··1体力 Physical Capbility2身体状况 Physical Condition3精神状态 Metal State4精神压力 Metal Stress5行为 Behavior6技术水平 Skills Level7训练知识转换 Training/Knowledge Transfer8管理监督员工的领导关系 Management/Supervision/Employee Leadership9承包商的选择和审查 Contractor Selection & Oversight10工程设计 Engineering/Design11工作计划 Work Plan12采购、材料处理及材料控制Puchasing, Material Handling & Material Control 13工具和设备 Tools & Equipment14工作规程政策标准程序（PSP）Work Rules/Policies/Standards/Procedures(PSP)15沟通Communication1-1视力低下Vision Deficiency 2-1原先受伤或得病Previous injury or illness3-1判断力差Poor Judgement4-1全神贯注于别的问题Preoccupation with problems5-1不合格的操作受到奖赏Inproper performance is rewarded6-1对所需求技术没有充分评估Inadequate assessment of requirement skills7-1没有进行充分的知识转换Inadequate knowledge transfer8-1角色和职责冲突Conflicting roles/responsibilities9-1承包商未进行资格预备审Lack of contractor pre-qualifications10-1技术设计欠妥Inadequate technical design11-1工作计划欠妥Inadequate work planning12-1收货项目与订购项目不符Incorrect item received13-1需求和风险评估欠妥Inadequate assessment of needs and risks14-1执行任务缺乏PSPLack of PSP for the task15-1在同伴间水平沟通不完善Inadequate horizontal communication between peers1-2听力低下Hearing deficiency 2-2疲劳Fatigue3-2记忆力丧失Memory Failure4-2受到挫折Frustration·节省时间或努力saves time or effort6-2缺乏技术实践Inadequate practice of skill·不能领会inablity to comprehend·报告关系不明确unclear reporting relationships9-2承包商资格预审欠妥Inadequate contractor pre-qualifications·技术输入陈旧design input obsolete11-2预防性保养欠缺Inadequate preventive maintenance·给供应商的规范不正确inadequate specifications to vendor13-2人的因素及人机控制考虑欠缺Inadequate human factors/ergonomics considerations·缺乏PSP的详细职责lack of defined responsibilities for PSP15-2上下级间垂直沟通不完善Inadequate vertical communication between supervisor and person1-3其他感官缺陷Other sensory deliciency ·由于工作量due to workload3-3协调不好或反应时间长Poor coordination or reaction time4-3对工作方向及要求模糊不清Confusing directions/demands·避免不便avoids discomfort6-3不经常操作的技术Inadequate performance of skill·导师资格欠缺inadequate instructor qualifications·报告关系矛盾conflicting reporting relationship9-3承包商选用欠妥Inadequate contractor selection·技术输入不正确design input not correct·维修需求评估assessment of needs·订购书上的规范不明确Inadequate specification13-3标准和规范不合适Inadequate standards or specifications·缺乏作业安全分析lack of job safety analysis15-3不同机构间沟通不完善Inadequate communication between different organizations1-4肺活量下降Reduced respiratory capacity ·由于缺乏休息due to lack of rest3-4情绪干扰Emotional Disturbance4-4目标或要求相冲突Conflicting directions/demands·哗众取宠gains attention6-4缺乏技术指导Lack of coatching on skill·培训设备不够inadequate training equipment·职责分配不清unclear assignment of responsibility9-4雇佣未经审核批准的承包商Use of non-approved contractor·技术输入不可用design input not available·润滑/维修lurication/servicing·对订单修改控制不当inadequate control on changes to orders13-4不适当的可用性Inadequate availability·作业安全分析不当Inadequate job safety analysis15-4工作组之间沟通不完善Inadequate communication between work groups1-5其他永久性身体残疾Other permanent physical dsiablities ·由于感官超载due to sensory overload3-5恐惧Fears or phobias4-5无意义的或品味低的活动Meanningless or degrading activities5-2没有适当的监督规范Improper supervisory example6-5没有充分温习训练以巩固技术Insufficient review of instruction to establish skill·误解指令说明misunderstood instructions·职责分配矛盾conflicting assignmnet of responsibility9-5无工程监管Lack of job oversight·设计输出不妥design output inadequate·调整/装配adjustment/assembly·供应商未经批准擅自更换替代品unauthorized substitution13-5调节、修理、保养欠妥Inadequate adjustment/repair/maintenance14-2PSP工作展开不力Inadequate development of PSP15-5班组倒班沟通不完善Inadequate communications between shifts1-6暂时残疾Temporary disability 2-3操作能力降低Deminished performance3-6缺乏机械知识Low mechniacal aptitude4-6情绪超负荷Emotional overload5-3对关键的安全行为没有充分的认识Inadequate identification of critical safe behaviors6-6其他因素Other7-2不能充分回想起训练内容inadequate recall of training material·授权不清或不妥improper or insufficient delegation of authority9-6工程监管欠妥Inadequate oversight·设计输入不可行design input infeasible·清洁/涂层cleaning/resurfacing·产品验收不完善Inadequate product acceptance requirements13-6废旧物品和再次利用物资处理不妥Inadequate salvage and reclamation·程序和设备设计不相一致inadequate coordination with process/euiqpment design15-6沟通方法不完善Inadequate communication methods1-7无力支撑身体姿势Inability to sustain body position ·由于温度极限due to temporature extremes3-7理解能力差Low learning aptitude4-7国际的评价决定要求Extremed judgement/decision demands5-4没有充分强调关键的安全行为Inadequate reinforcement of critical safe behaviors不适用 Not Applicable·缺乏强化培训Training not reinforce on thr job8-2不适宜的领导关系Inadequate leadership9-7其他因素Other·设计输出不清design output unclear11-3维修性保养欠缺Inadequate repair·未进行产品验收no acceptable verification performed13-7不合适部件拆卸和更换欠妥Inadequate removal/replacement of unsuitable items·员工参与PSP制定安排不当inadequate emplyee involvement in the development15-7沟通手段缺乏No communication methods available1-8身体活动范围受限Restricated range of body body movement ·由于缺氧due to oxygen efficiency3-8受药物影响Influenced by medication4-8过度的精力集中Extreme concentration perceptiondemands·正确的行为被指责proper performance is criticized·缺少再培训inadequate refresher training frequency·业绩标准缺乏或力度不够standards of performance missing or not enforced不适用Not Applicable·设计输出不正确design output not correct·维修需求信息沟通communication of needed repair12-2对材料和设备研究不足Inadequated research on materials/equipment13-8无设备记录档案No equipment record history·纠正行为的详细说明不充分Inadequate definition of corrective actions15-8指令不准确Incorrect directions1-9物质过敏症Substence sensitivities or allergies ·由于大气压变化due to atmosphere3-9其他因素Other4-9极度的乏味Extreme boredom·同事的不当压力inappropriate peer stress7-3培训工作欠缺inadequate trainig effort·职责和义务不明inadequate accoutability·设计输出不一致design output not correct·工作计划安排scheduling of work12-3产品运输方式线路欠妥Inadequate mode or route of shipment13-9设备记录档案不完备Inadequate equipment record history·格式不妥使PSP不实用Inadequate format for easy use15-9工作更换没有很好沟通Inadequate communication due to job turnover1-1身高不够或体力不足Inadequate size or length 2-4血糖降低Blood sugar insufficency不适用Not Applicable4-10其他因素Other·不适当的表现反馈inadequate performance feedback·培训计划设计不当inadequate training program design·执行情况反馈不够或错误inadequate or incorrect performance feedback·没有独立的设计审查no independent design review·部件检查examination of parts12-4材料处理欠妥Improper handling of material13-10其他因素Other14-3由于内容不完善，PSP执行不力Inadequate implementation of PSP, due to deficiencies15-10安全和健康保护资料、规章制度或指导准则没有很好沟通Inadequate communication of safety and health data, requlations or guidelines1-11由于药物疗法造成能力下降Diminished capacity due to medication 2-5由于使用药物或酒精而使能力减弱Imparement due to drug or alcohol use不适用 Not Applicable·不适当的纪律处置inadequate disciplinary process·培训目标不准确inadequate training goals/objectives·缺少现场走访inadequate work site walk-through10-2所采用标准、规范和设计指导思想欠妥Inadequate standards, specifications,and/or design criteria·部件更换parts substitution12-5材料或零部件保管不妥Improper storage of materials or spare parts不适用 Not Applicable·自相矛盾的需求contradictory requirements15-11没有选用标准术语Standard terminology not used1-12其他因素Other 2-6其他因素Other5-5过分的急功好进Inappropriate aggression·对新员工缺乏教育inadequate new employee orientation·安全推广不力inadequate safety promotion10-3潜在问题估计不足Inadequate assessment of potential failure11-4过度磨损和撕裂Excessive wear and tear12-6材料包装不妥Inadequate material packing·混款含糊的模式confusion format15-12没有使用查证和重复技术Verification/repeat back techniques not used不适用Not Applicable不适用Not Applicable5-6使用不适当的方法刺激生产Improper use of production incentives·初始培训不妥inadequate initial training8-3工地或工作中隐患（危险）整改不力Inadequate correction of prior hazard/incident10-4人机工程学设计欠妥Inadequate ergonomic design·使用计划不当inadequate planning of use12-7危险品不能正确鉴别Improper identification of hazardous maerials·每一步超过一个行为more than one action per step15-13口信过长Messages too long 5-7监督暗中催促Sueprvisor implied haste·无法判定是否合适上岗inadequate means to determine if qulified for job8-4不能明确鉴别工地和工作中危险隐患Inadequate identification of worksite/job hazards10-5施工监察欠妥Inadequate monitoring of construction·超期服役extension of service life12-8使用不当或废弃材料处置Improper salvage and/or waste disposal·程序中无确认步骤no check-off spaces provided15-14讲话干扰Speech interference 5-8雇员性急Employee perceived haste7-4没有提供培训No traning provided8-5不合适的变更管理系统Inadequate management of change system10-6操作准备工作评估欠妥Inadequate assessment of operationalreadiness·装载不当Improper loading12-9健康安全资料使用不当Inadequate use of safety and health data·不准确的步骤顺序inaccurate sequence of steps15-15其他因素Other 5-9其他因素Other·没有认识到培训的必要性need for training not identified8-6事故报告调查机制不完善Inadequate incident reporting/investigation system10-7对最初操作监察不力Inadequate monitoring of initial operation·未经训练的人使用used by untrained people12-10其他因素Other·混乱模糊的指令confusing instructions不适用 Not Applicable 不适用Not Applicable·培训记录不对或过期training records incorrect or out of date8-7安全会议不足或没有Inadequate or lack of safety meetings10-8评估欠妥和文档变更管理欠妥Inadequate evaluation and/ordocumentation of change·使用意图错误use of wrong purpose不适用 Not Applicable·技术性错误technical error/missing steps·未经培训就使用新的操作方法new work methods introdued without traiing8-8安全业绩考核和评估不当Inadequate performance measurement & assessment10-9其他因素Other11-5有关参考资料或文献不足Inadequate reference materials or publication·过多的说明excessive reference·故意不参加培训decision made not to train8-9其他因素Other不适用Not Applicable11-6审核检查监视欠缺Inadequate audit/inspection/monitoring·潜在的情形没有覆盖potential situations not covered7-5其他因素Other不适用Not Applicable·无文件no documentation14-4PSP强化措施不力Inadequated enforcement of PSP不适用Not Applicable·未明确整改责任no correction responsibility assigned·对工作缺乏监察inadequate monitoring of work·整改措施不落实no accountability for corrective action·监督知识不足inadequate supervisory knowledge11-7工作安排欠妥Inadequate job placement·强化不充分Inadequate reinforcement·没有确定合适的人选appropriate personnel not identified·没有纠正不符合non-compliance not correct·没有可用的合适人选appropriate personnel not available14-5PSP沟通传达不力Inadequate communication of PSP·没有提供合适人选appropriate personnel not provided·给工作组分发不完全incomplete dsitribution to work group11-8其他因素Other·培训整合不完善incomplete integration with training不适用Not Applicable·不妥的翻译inadequate translation to appropriate languages·已过是的PSP仍在使用out of date revisions still in use14-6其他因素Other不适用Not Applicable可能的直接原因 POSSIBLE SYSTEM CAUSES行 为 类 ACTIONS条 件 类 CONDITIONS人 为 因 素 PERSONAL FATORS工 作 因 素 JOB FATORS可能的系统原因 POSSIBLE SYSTEM CAUSES事故根源综合分析表Comprehensive List of Causes事故INCIDENT调查准备Preparation Investigation·Document the type/severity of event 记录事故的类型和严重程度·Cover the who/what/when/where/how as known as the time包括所涉及的人、事件、时间、地点和目前的进展根源分析第一步：收集证据RCA Step 1: Data Collection·Collect Evidence 收集证据·People, Parts, positions and paper 认证、物证、位置和文件根源分析第2步：找出关键起因RAC Step 2: Identify Critical Factors·Analyze Information 分析所收集的信息·Cause Factor Charting 重建起因事件链人证People物证Parts位置Positions文件Paper解决方案Solutions根源分析第3步：根源分析Management Suppor and Responsibility管理层支持和责任体系创建事故分析的企业文化Preparing 准备Classfication System 事故分类系统Policy Procedures for notification事故通报程序Policy Procedures for notification成立事故调查小组Team supplies and training小组成员培训和组件Management Suppor and Responsibility事故通报、事件分类和启动调查小组Begain Investigation 开始调查Develop Specific Plan 制定调查计划Secure Evidence保护证据Collect Evidence收集证据People, Parts,Position and Paper 人证、物证、位置和文件Protective Evidence保护证据Overall Investigation Progress事故调查总流程图RCA Step 1Data Collection根源分析第一步收集证据Analyse Information分析所收集的信息Identify Critical Causal Factors识别事故关键起因Identify Root Cause事故起因根源分析看不清楚原文Formal Report完成调查报告Implement Recommendation 实施整改计划建议Follow-up / Audit后续检查审核看不清楚原文RCA Step 2Identify Critical Factors根源分析第二步找出关键原因RCA Step 3Identify Critical Factors根源分析第三步根源分析RCA Step 4Identify Critical Factors根源分析第四步？？？？Complete结束损失LOSEPeople,preoperty, production事故INCIDENTContatc with energy or substance直接起因IMMEDIATE CAUSESUnsafe acts and / consitions系统原因BASIC CAUSESPeople,preoperty, production缺乏控制LACK OF CONTROLInadeqaute management system引发CAUSATION调查INVESTIGATIONFor each identified critical factor, consider if any of the listed rootcause categories applu. If 'yes', circle the specific root cause. if noneof the root causes in the category apply, then check the 'notapplicable' box at the bottom of the column.针对每个关键起因，逐个分析所列的事故根源是否适用。