条分缕析 前车可鉴To make a root cause analysis, to learn lessons from the past 根源分析第2步：找出关键起因 PCA Step 2: identify critical factors 分析收集的信息 Analyze information 重建起因事件链 Causal factor charting 识别事故关键起因 Identify critical causal factors
可能的间接原因Possible indirect causes 个人因素Personal factors 1.行为诱因 behavior driver 1.1省时间save time 1.2嫌麻烦avoid 1.3 雇 员 性 急 employee perceived haste 1.4同事催促 peer pressure 1.5监督催促 Supervisor implied haste 1.6不适当的行为反馈 Inadequate performance feedback 1.7不适当的激励机制 Inadequate incentive system 1.8不适当的处罚 Inadequate punishment 1.9其它因素other 不适用not applicable 2. 工 作 压 力 Working pressure 2.1 工 作 量 过 大 work overload 2.2 焦 虑 或 挫 折 preoccupation with problems or frustration 2.3 精 神 负 担 过 重 emotional overload 2.4决策或责任压力大 Extreme judgment/decision demands 2.5对工作方向及要求 模糊不清 Confusing directions/demands 2.6过度的精力集中 Extreme concentration 2.7极度的乏味 Extreme boredom 2.8其它因素other 不适用 not applicable 3.心理素质 Mental capability 3.1情绪干扰emotional disturbance 3.2害怕或恐惧 fears or phobias 3.3性格问题personality 3.4 动 手 能 力 差 low mechanical aptitude 3.5理解能力差 Low learning aptitude 3.6记忆能力差 Memory failure 3.7协调或反应能力差 Poor coordination or reaction time 3.8判断力差 Poor judgment 3.9其它因素other 不适用 Not applicable 4.体能素质 Physical capability 4.1疲劳Fatigue/tiredness 4.2视力低下 vision deficiency 4.3听力低下 hearing deficiency 4.4感到体力虚弱 felt weak 4.5身高不够 inadequate size 4.6速度不当 inadequate speed 4.7物质过敏症 substance 4.8旧伤旧病复发 previous injury or illness 4.9其它感官缺陷 other sensory deficiency 4.10其它身体永久伤残 other permanent physical disabilities 4.11其它因素other 不适用not applicable 5.技能素质skill level 5.1对所需求技术没有充 分 评 估 inadequate assessment of required skills 5.2缺少培训或证书 Lack of training or certificates 5.3故意不参加培训 Decision made not to train 5.4缺乏技术实践/练习 Lack of practice of skill 5.5缺乏技术指导 Lack of coaching on skill 5.6不经常操作的技术 Infrequent performance of skill 5.7没有查看指南以明确 技 术 要 求 not review of instruction to establish skill requirements 5.8缺乏隐患存在意识 Lack of knowledge of hazards present 5.9其它因素other 不适用not applicable
人非圣贤 孰能无过 To error is human, to divine is God 调查准备 Preparing Investigation 记录事故的类型和严重程度 Document the type/severity of event 包括所涉及的人、事件、地点和目前的进展 Include the who/what/when/where/how known at the time 成立事故调查小组investigation team establishment 根源分 析第 1 步： 收集证 据 RCA Step 1:Data collection 收集证据collect evidence 人证、物证、位置和文件 People/parts/positions and paper 保护证据preserve evidence
根源分析第3步： 分析根源RCA step3:Identify Root Cause
可能的直接原因Possible immediate causes 行为Behaviors 1. 疏 忽 / 缺 乏 安 全 意 识 2. 遵 守 工 作 程 序 Following 1. of awareness Inattention/Lack疏忽/缺乏安全意识 procedures 1.1位置不当 1.1位置不当Position in danger 2.1例外违规exceptional violation 1.2无意识的人为差错 by individual/group/supervisor 1.2 无 意 识 的 人 为 差 错 Unintentional1.3忽视周围环境 human error 2.2个人/班组/主管习惯性违规 1.4注意力分散 to routine violation by 1.3忽视周围环境Inattention surroundings 1.5未向他人提供警告 individual/group/supervisor 1.6不假思索的常规活动2.3个人/班组/主管故意破坏 1.4 注 意 力 分 散 distracted by 1.7嬉闹/暴力等不当行为 other concerns Acts of sabotage by 1.8使用药物或酒精 individual/group/supervisor 1.5 未 向 他 人 提 供 警 告 No 1.9其它因素 warning provided to others 2.4 无 程 序 可 用 procedure was not available 1.6不假思索的常规活动Routine activity without thought 2.5不理解程序 Procedure was not understand 1.7嬉闹/暴力等不当行为 Horseplay/violence or other 2.6采用了错误的程序 inappropriate workplace Use of improper procedure behaviors 2.7其它因素Other 1.8使用药物或酒精Use of drugs or alcohol 1.9其它因素Other 3.工具或设备使用 Use of tools or equipment 3.1设备/车辆使用不当 Improper use of equipment/vehicle 3.2工具使用不当 Improper use of tools 3.3使用有缺陷设备（明知)Use of defective equipment(aware) 3.4使用有缺陷工具（明知） Use of defective tools(aware) 3.5工具、设备或物料放置欠妥 Improper placement of tools, equipment or materials 3.6 设 备 / 车 辆 操 作 速 度 欠 妥 operation of equipment/vehicle at improper speed 3.7对正在运行的设备进行维修 Servicing of equipment in operation 3.8其它因素other
可能的直接原因Possible immediate causes 工具与设备tools and equipment 5.工具/设备及车辆Tools, equipment and vehicles 5.1设备故障 Equipment failure 5.2设备准备欠妥 Improperly prepared equipment 5.3工具缺陷 Defective tools 5.4工具准备欠妥 Improperly prepared tools 5.5车辆故障 Defective vehicle 5.6车型和用途不符 Inadequate vehicle for the purpose 5.7 工 艺 技 术 流 程 缺 陷 defective technical process 5.8其它因素other 6.保护系统protective systems 6.1 缺 少 保 护 性 装 置 lack of protective devices 6.2保护性装置有缺陷defective protective devices 6.3安全装置欠妥 Inadequate safety devices 6.4安全装置有缺陷 Defective safety devices 6.5缺少上锁挂牌或警示标示 Defective lockout/tagout or warning signs 6.6上锁挂牌或警示标示有缺陷 Defective lockout/tagout or warning signs 6.7个人保护用品有缺陷 Defective personal protective equipment 6.8其它因素other 场所workplace 7.工作暴露work exposures 7.1 明 火 或 爆 炸 性 物 品 Fire explosion 7.2噪音Noise 7.3 带 电 电 气 系 统 Energized electrical systems 7.4 非 电 气 能 源 系 统 Energized system,other than electrical 7.5幅射radiation 7.6 极 高 / 低 温 temperature extreme high/low 7.7 化 学 危 险 品 hazardous chemicals 7.8 机 械 危 险 物 mechanical hazards 7.9坠物fall objects 7.10生物毒害biological hazards 7.11风暴或自然现象storms or acts of nature 7.12其它因素other 8.作业场所环境/布置work place environment/layout 8.1 拥 挤 或 活 动 受 制 congestion or restricted motion 8.2 照 明 不 足 或 光 线 太 强 inadequate/excessive illumination 8.3 受 限 空 间 或 通 风 不 足 confined space or inadequate ventilation 8.4高空作业work at height 8.5 地 面 或 过 道 打 滑 slippery floors or walkways 8.6缺乏进出管制entry controls less than adequate 8.7 布 局 不 妥 displays less than adequate 8.8 标 示 不 妥 labels less than adequate 8.9 超 出 范 围 或 视 力 受 限 locations out of reach or sight 8.10互相矛盾的信息conflicting information is presented 8.11其它因素other