,41.0Process affected by humidity, vibration, noise, lighting,…,生产工艺受到湿度、震动、噪音和光线等的影响。42.0Too much noise,噪音大,43.0Poor lighting,照明不足,44.0Extreme temperatures,极端温度,45.0Influence of weather,天气的影响,46.0Housekeeping,现场整洁Mess,脏乱,47.0Slippery floor,地面滑,48.0Obstacles,有障碍物,49.0People performance,员工的行为Communication,沟通Information improperly disseminated,信息传递不正确,50.0Forget to communicate,忘记沟通,51.0Competency,能力Lack of experience of the worker in performing this task,执行任务的员工经验不足,52.0No training,未接受过培训,53.0Training not understood,未理解所培训的内容,54.0Mistake,失误Documents improperly interpreted,对文件的理解有误,55.0Doesn’t understand information,没有理解所收到的信息,56.0Worker distracted in the workplace,工作时注意力不集中,57.0Not fit for duty,不能胜任工作Too much judgment required to perform the task,完成工作任务需要做出许多判断,58.0Too much information at the same time,在同一时间内需要了解的信息过多,59.0Fatigue ,疲劳,60.0Physically unable for the job,身体条件无法胜任工作,61.0Alcohol, drugs or medicines,酒精、毒品或药品,62.0Under stress for work or personal reasons,有来自工作或个人方面的压力,63.0Behaviour,行为Horseplay,工作时玩闹,64.0Use without authorisation,擅自使用设备、工具等,65.0Defeat safety devices without authorisation,擅自摘除安全设施,66.0Lack of motivation,缺乏积极性,67.0Lack of vigilance,警惕性不强,68.0Deliberate mistake,故意出错,69.0Inattention to details of procedure,忽视了操作程序的部分细节,70.0Management,管理Work permit procedure (and LOTO procedures),作业许可（以及挂牌上锁程序）,71.0,72.0Guidelines for judgment unavailable,没有作业情况判别指导书,73.0Management of change,变更管理,74.0,75.0Guidelines for judgment unavailable,没有制定变更管理的判别指导书,76.0Other procedures,其它的规程,77.0,78.0Guidelines for judgment unavailable,没有作业情况判别指导书,79.0Work instructions are not clearly written,作业指导写得不清楚,80.0Work instructions are not complete,作业指导不完整,81.0Training,培训Proper training to perform the task not administered to the worker,没有针对员工所从事的作业任务提供适当的培训,82.0Workers not trained properly ,员工培训不到位,83.0Testing performed not significant,培训后的测试流于形式，没有发挥功效,84.0No training for wearing PPE,没有进行PPE穿戴的培训,85.0No training for using tools,没有进行使用工具的培训,86.0Role and accountability,岗位职责Unclear job,工作任务不清,87.0Unclear responsibilities,职责不清,88.0Performance setting,绩效指标的设定Performance expectations for team or individuals not set,未制定团队或个人的绩效目标,89.0Commitment,管理层的义务Inadequate Policy Setting,政策不健全,90.0Lack of visible and accountable leadership ,缺乏领导可视化,91.0Lack in the follow-up on improvement actions,缺乏对整改措施的跟踪检查,92.0Supervision,监督Critical safety risks not clearly communicated to the worker,没有清晰地向员工说明重大安全风险,93.0Resources,资源的支持Not enough workers,人手不足