事故调查根本原因分析方法简介.ppt

事故调查根本原因分析方法简介 内容 事故调查的基本观念 收集信息 综合原因表CLC 提出改进措施 BP的历程 事故现场调查 案例分析 Case Study 0820 Roll-over Accident 有了原始信息以后 、、、 好积木的特征 一个证据项是一块积木 重点在事实 可以包括假定，但必须明确标记出来 具体 包含事件的时间，发生地点 证据来源 与调查有关 拼制时间顺序图 使用白板或壁挂纸 在图的底部划条临时的时间线 找出事件和状况的总体顺序 事件顺序图的优点 把证据组织起来 指导调查 便于事件顺序的更新 便于找出关键起因 简化事故调查报告的组织和准备 根本原因（系统原因） 如何使用CLC? 关键起因是原材料 针对每项关键起因进行分析 依次考虑每一类原因，不要颠来倒去 使用CLC前 收集所有相关证据 绘制事件顺序图 确定关键起因 完善关键起因的用词以使其不会被误读 调查接近尾声，拿根本原因怎么办 调查组的最后行动 给每一个原因制定整改措施 准备书面正式报告 提交管理层 分享 解决方案 There are several things the investigation team must be clear on, these include: Why we are investigating? What do we seek during our investigation? How can we achieve these goals? In short our raison dêtre is prevention improvement not blame. To this end we seek facts in order to accurately reconstruct events so that we establish exactly What happened, How it happened and, most importantly Why it happened. It is only from this position of understanding that preventative measure can be taken where necessary. Facts = “Anything which can be perceived by the five senses” We often hear that facts must be corroborated. Whilst this is an aim it is not a pre-requisite. Facts can be split into TWO types, Irrefutable and Refutable. We can only make the decision as to which is which, once we have exhausted all reasonable lines of enquiry. Evidence comes in three types. REAL: the things we can touch and examine physically, DOCUMENTARY: Those paper records offering historical accounts and ORAL: The verbal accounts of Witnesses. Each of the above Evidence types has either a Direct or Indirect link to the incident. Simply put the Direct evidence type will have an immediate connection to the events. Indirect evidence will be a step or stage removed from events but still has relevance in allowing the investigators to understand How or Why things came to be. The sources of the evidence can be recalled by use of the mnemonic “4P’s” People Parts Paper Positions Whatever th