事故根源分析
Root Cause Analysis
事故根源分析
Getting hurt is not generally a conscious
decision...
受伤都是意外的，不是自觉的…
...Working Safely Is!
但工作安全是可以自觉控制的!
Group Exercise 分组练习
•Discuss other reasons we should investigate near misses and close calls
讨论我们调查未遂事件的其他原因•5 minutes
5分钟时间
Responsibility 职责•Ensure employees understand what an accident is. 确保员工明白什么是事故。•Ensure that all associates understand why they must report accidents.
确保所有人员理解为什么一定要报告事故。
Responsibility 职责•Investigate every accident! 调查每次事故的原因–Major
重大事故
–Minor
小事故
–Property
财产损失
–Near Miss
未遂事件
Before You Discipline (5 Questions)在你开始严肃纪律前 （问自己5个问题）•Leadership requires discipline when justified! 即使理由充分，领导也需要严肃纪律！•Before you discipline ask yourself “Have I”: 在你开始推行纪律前，问问你自己“我是否”：–set an example by following safety rules/policies 以身作则了？
–provided adequate resources and support
是否提供了足够的资源和支持使别人能遵守纪律
Before You Discipline (5 Questions)在你开始严肃纪律前 （问自己5个问题）–provided adequate training
是否提供了足够的培训
–insisted on compliance by enforcing safety rules in the past 在过去是否坚持遵守安全法规
–provided adequate supervision by identifying and correcting hazards before someone got hurt
在发生事故之前就安排足够的监管力量，发现和消除事故隐患
Before the Interview
在面谈之前
•Preparation
准备
–Who should do the interview?
谁应当负责面谈工作？
•Interviewer should have credibility with the interviewee 面谈组织者应当得到受访者的信任
•Interviewer should be aware of group dynamics 面谈组织者应当认识到可能对所涉及到的组织的影响
Before the Interview
在面谈之前
–Have prepared questions, just in case 事先准备好一些问题，以防万一
–Meet on interviewees’ turf or neutral location 站在被访者的或中立的立场上考虑问题•Preferably were the incident occurred
面谈最好仅针对刚发生的事件（“就事论事”）
Who Should be Interviewed?
哪些人应该受访？
•Injured and others directly involved
受伤者及其他直接当事人
•Witnesses
目击证人
•Others who do the same job
其他相同工作人员
•Maintenance personnel
设备维护人员
•Engineering
工程人员
•Those who set up the equipment
设备装配人员
•Other experts
其他专家
Fact Finding: The Interview
实情调查：面谈
•Interview Tips (put the interviewee at ease) 面谈技巧 （使受访人处于轻松的状态）–Create a positive environment
营造一个积极的面谈环境
–Ask questions without being aggressive
在较为平和的气氛下提出问题
–Be patient, do not talk too much
保持耐心，不要说过多的话
–Show interest in the interviewee
对受访者的回答表现出兴趣
–Avoid criticism
避免批评受访者
You are investigating the incident/accident, not the person 你是在调查事故，不是在调查人 not the person
During the Interview
在面谈中
What techniques can you use for more effective interviews?有效的面谈可采用哪些技巧？
•As soon as possible and at the scene 尽可能快当场面谈
•Put at ease
营造轻松的气氛
–fact finding, not fault finding
调查事故情况，不是调查当事人的过失
–start with easily answered questions (conditions, etc.) 以容易回答的问题开始提问（受访者身份等）
–seek privacy
面谈情况应保密
–ask for prevention ideas
寻问预防安全事故的建议
During the Interview
在面谈中
•Ask open questions (what, when, where)
询问开放性的问题（发生什么事情，何时，在哪里）•One-on-One and One at a time
每次面谈时采用一对一的方式
Fact Finding: Interview Questions
事件调查：面谈的问题
•Don’t ask leading questions
别提对答案有诱导性的问题
–No
避免
•Does your supervisor discuss safety with you?
你们的主管与你们讨论安全生产的问题吗？
–Yes
应该
•Who discusses safety with you?
谁与你们讨论安全生产问题？
During the Interview
面谈过程中
•Phrases to remember
记住适用下列用语
–“Please help me understand what happened”
“请帮我弄明白到底发生了些什么”
–“Go on”
“说下去”
–“What does that mean to you”
“那对你来说意味着什么”
–“Can you explain that further”
“你能进一步解释一下吗”
–“…[dead air]…”
–“…[dead air]…”
Interview Quiz 面谈中的小测试
•Is this a good question?
这个问题问的是否正确？
–In which direction was the John running when he tripped on the pallet?
当John摔倒在货盘上时，他在朝哪个方向跑？
•Leading question that assumes:
诱导性的问题：
–John was running John在跑
–John fell on a pallet John摔倒在货盘上• What would be a better question?
怎样更好的提问？– What was John doing before he fell? John在摔倒之前在干什么?– Why do you think John was fell down? 你认为John摔倒的原因是什么?
Interview Quiz 面谈中的小测试
•Is this a good question?
这个问题问的好不好?
–Did you see Jane reach past the guard and stick her hand inside the machine?
你看到Jane越过警戒线并把手放进机器里了吗？
•Leading question that assumes:
引导性的问题这里有：
–Jane did reach past the guard Jane确实越过了警戒线
•What would be a better question?
怎样更好的提问？
–What did you see the operator do?
你看到这个工人当时如何做呢?
Interview Quiz 面谈中的小测试
•Is this a good question?
这个问题问的好不好?
–Did you realize that Ed was angry before he got the fork truck? 你注意到 Ed在得到叉车前很生气吗?
•Leading question that assumes:
引导性的问题这里有：
–Ed was angry Ed很生气
•What would be a better question?
怎样更好的提问？
–How would you describe Ed’s behavior before he got the fork truck? 你能描述一下Ed在得到叉车前的表现吗?
of BricksBucket
桶装砖事故
A Series of Unfortunate Events
一连串的不幸事件
F BRICKS STORY THE BUCKET OTHE BUCKET OF
Reinforcer)(Interviewing Technique (Interviewing Technique ReinforcerReinforcer)
The following letter is a reprint of an actual letter sent by an employee to the Petrolane-Utah Gas Service.
I am writing in response to your request for additional information. In the accident reporting form, I put “trying to do the job alone” as the cause of the accident. You said in your letter that I should explain more fully and I trust that the following information will be sufficient.
I am a bricklayer by trade. On the date of the accident, I was working alone on the roof of a new six story building. When I completed my work, I discovered that I had about 500 pounds of bricks left over. Rather than carry the bricks by hand, I decided to lower them in a barrel by using a pulley which fortunately was attached to the side of the building at the sixth floor.
Securing the rope at ground level, I went up to the roof, swung the barrel out and loaded the bricks into it. Then I went back to the ground and untied the rope, holding it tightly to ensure a slow descent of the 500 pounds of brick. You will note in the accident report that I weigh 165 pounds.
Due to my surprise at being jerked off the ground so suddenly, I lost my present state of mind and forgot to let go of the rope. Needless to say, I proceeded at a rather rapid rate up the side of the building.
In the vicinity of the third floor, I met the barrel coming down. This explains the fractured skull and broken collarbone.Slowed only slightly, I continued my rapid ascent, not stopping until the fingers of my right hand were two knuckles deep into the pulley. Fortunately, by this time, I had regained my present state of mind and was able to hold tightly to the rope in spite of my pain. At approximately the same time, however, the barrel of bricks hit the ground and the bottom fell out of the barrel. Devoid of the weight of the bricks, the barrel now weighed approximately 50 pounds.
I refer you again to my weight. As you might imagine, I began a rapid descent of the building. In the vicinity of the third floor, I met the barrel coming up. This accounts for the two fractured ankles and the lacerations of my legs and lower body. The encounter with the barrel slowed me enough to lessen my injuries when I fell on the pile of bricks. Fortunately, only three vertebrae were cracked.
I am sorry to report, however, that as I lay there on the bricks in pain, unable to stand, and watching the empty barrel six stories above me, I again lost my present state of mind and let go of the rope. The empty barrel weighed more than the rope, so it came back down. And that accounts for my two broken legs.
I hope I have furnished the information you required as to how the accident occurred.
Sincerely,
Joe Schmoe
A Series of Unfortunate Events一连串的不幸事件
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•桶装砖事故（免谈技巧强化）下面这封信是一名Petrolane-Utah Gas Service的员工的真实来信。应您的要求，我向您写这封信，想让您了解更多关于事故的真实情况。在事故报告书中，我写的事故原因是“设法自己独立完成工作”。您在信中提到要我将当天事故发生的经过描述的更详细些，所以我给您写来这封信，告诉您更多当时的情况。我是一名搬砖工。出事那天，我当时正一个人沿着一幢新建六层楼房的房顶走。当我干完活后，我发现还有大约500磅重的砖块要搬。这时我正巧在六楼一角落处发现一个滑轮一辆皮带轮的拖车，我就想把砖块装入一个桶中再通过滑轮放到地面上放在拖车上搬走。在底层在桶上系好绳索安全带后，我爬到屋顶上拿出桶，并往里面放砖块。然后，我回到地面解开安全带，紧紧握住绳索，试图将这500磅的砖块慢慢降下来。您在事故报告中就已经知道我的体重是165磅。我突然之间就被一股猛力拉离了地面，由于当时感到紧张和害怕，我失去了意识并忘了放掉手中的绳索。接下来显而易见，我被这股猛力迅速地拉向楼顶。就在我大概被拉到三楼的时候，碰撞到了正从上往下降的运砖桶。这次碰撞造成我头骨裂开，锁骨断裂。仅是停顿了一会，我又继续快速被往上拉，一直到我右手指的两个关节插入到滑轮拖车中才停下来。幸运的是，那时我恢复了意识，尽管当时非常疼痛，但我仍旧紧紧拉住绳索。大约就在那时，落下去的桶跌落到地上，砖块全都摔到了桶外边。这只空桶的重量大约是50磅。我再次提醒您我的体重。您可能能够想像，我又开始快速地往下降。大概落到三楼附近，我再次碰撞到了从下面升上来的空桶。这次碰撞又造成我两根踝骨断裂，腿和下半身都撞破。幸运的是这次碰撞减慢了我下落的速度，使我在跌到那堆砖上时只摔断了三根椎骨。我很遗憾地告诉您，当我摔到那堆砖上之后，由于疼痛我站不起身来，只能眼睁睁地看着那只吊在六层楼高的空桶。那时我又失去了知觉，手松开了绳索。空桶再次掉了下来，这次又造成我两条腿被砸伤。我希望这次向您提供的事故情况能够满足您的要求。真诚地Joe Schmoe
The Interview面谈
•You have 5 minutes to:你有5分钟：
–Create an non controversial atmosphere 营造一种和谐的谈话氛围–Gather additional facts 收集更多资料
–Ask open ended questions 提开放的问题–Actively listen 仔细聆听
–Ask Primary and Secondary Questions寻问首要和其次的问题
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为什么？为什么？为什么？为什么？为什么？
5个为什么
•车间滑倒
Controls and Countermeasures 控制措施和对策
•Identify those persons who are responsible for
指定负责整改的人员corrective/preventive actions.corrective/preventive actions.
•Set corrective/preventive action target dates, and follow up to ensure action is completed and effective. 确定整改的目标和期限，后续工作要保证整改effective.
完成并且行之有效
•Share results with similar operations within plant and across plants. Video Reenactment excellent tool to accomplish this.
将整改的结果告知给相似的部门和整个公司，并用录像演示
Summary for
Effective Root Cause Analysis 有效的根本原因分析方法小结
4Techniques are merely tools and can be misused and/or misapplied.技术不过是方法，可能会被误用
4Techniques inherently overlap and should be used together to check or confirm facts.
技术是交叉的，可以用多种技术寻找并确定真相
4Integrate findings from various techniques and use parts from all tools.用不同的方法整合发现的事物
4Scale the scope of the analysis to suit the severity or complexity of the accident.
衡量分析的范围以与事故的严重性和复杂性相符合4Active management role is critical.发挥管理层的作用是很关键的
一份好的事故调查报告
被落石砸扁的 Pajero