Accident Investigation and Root Cause Analysis
安全事故根源分析图中英文
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
Accident Investigation Report 事故调查报告
Accident Investigation Report 事故调查报告
当班主管姓名
□人身伤亡事故□交通运输事故□火灾事故
□爆炸事故□职业病事故□其它事故
Accident Investigation Report 事故调查表（续）Corrective Actions纠正措施Preventative Actions预防措施
Action Plan计划方案（事故调查组填写）Action Plan计划方案（事故调查组填写）
Action Taken实施方案（事故发生部门填写）Responsible Person责任人:Action Taken实施方案（事故发生部门填写）Responsible Person责任人:
Check Result检查结果（以下栏目由事故调查组和事故发生部门共同填写）Exceutive Result实施结果:Exceutive Result实施结果:
Status状态
□Open开放□结束Closed Status状态
□Open开放□Closed结束
Actual Closure Date实际完成日期Actual Closure Date实际完成日期公司管理层：。
事故发生的根源分析(英文版)(ppt 50页)
– Every Imerys employee is a valuable asset.
每个Imerys的员工都是公司的重要财富
Getting hurt is not generally a conscious decision...
Why Investigate Incidents and Near misses? 为什么要调查事故和未遂事件？
But we can pick where we focus…
但是我们能选择努力 的方向。
1 FATAL 身亡
30 DISABLING 残疾
(Severe 重伤)
300 MEDICAL 疗伤
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!
Why Investigate Incidents and Near misses? 为什么要调查事故和未遂事件？
Because we don’t get to pick where we land…
• 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。
During the Interview 面谈过程中
• Phrases to remember 记住适用下列用语
安全工程专业英语课文翻译
Accident causation models 事故致因理论Safety officer 安全官员Safety management 安全管理Safety committee 安全委员会Physical conditions 物质条件Shop-floor 生产区Machine guarding 机械保护装置Unionized company集团公司House-keeping 工作场所管理Seniority 资历、工龄Top management 高层管理人员Local culture 当地文化Human errors 人因失误Absenteeism rate 缺勤率Accident-proneness models 事故倾向模型Power relations 权力关系Munitions factory 军工厂Status review 状态审查Causal factors 起因Lower-level management 低层管理者Risking taking 冒险行为Business performance 组织绩效Corporate culture 企业文化Most senior executive 高级主管Loss prevention 损失预防Supervisory level 监督层Process industry 制造工业Safety principle 安全规则Hazard control 危险控制Wall-board 公告栏Intensive study 广泛研究Implement plan 执行计划Organizational performance 企业绩效Hazard identification 危险辨识Mutual trust 相互信任Safety performance 安全性能One comprehensive definition for an organizational cultubasic assumptions –invented, discovered, or developed by a given group as it learns to cope wit h its problems of external adaptation and internal integration –that has wo rked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to thos e problems”译文：Schein给出了组织文化的广泛定义，他认为组织文化是由若干基本假设组成的一种模式，这些假设是由某个特定团体在处理外部适应问题与内部整合问题的过程中发明、发现或完善的。
安全生产经理翻译
安全生产经理翻译The Role of a Safety Production ManagerA safety production manager plays a crucial role in ensuring the wellbeing of employees and the prevention of accidents in the workplace. They are responsible for maintaining and improving safety standards and implementing procedures that minimize the risks associated with work activities. Here are some of the key responsibilities of a safety production manager.1. Developing and implementing safety policies: A safety production manager is responsible for creating safety policies and procedures that comply with local regulations and industry standards. They must develop a safety plan that outlines the actions to be taken in case of an emergency and ensures that all employees are aware of and trained on these policies.2. Conducting risk assessments: To identify potential hazards in the workplace, a safety production manager must conduct regular risk assessments. This includes inspecting machinery and equipment, reviewing work procedures, and analyzing accident and near-miss reports. By identifying and addressing potential risks, they can prevent accidents and reduce the likelihood of injuries or illnesses.3. Training and education: A safety production manager is responsible for developing and implementing training programs to educate employees on safety procedures and practices. They must ensure that all employees receive proper training and have access to information on safe working practices. This includes conductingsafety orientation for new hires and organizing regular training sessions on specific safety topics.4. Accident investigation and reporting: When accidents or near-misses occur, a safety production manager is responsible for investigating the incident to determine the root cause and prevent future occurrences. They must document and report the incident to management and regulatory authorities, as required by law. By conducting thorough investigations, they can identify areas for improvement and implement corrective actions.5. Inspections and audits: A safety production manager must conduct regular inspections and audits to ensure that safety policies and procedures are being followed. This includes inspecting the workplace for potential hazards, reviewing safety equipment and PPE usage, and evaluating emergency response plans. They must also monitor employee compliance with safety rules and implement corrective actions when necessary.6. Maintaining records: It is important for a safety production manager to maintain accurate records of safety inspections, training sessions, accidents, and near-misses. These records help track safety performance, identify patterns or trends, and assess the effectiveness of safety programs. They must also keep records of employee certifications and licenses to ensure compliance with regulatory requirements.In conclusion, a safety production manager plays a critical role in maintaining a safe and healthy work environment. By implementing safety policies, conducting risk assessments,providing training, investigating accidents, conducting inspections, and maintaining records, they ensure that employees are protected from hazards and that the company remains in compliance with safety regulations.。
事故发生的根源分析英文版
– 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）
Things that make you go Hmmm… 解决问题的策略
Cause & Corrective Action: 原因&整改措施
Employee failed to notice protrusion of table in line of path…
员工未能注意到桌子挡住了行走区域 Discipline employee to be aware of walking path
Protect company interests 维护公司的利益（表明公司对员工生命安全的高度重视）
– Every Imerys employee is a valuable asset.
每个Imerys的员工都是公司的重要财富
Getting hurt is not generally a conscious decision...
(Serious 受伤)
3,000 FIRST AID 急救
(Minor 轻伤) 30,000 NEAR MISSES
侥幸脱险 (Unsafe acts-Unsafe conditions 不安全的操作和状态)
Effort 努力方向
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
Accident Investigation
Accident InvestigationWhat is an accident and why should it be investigated?The term "accident" can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.An incident usually refers to an unexpected event that did not cause injury or damage this time but had the potential. "Near miss" or "dangerous occurrence" are also terms for an event that could have caused harm but did not.Please note: The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident". It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken -- making the event not one of fate or chance (thus, the word incident is used). For simplicity, we will use the term accident to mean all of the above events.The information that follows is intended to be a general guide for supervisors or joint occupational health and safety committee members. When accidents are investigated, the emphasis should be concentrated on finding the root cause of the accident rather than the investigation procedure itself so you can prevent it from happening again. The purpose is to find facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event.Reasons to investigate a workplace accident include:∙most importantly, to find out the cause of accidents and to preventsimilar accidents in the future∙to fulfill any legal requirements∙to determine the cost of an accident∙to determine compliance with applicable safety regulations∙to process workers' compensation claimsIncidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.Who should do the accident investigating?Ideally, an investigation would be conducted by someone experienced in accident causation, experienced in investigative techniques, fully knowledgeable of the work processes, procedures, persons, and industrial relations environment of a particular situation.Some jurisdictions provide guidance such as requiring that it must be conducted jointly, with both management and labour represented, or that the investigators must be knowledgeable about the work processes involved.In most cases, the supervisor should help investigate the event. Other members of the team can include:∙employees with knowledge of the work∙safety officer∙health and safety committee∙union representative, if applicable∙employees with experience in investigations∙"outside" expert∙representative from local governmentShould the immediate supervisor be on the team?The advantage is that this person is likely to know most about the work and persons involved and the current conditions. Furthermore, the supervisor can usually take immediate remedial action. The counter argument is that there may be an attempt to gloss over the supervisors shortcomings in the accident. This situation should not arise if the accident is investigated by a team of people, and if the worker representative(s) and the members review all accident investigation reports thoroughly.Why look for the root cause?An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine some underlying factors in a chain of events that ends in an accident.The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:∙Was the worker distracted? If yes, why was the worker distracted?∙Was a safe work procedure being followed? If not, why not?∙Were safety devices in order? If not, why not?∙Was the worker trained? If not, why not?An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent "carelessness".What are the steps involved in investigating an accident? The accident investigation process involves the following steps:∙Report the accident occurrence to a designated person within theorganization∙Provide first aid and medical care to injured person(s) and preventfurther injuries or damage∙Investigate the accident∙Identify the causes∙Report the findings∙Develop a plan for corrective action∙Implement the plan∙Evaluate the effectiveness of the corrective action∙Make changes for continuous improvementAs little time as possible should be lost between the moment of an accident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera, film, camera flash, tape measure, etc.) should be immediately available so that no time is wasted.What should be looked at as the cause of an accident? Accident Causation ModelsMany models of accident causation have been proposed, ranging from Heinrich's domino theory to the sophisticated Management Oversight and Risk Tree (MORT).The simple model shown in Figure 1 attempts to illustrate that the causes of any accident can be grouped into five categories - task, material, environment, personnel, and management. When this model is used, possible causes in each category should be investigated. Each category is examined more closely below. Remember that these are sample questions only: no attempt has been made to develop a comprehensive checklist.Figure 1: Accident CausationTaskHere the actual work procedure being used at the time of the accident is explored. Members of the accident investigation team will look for answers to questions such as:∙Was a safe work procedure used?∙Had conditions changed to make the normal procedure unsafe?∙Were the appropriate tools and materials available?∙Were they used?∙Were safety devices working properly?∙Was lockout used when necessary?For most of these questions, an important follow-up question is "If not, why not?"MaterialTo seek out possible causes resulting from the equipment and materials used, investigators might ask:∙Was there an equipment failure?∙What caused it to fail?∙Was the machinery poorly designed?∙Were hazardous substances involved?∙Were they clearly identified?∙Was a less hazardous alternative substance possible and available?∙Was the raw material substandard in some way?∙Should personal protective equipment (PPE) have been used?∙Was the PPE used?∙Were users of PPE properly trained?Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist.EnvironmentThe physical environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the accident is what is important, not what the "usual" conditions were. For example, accident investigators may want to know:∙What were the weather conditions?∙Was poor housekeeping a problem?∙Was it too hot or too cold?∙Was noise a problem?∙Was there adequate light?∙Were toxic or hazardous gases, dusts, or fumes present? PersonnelThe physical and mental condition of those individuals directly involved in the event must be explored. The purpose for investigating the accident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics are considered. Some factors will remain essentially constant while others may vary from day to day:∙Were workers experienced in the work being done?∙Had they been adequately trained?∙Can they physically do the work?∙What was the status of their health?∙Were they tired?∙Were they under stress (work or personal)?ManagementManagement holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an accident investigation. Failures of management systems are often found to be direct or indirect factors in accidents. Ask questions such as:∙Were safety rules communicated to and understood by allemployees?∙Were written procedures and orientation available?∙Were they being enforced?∙Was there adequate supervision?∙Were workers trained to do the work?∙Had hazards been previously identified?∙Had procedures been developed to overcome them?∙Were unsafe conditions corrected?∙Was regular maintenance of equipment carried out?∙Were regular safety inspections carried out?This model of accident investigations provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place some of the sample questions in different categories; however, the categories are not important, as long as each pertinent question is asked. Obviously there is considerable overlap between categories; this reflects the situation in real life. Again it should be emphasized that the above sample questions do not make up a complete checklist, but are examples only.How are the facts collected?The steps in accident investigation are simple: the accident investigators gather information, analyze it, draw conclusions, and make recommendations. Although the procedures are straightforward, each step can have its pitfalls. As mentioned above, an open mind is necessary in accident investigation: preconceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be drawn until all the information is gathered.Injured workers(s)The most important immediate tasks--rescue operations, medical treatment of the injured, and prevention of further injuries--have priority and others must not interfere with these activities. When these matters are under control, the investigators can start their work.Physical EvidenceBefore attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. In some jurisdictions, an accident site must not bedisturbed without prior approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as:∙positions of injured workers∙equipment being used∙materials or chemicals being used∙safety devices in use∙position of appropriate guards∙position of controls of machinery∙damage to equipment∙housekeeping of area∙weather conditions∙lighting levels∙noise levels∙time of dayYou may want to take photographs before anything is moved, both of the general area and specific items. Later careful study of these may reveal conditions or observations missed previously. Sketches of the accident scene based on measurements taken may also help in subsequent analysis and will clarify any written reports. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the accident scene should be prepared.Eyewitness AccountsAlthough there may be occasions when you are unable to do so, every effort should be made to interview witnesses. In some situations witnesses may be your primary source of information because you may be called upon to investigate an accident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.Witnesses should be kept apart and interviewed as soon as possible after the accident. If witnesses have an opportunity to discuss the event among themselves, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts.Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene of the accident where it is easier to establish the positions of each person involved and to obtain a description of the events. On the other hand, it may be preferable to carry out interviews in a quiet office where there will be fewer distractions. The decision may depend in part on the nature of the accident and the mental state of the witnesses.InterviewingInterviewing is an art that cannot be given justice in a brief document such as this, but a few do's and don'ts can be mentioned. The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event:DO...∙put the witness, who is probably upset, at ease∙emphasize the real reason for the investigation, to determine whathappened and why∙let the witness talk, listen∙confirm that you have the statement correct∙try to sense any underlying feelings of the witness∙make short notes or ask someone else on the team to take themduring the interview∙ask if it is okay to record the interview, if you are doing so∙close on a positive noteDO NOT...∙intimidate the witness∙interrupt∙prompt∙ask leading questions∙show your own emotions∙jump to conclusionsAsk open-ended questions that cannot be answered by simply "yes" or "no". The actual questions you ask the witness will naturally vary with each accident, but there are some general questions that should be asked each time:∙Where were you at the time of the accident?∙What were you doing at the time?∙What did you see, hear?∙What were the environmental conditions (weather, light, noise, etc.) atthe time?∙What was (were) the injured worker(s) doing at the time?∙In your opinion, what caused the accident?∙How might similar accidents be prevented in the future?If you were not at the scene at the time, asking questions is a straightforward approach to establishing what happened. Obviously, care must be taken to assess the credibility of any statements made in the interviews. Answers to a first few questions will generally show how well the witness could actually observe what happened.Another technique sometimes used to determine the sequence of events is to re-enact or replay them as they happened. Obviously, great care must be taken so that further injury or damage does not occur. A witness (usually the injured worker) is asked to reenact in slow motion the actions that preceded the accident.Background InformationA third, and often an overlooked source of information, can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past accident reports, formalized safe-work procedures, and training reports. Any pertinent information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar accidents.What should I know when making the analysis and conclusions?At this stage of the investigation most of the facts about what happened and how it happened should be known. This has taken considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question--why did it happen? To prevent recurrences of similar accidents, the investigators must find all possible answers to this question.You have kept an open mind to all possibilities and looked for all pertinent facts. There may still be gaps in your understanding of the sequence of events that resulted in the accident. You may need to reinterview some witnesses to fill these gaps in your knowledge.∙When your analysis is complete, write down a step-by-step account ofwhat happened (your conclusions) working back from the moment ofthe accident, listing all possible causes at each step. This is not extrawork: it is a draft for part of the final report. Each conclusion should bechecked to see if:∙it is supported by evidence∙the evidence is direct (physical or documentary) or based oneyewitness accounts, or∙the evidence is based on assumption.This list serves as a final check on discrepancies that should be explained or eliminated.Why should recommendations be made?The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar accidents. Once you are knowledgeable about the workprocesses involved and the overall situation in your organization, it should not be too difficult to come up with realistic recommendations. Recommendations should:∙be specific∙be constructive∙get at root causes∙identify contributing factorsResist the temptation to make only general recommendations to save time and effort.For example, you have determined that a blind corner contributed to an accident. Rather than just recommending "eliminate blind corners" it would be better to suggest:∙install mirrors at the northwest corner of building X (specific to thisaccident)∙install mirrors at blind corners where required throughout the worksite(general)Never make recommendations about disciplining a person or persons who may have been at fault. This would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future accident investigations.In the unlikely event that you have not been able to determine the causes of an accident with any certainty, you probably still have uncovered safety weaknesses in the operation. It is appropriate that recommendations be made to correct these deficiencies.The Written ReportIf your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings such as:∙If a limited space is provided for an answer, the tendency will be toanswer in that space despite recommendations to "use back of form ifnecessary."∙If a checklist of causes is included, possible causes not listed may beoverlooked.∙Headings such as "unsafe condition" will usually elicit a singleresponse even when more than one unsafe condition exists.∙Differentiating between "primary cause" and "contributing factors" canbe misleading. All accident causes are important and warrantconsideration for possible corrective action.Your previously prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of theaccident that you have so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.If doubt exists about any particular part, say so. The reasons for your conclusions should be stated and followed by your recommendations. Weed out extra material that is not required for a full understanding of the accident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good accident report is quality, not quantity.Always communicate your findings with workers, supervisors and management. Present your information 'in context' so everyone understands how the accident occurred and the actions in place to prevent it from happening again.What should be done if the investigation reveals human errorA difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough worksite accident investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual.Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation. Furthermore, it will also allow future accidents to happen from similar causes because they have not been addressed.However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures.How should follow-up be handled?Management is responsible for acting on the recommendations in the accident investigation report. The health and safety committee, if you have one, can monitor the progress of these actions.Follow-up actions include:∙Respond to the recommendations in the report by explaining whatcan and cannot be done (and why or why not).∙Develop a timetable for corrective actions.∙Monitor that the scheduled actions have been completed.∙Check the condition of injured worker(s).∙Inform and train other workers at risk.Re-orient worker(s) on their return to work.。
模具加工事故检讨书范文
模具加工事故检讨书范文英文回答：Mold Processing Accident Investigation and Corrective Action Report.1. Accident Description.On [date of accident], an accident occurred in the mold processing workshop, resulting in injuries to [name of injured person]. The accident occurred when the employee was operating a milling machine and the workpiece unexpectedly came loose, striking the employee's hand.2. Root Cause Analysis.Based on an investigation of the accident, thefollowing root causes were identified:Inadequate workpiece securing: The workpiece was notproperly secured to the milling machine table, allowing it to move during operation.Insufficient training: The employee involved in the accident had not received adequate training on the operation of the milling machine.Lack of protective equipment: The employee was not wearing appropriate protective gloves or safety glasses at the time of the accident.3. Corrective Actions.To prevent similar accidents from occurring in the future, the following corrective actions have been implemented:Improved workpiece securing: All workpieces must be securely fastened to the milling machine table using appropriate clamps or fixtures.Enhanced training: All employees operating millingmachines will receive comprehensive training on the equipment and safety procedures.Enforcement of protective equipment: The use of appropriate protective equipment, including gloves and safety glasses, will be strictly enforced.Regular inspections: Regular inspections of allmilling machines and associated equipment will be conducted to ensure proper operation and safety.4. Conclusion.The accident investigation and corrective action plan have identified the root causes of the accident and implemented measures to prevent similar occurrences. The company is committed to maintaining a safe work environment and will continue to monitor and improve safety procedures as needed.中文回答：模具加工事故检讨书。
安全工程专业英语术语
安全工程专业英语课程安全工程专业英语题目安全工程专业英语作业院系专业班级学生姓名学生学号指导教师1、potential accident 潜在事故Accidents, or potential accidents, are first considered to be the result of a number of interacting causes within the system.2、fire and explosion protection 火灾与爆炸控制This paper analyses the mechanism of fire protection and explosion suppression and introduces its application.3、System safety 系统安全System safety concepts are based on the idea that an optimum degree of safety can be achieved within the constraints of system effectiveness.4、safety system engineering 安全系统工程Introduces the application of safety system engineering in coal mine, analyses the exiting problems, discusses the development of the engineering in coal mine.5、system hazard 系统危害The objectives of such programs are to recognize，evaluate，and control system hazards as early in the life cycle as possible.6、inherently safe system 本质安全Adequate safety input during the initial phases is the key to produce an inherently safe system.7、safety device 安全防护装置An emergency hammer is a safety device used in vehicles to break through window glass in an emergency.8、hazard control 危险控制Loss prevention is a concept that is often used in the context of hazard control in process industry.9、hazard identification 危险辨识Description of the hazard identification and assessment activities10、Hazard analysis 危险分析Hazard analysis is not an intuitive process.11、Hazard control 危险控制Hazard control typically is accomplished through either engineering, educational, or administrative solutions.12、hazardous material 危险物质Of primary importance in engineering solutions is reducing the amount of energy or hazardous material in the system.13、domino effect 多米诺效应There were no precedents for judging whether the biggest insurance company could be allowed to fail or whether a domino effect would follow.14、major hazard 重大危险源Supervision for major hazard is an essential means to promote safety production at enterprises, prevent great industrial accidents and ensure urban public safety.15、local resistance 局部阻力However, for pipes with local resistance loss, the friction head loss caused by the viscosity of fluid does exist, which may lead to the calculation error.16、safety management 安全管理The most important aim of safety management is to maintain and promote workers’ health and safety at work.17、accident causation models 事故致因模型All modern theories are based on accident causation models which try to explain the sequence of events that finally produce the loss.18、machine guarding 机械保护装置Safety practitioners concentrated on improving machine guarding, housekeeping, and inspections.19、human errors 人因失误Rasmussen and Jensen have presented a three-level skill-rule-knowledge model for describing the origins of the different types of human errors. 20、poor physical condition 物的不安全状态In the beginning of the 20th century, it was believed that the poor physical conditions are the root causes of accidents.21、Safety practitioner 安全工作者Safety practitioners concentrated on improving machine guarding, housekeeping, and inspections.22、poor human act 人的不安全行为In most cases an accident is the result of two things: the poor human act, and the condition of the physical or social environment.23、Mine ventilation 矿山通风Mine ventilation involves the control of the atmospheric environment. 24、safety lamps 安全灯These safety lamps soon replaced oil lamps and open flared candles as a source of working light.25、Accident-proneness models 事故倾向模型Accident-proneness models suggest that some people are more likely to suffer accident than others.26、process industry 制造工业This is also natural, since accidents in process industry can have catastrophic consequences.27、safety shoes 安全鞋28、safety belts 安全带29、safety glasses 安全防护眼镜Included here are those safety devices the worker would wear on his or her person such as special clothing, safety shoes, goggles, safety belts, gloves, respirators, safety glasses, etc30、safety officer 安全官员31、safety committee 安全委员会These include ：organizational responsibility for safety, management attitudes towards safety, management activity in responding to health and safety problems, safety training and promotion，level of risk at the workplace，workers' involvement in safety，and status of the safety officer and the safety committee.32、safety lectures 安全专题33、safety assessment evaluation 安全评价34、safety policy 安全方针A status review is the basis for a safety policy and the planning of safety activities.35、safety principles 安全规则Som0e companies have developed so-called “safety principles’ which cover the key areas of the company’s safety policy.36、safety efforts 安全投入Because of accelerating technology and demands for a “first time safe” operation, a need has arisen to formally organize safety efforts throughouta system's life cycle.37、safety criteria 安全标准Program activities in the concept phase include establishing safety criteria within the definition of the system task.38、shop-floor 生产区The studies of Wobbe reveal that shop-floor workers in the USA are, in general, less trained and less adaptable than those in Germany or Japan.39、absenteeism rates 缺勤率Oxenburgh has studied the total costs of absence from work, and found that local culture and legislation has a strong effect on absenteeism rates.40、reliability engineering and risk analysis 可靠性工程与风险分析41、system safety engineering 系统安全工程To meet this need, the concepts of system safety and the field of system safety engineering have evolved.42、engineering practice 工程实践The safety realized in a system was only a byproduct of good engineering practice.43、system effectiveness 系统有效性System safety concepts are based on the idea that an optimum degree of safety can be achieved within the constraints of system effectiveness.44、system design 系统设计A gross hazard analysis is often performed for each alternative approach to system design.45、Operation Phase 运行阶段Periodic safety inspections, maintenance, training, and performance reviews are conducted in the operation phase to maintain or improve the safety achieved previously.46、protective devices 报警装置When neither design selection nor design features can effectively control a known hazard，warning devices should be used to detect the hazardous condition and generate a warning signal.47、protective apparel 防护用品For these hazards, the best course of action is to use protective apparel to protect the worker in the event of a mishap.48、accident prevention 事故预防System safety engineering is a relatively new approach to accident prevention.49、exposure limit 暴露极限50、ventilation system 通风系统If the dust is not above accepted exposure limits and the smell is notoverwhelming, then the company may elect to install a new ventilation system, but not until the next year because of budgetary constraints.51、accident investigation 事故调查52、labor management committee 劳动管理委员会These items include jobsite safety inspections, accident investigations, safety and health committees, and project safety inspection programs that involve supervisors and, if you have them, joint labor management committees.53、industrial accident 工业事故To prevent industrial accidents, the people, machines, and other factors which can cause accidents, including the energies associated with them, must be controlled.54、Accident Types 事故类型55、Struck-against 撞击56、Struck-by 打击57、walk-round inspection 巡视Look at the first four basic accident types--- Struck-against, Struck-by, contact-with and contacted-by---in more detail, with the job step walk-round inspection in mind.58、worker-oriented 以人为本Hazard identification, as envisioned in this section, is a worker-oriented process.59、accident investigation 事故调查Although accident investigation is an after-the-fact approach to hazard identification ，it is still an important part of this process.60、accident prevention 事故预防The recurrence of accidents of a particular type or those with common causes shows areas needing special accident prevention emphasis.61、OHSMS 职业健康安全管理体系What is an occupational health and safety management system (OHSMS)?62、industrial hygiene 工业卫生Industrial hygiene has been defined as that science and art devoted to the anticipation, recognition, evaluation and control of those environmental factors or stress, arising in or from the workplace, which may cause sickness, impaired health and wellbeing, or significant discomfort and inefficiency among workers or among the citizens of the community.63、Physical hazards 物理危害、物质危害64、Non ionizing and ionizing radiation 非电离辐射与电离辐射Physical hazards include excessive levels of Non ionizing and ionizing radiation, noise, vibration, and extremes of temperature and pressure. 65、biological hazards 生物危害Biological hazards include vermin, insects, fungi, viruses, and bacterial contaminants.66、Chemical hazards 化学危害Chemical hazards arise from excessive airborne concentrations of mists , vapors, gases ,or solids that are in the form of dusts or fumes.67、safety electricity 安全用电68、Electrical equipment 电力设备Be careful when using machinery or electrical equipment.69、explosion venting 爆炸泄压Provide an explosion venting surface or vents, taking care to vent a pressure wave to areas where people or other equipment will not become involved.70、fire suppressant 灭火剂The net also contains a tube for dispensing fire suppressant agent.71、secondary explosion 二次爆炸The dominant mechanisms of the occurrence of the secondary explosion during the venting processes were elucidated according to the numerical and relevant experimental results.72、fire ground 火场A system to detect and warn the dangerous gas in the fire ground is researched and developed.73、fire protection 消防Other than providing such emergency services as police and fire protection, U.S. policy generally favors competition in an open market rather than a nationalized equivalent.74、physical explosion 物理爆炸The latter is a kind of physical explosion with a serious destructive force. To study the generation mechanism of BLEVE a small-scale experimental device has been set up to conduct simulation tests.75、chemical explosion 化学爆炸With the development of chemical industry, accidents of poisonous gas leakage, chemical explosion and fire increase and occur more frequently in China.76、nature gas explosion 天然气爆炸The chemical reaction and explosive ingredients present in a smoke explosion or nature gas explosion are the same as in any ordinary combustion explosion.77、peak pressure 峰值压力In this paper some problems, which exist in the peak pressure measurements under impulsive loading of explosion by the gun copper ingot, are discussed and an improved method is presented.78、lifting and mechanical safety 起重与机械安全79、boiler and pressure vessel safety technology 锅炉压力容器80、fire suppression system 灭火系统In recent years, many new varieties of automatic sprinkler have been developed in order to improve the performance of fire suppression system.81、coolant system 冷却系统But the tsunami wiped out power to the plant, which took down the main coolant system, and a wave destroyed the diesel-based backup system. 82、electric system 电气系统It would vastly improve the reliability, availability and efficiency of the electric system.83、rated capacity 额定容量Rated capacity of the battery cell rated capacity refers to discharge certain conditions, the battery voltage discharge to the deadline for the release of electricity.84、operating voltage 工作电压Increasing the operating voltage will boost the energy density of the composite significantly.85、work cycle 工作周期The paper introduced the technical parameters, basic structure and work cycle of each subsystem of air compressor with the aim to improve the operation level of workers.86、domino effect 多米诺效应There were no precedents for judging whether the biggest insurance company could be allowed to fail or whether a domino effect would follow.87、safety device 安装防护装置An emergency hammer is a safety device used in vehicles to break through window glass in an emergency.88、environmental protection 环境保护The pollutants studied in the report do not include ozone, the chemical for which the Environmental Protection Agency proposed new regulations last week.89、dumper truck 翻斗车CCTV footage released yesterday showed pandemonium at the hotel gates after a dumper truck rammed into the retractable metal barrier there.90、artificial respiration 人工呼吸She brought her to life by artificial respiration.91、contingency plan 应急预案Now that we have a plan in place for our current situation and a contingency plan for our risk, we can relax a little.92、pressure vessel 压力容器The powerful system has the capacity to propel thousands of gallons of water a minute throughout a reactor pressure vessel and storage pool.93、safety checklist 安全检查表94、preliminary hazard analysis 预先危险分析The method and steps of preliminary hazard analysis (PHA) is introduced. To analyze the possible hazards in engineering by PHA may help to bring forward related prevention measures.95、event tree analysis 事件数分析Both event tree analysis (ETA) and deterministic analysis methods are applied to constructing the dynamic analysis model for the steam generator tube ruptures (SGTR).96、fault tree analysis 事故树分析From the perspective of systems engineering, Fault Tree Analysis method which is widely used in system security study is used for analysis of urban rail transit accident.97、occupational disease 职业病The occupational disease certificate should be jointly signed by all participating physicians and stamped by the responsible healthcare agency.98、lower explosive limit 爆炸下限The conflicting problem of flash point and lower explosive limit as a criterion of hazard is studied in this paper.99、reactive mode 事后模式The information at this point, while critical, is used in a reactive mode. 100、top event 顶事件And then expatiate the qualitative analysis and quantitative analysis of fault tree analysis, establishes a fault tree with "actuator immovable" as the top event.101、human factor engineering 人因工程The human factor engineering design has long been an important part of that of main control room in a nuclear power plant.102、HRA（human reliability analysis）人的可靠性分析103、PRA（probability risk analysis）概率风险分析The lack of data and availability is a major problem that embarrasses human reliability analysis (HRA) for a long time.104、fatal accident frequency rate 死亡事故频率105、welding flash 弧光灼伤Welding flash damages, moving back space and resetting distance can be adjusted freely.106、terrestrial radiation 地面辐射Mineral dust affects the radiation and energy budget of the earth mainly by absorbing and scattering solar and terrestrial radiation, and thus affects the climate change.107、sound level meter 噪声计The study was undertaken using a sound level meter operated by a passenger in each car tested.108、management review 管理评估The software project manager with the help of the management review team updates the software development plan as needed.109、unsafe act 不安全行为Any unsafe act or condition should be reported promptly to your immediate supervisor.110、hazard assessment 危险评价This paper presents a model of campus network user behavior hazard assessment based on the LEC method, and introduces its practical application on network management system.112、safety culture 安全文化Clearly there are many reactors and they're all built of the same type and the same technology but some are run better than others and safety culture is clearly the difference.113、accident reports system 事故报告体系114、safety slogans 安全标语The safety note boards, slogans, and varied operation regulation boards will de installed on the constructing field, forming a good atmosphere of product safety.115、emergency response 应急响应So this platform is completely revolutionizing the way that emergency response takes place, first of all, and with rebuilding efforts.116、status review 状态评审It shall lead to action to support the determination of key customer- related trends and correlation for status review, decision-making and longer term planning.117、quality and environmental management syste质量与环境管理体系The Company's products quality system and environmental management system have received the international certificates.118、safety ergonomics 安全人机工程Base on statistical analysis of the active ammunition packages, this paper emphasizes the important senses of application of safety ergonomics to ammunition packaging design.119、safety principles 安全学原理You can keep yourself safe by complying with some basic safety principles and donning a properly fitted helmet120、industrial ventilation 工业通风Wall exhaust fan manufacturers, industrial ventilation and the wall exhaust fan industrial ventilation suppliers guide find a wall.121、chemical industrial safety 化工安全Coal gasification technology possess very important role for coal industry industrial structure adjustment, coal chemical industrial development and nation energy safety in China.122、electrical safety 电气安全The Dielectric Withstand Test is the third test required by the electrical safety testing standards.123、safety monitoring and control technology 安全监测与监控技术And taking Qidong coal mine as an example, it analyzes the application of video technology based on network in the safety monitoring and control system of coal mine.124、explosion suppression 爆炸抑制Model for analyzing the explosion suppression mechanism of void design reticulated polyurethane foam for fuel tank was set up.125、construction safety 建筑安全Construction safety management and construction the safe technique istwo basic factors to realize safety produce target manage.126、confined spaces 密闭空间In the heat of the chase sparrow hawks have collided with windows, struck cars and become trapped in confined spaces ranging from garden sheds to lobster pots.127、electrical circuits 电路The work also indicates that thermal equivalents of electrical circuits are possible.128、electromagnetic radiation 电磁辐射This makes them ideal for long-distance travel, as neutrinos are undisturbed by gas, dust and other matter that can block radio waves and other types of electromagnetic radiation.129、high frequency noise 高频噪声The small eddies created near the exhaust duct cause high frequency noise but downstream of the exhaust jet the larger eddies create low frequency noise.130、Counter-measure 干预措施England's manager Walter Winter bottom, acknowledging the problem, held a team meeting to try to come up with a counter-measure for the full international that was scheduled for a few days later.131、neutral conductor 中性导体The independent PE grounding system and N neutral conductor in switchgear vessel should be connected to the ground securely132、branch-circuit 分支电路This system also has a 4-branch parallel fully-controlled rectification circuit.133、ball valves 球形阀Ball Valves screwed to NPT or an alternative as per Contractor's recommendation, subject to approval by Client134、color coded 色标Inside the doc uments you’ll find a plethora of links and cross references, nicely color coded and branded as to what sort of information they lead to.135、interlocked guard 连锁保护装置136、elevating work platform 升降台Elevating work platform truck will be used for cleaning part of external windows.138、dense concrete 密实混凝土Dense concrete is one of upper flow regime, which is widely used in various fields.139、Respiratory tract 呼吸道One feature seen in many patients is the development of lower respiratory tract early in the illness.140、Digestive tract 消化道Go with your gut: Japanese scientists recently identified umami receptors not only on the tongue but throughout the digestive tract.141、Safety manager 安全经理The research can be referenced during the safety management and psychoanalysis process of safety manager in enterprise.142、Process engineer 生产工程师The project manager now understands the value of these work products, and he or she can quickly negotiate with the process engineer as to which ones are required for a particular project.143、welding arc 焊弧In this paper the temperature of underwater welding arc is investigated systematically by means of spectral diagnostics of plasma.144、Plant manager 工厂经理As she answers some of the questions the plant manager is likely to pose,Carol will likely need to set some emergent identity goals.145、carbon monoxide 一氧化碳That produces hydrogen and carbon monoxide, which can be converted to a liquid fuel.146、Responsible official 负责人At the same time, funding the development and construction of the main users CBD Liuweiguo responsible official of the company has only received 600 million authorized capital statement145、Industrial hygiene 职业卫生Osram said it used the latest technology employing solid mercury to maintain high standards of industrial hygiene equivalent to those in Germany.146、Mine industry 矿业The housing is not the main body of the mine industry. It is only to serve the employees of the mine.147、Nuclear power plant 核电厂This problem was highlighted by the earthquake centered near the KashiwazakiKariwa nuclear power plant in 2007.148、Material safety data sheet 安全清单This product is not expected to cause health concerns when used for the intended application and according to the recommendations in the Material Safety Data Sheet .149、explosion isolation 爆炸隔绝150、safety laws and regulations 安全法律法规Article 22 Motor vehicle drivers shall abide by road traffic safety laws and regulations, and drive the vehicle safely and courteously according to the operation rules.AbstractThe purpose of this article is to introduce safety management system from three aspects of accident causation models, organizational activity and safety policy and planning. All modern theories are based on accident causation models. Accident theories aim to clarify the accident phenomena, and to explain the mechanisms that lead to accidents. The development and importance of accident causation models will be introduced clearly in this paper. Safety management as an organizational activity is very important for enterprise.That a company’s organizational culture determines the maximum level of safety the company can reach. Good organizational culture and safety culture are conducive to establish a Reasonable safety management system. This paper treats an important problem in the factors affecting the development of Enterprise safety culture. Organizations activity and safety culture behave differently in the different parts of the world. Reasons for the differences are discussed in this paper. Safety policy and planning is an important guarantee for the development of enterprises in safety state. In this paper, it is made by some standards form BS8800. Through this article, the development of Safety Management System can be fully understand, and it describes a exceeding effective method about how to build a complete Safety Management System.Key words: safety management system accident causation models BS8800 Organizational activity safety culture safety policyAcademic Report about Fire Extinguishing System of Chaoliutequ Underground Emporium Chaoliutequ, underground emporium is a public gathering places. There are about more than one hundred and seventy stores. Most of them sell clothing , shoes, caps and cosmetics.And most of the goods belong to flammable materials. The features of underground emporium is too many customers, goods and electrical equipments. The possibility of a fire disaster is very large in there. In case of fire, it can cause heavy casualties and property losses. And it is very important to carry out fire risk assessment on underground emporium to prevent and control fire efficiently.This article is through the relevant information to understand underground mall, and familiar with the layout of the building. Firstly, we have analyzed the fire characteristics of Chaoliutequ underground emporium. Basement of high-rise building fire resistance rating should be level, and its fire protection district should not exceed 1000. The total area of Chaoliutequ underground emporium is about 4000 cubic meters, so we divided it into five fire protection district. To study evacuation in fire plays an important role in underground emporium’s fire safety. The width of safety exit is determined by the calculation of Safety evacuation width index. After calculated, the safety exit’s total width of underground emporium is 18.2 meter. Chaoliutequ, underground emporium is givenpriority to with solid fire. The fire extinguisher is calculated and adopted the salt dry powder extinguisher of portable ammonium phosphate. The radius of protection of fire hydrant is 21 meter, and the distance between each other not more than 30 meters. Sprinkler systems must be installed in the underground emporium, and to choose the vertical enclosed sprinkler.Under the ceiling installation shower water distribution pipe, top and bottom side should not be more than eight only. 332 nozzles are arranged in the Sprinkler systems. In case of fire, the sprinkler systems or fire alarms may turn on.Finally, we have completed the fire safety design of the Chaoliutequ underground emporium.。
东航坠机事件过程英语作文
东航坠机事件过程英语作文Title: Analysis of the China Eastern Airlines Crash Incident。
On March 21, 2023, China Eastern Airlines flight MU5735, a Boeing 737-800 aircraft, tragically crashed in the mountains of southern China. This incident shocked theworld and led to extensive investigations to determine the cause. Let's delve into the sequence of events leading upto the crash and the subsequent findings.The flight took off from Kunming ChangshuiInternational Airport bound for Guangzhou Baiyun International Airport. Initially, the journey proceeded without any apparent issues. However, approximately onehour into the flight, the aircraft suddenly deviated fromits flight path and began to descend rapidly. Thisdeviation from the planned trajectory was the first indication of a problem.Air traffic control lost contact with the aircraft, sparking immediate concern. Search and rescue teams were dispatched to locate the missing plane. Tragically, the wreckage was found in a mountainous area near the city of Wuzhou, Guangxi Province.In the aftermath of the crash, investigators from China's Civil Aviation Administration, along with international aviation experts, commenced a thorough examination to determine the cause of the accident. The investigation involved analyzing flight data recorders, cockpit voice recordings, wreckage debris, and other relevant evidence.One of the key findings was related to the aircraft's sudden and unexplained descent. It was discovered that the plane experienced a loss of altitude at an alarming rate, far beyond normal operational parameters. This abrupt descent suggested a catastrophic event onboard, rather than a gradual mechanical failure.Further analysis revealed evidence of a structuralfailure in the aircraft's tail section. Specifically, investigators identified a fracture in the vertical stabilizer, also known as the tail fin. This critical component plays a vital role in stabilizing the aircraft during flight, particularly in maintaining directional control.The fracture in the vertical stabilizer was a significant breakthrough in the investigation. It indicated a structural failure that compromised the aerodynamic stability of the aircraft. Such a failure would have profound implications for the flight's controllability, potentially leading to the loss of control experienced by the pilots.Moreover, examination of maintenance records and previous inspections revealed no prior indications of structural defects or issues with the vertical stabilizer. This raised questions about the integrity of the aircraft's maintenance procedures and the effectiveness of regulatory oversight.In addition to the structural findings, investigators scrutinized other factors that may have contributed to the accident, including weather conditions, pilot performance, and air traffic control procedures. However, the evidence pointed primarily to the structural failure as the primary cause of the crash.In response to the investigation's findings, regulatory authorities implemented several safety measures to prevent similar incidents in the future. These measures included enhanced inspection protocols for aircraft structural components, revised maintenance procedures, and improved training for flight crew members.The China Eastern Airlines crash of flight MU5735 was a tragic event that underscored the importance of rigorous safety standards in aviation. By identifying the root cause of the accident and implementing preventive measures, the aviation industry aims to mitigate the risk of such incidents and ensure the safety of air travel for passengers and crew alike.In conclusion, the crash of China Eastern Airlinesflight MU5735 was a sobering reminder of the inherent risks associated with air travel and the critical need for continuous improvement in aviation safety practices. Through thorough investigation and proactive measures, the industry strives to uphold the highest standards of safety and prevent future tragedies.。
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CoreAdvantageSM
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Slide 7
The Game of Chances
1 Fatality 10 Serious Injuries 100 Minor Injuries 1,000 Near Miss Incidents 10,000 At Risk Behaviors
CoreAdvantageSM
Should I go back and get the correct tool?
FAST
R I S K
Which do you Choose?
SLOWER
CoreAdvantageSM
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Barriers to Safe Performance - Comfort
Should I wear the respirator?
Accident/Incident Investigation and Root Cause Identification
Core
AdvantageSM
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Jerry Ryan, Ph.D., CIH
1989 Hardscrabble Place Boulder, CO 80305 303.499.4111 Fax: 303.499.4119
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Gathering Data
GOAL
The goal is to obtain verifiable & objective data.
CoreAdvantage
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Slide 21
4 P’s
PEOPLE
PARTS
Sources of Data
PAPER
POSITION
CoreAdvantage
Establishing the Event Sequence
Incident Investigation (ቤተ መጻሕፍቲ ባይዱata Collection)
Identifying Causal Factors
Root Cause Analysis
Implementing Solutions & Closing the Loop
Operator pushed start button Table Saw started Blade strikes scrap wood Op struck by scrap
Used right hand Left hand on table top 4” from blade
Scrap wood in contact w/ blade Left hand in line of fire
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People (all of us) Are Poor Observers & we are Typically Biased
CoreAdvantage
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Slide 23
What do you see?
CoreAdvantage
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Describe Picture
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Event Sequence
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Event Chain Event & Causal Factor Charting
Events – These are action steps that occurred (verb & a subject), e.g., “Operator pushed start button”. Placed in rectangle Incident – Description of the incident being investigated. Placed in circle.
Negative & Limiting Beliefs
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Slide 13
Cultural Strengths
Contributing Knowledge S&H Excellence Systems & Continuous Improvement Supportive & Empowering Beliefs Clear SOP’s Trust & Respect We: Win-Win Consistency Positive Leadership Letting go of Past Personally Responsibility Communication
Comfortable
R I S K
Which do you Choose?
Uncomfortable
CoreAdvantageSM
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Risk Perception is a Barrier to Safe Performance
The problem is that it is part of our nature to accept these types of risks. All too often what we ask people to do for safety goes against human nature!
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Accident Causation
Things People Do Decisions Choices Risk Taking Abilities Attitudes Focus …etc Incident Injury or Loss Errors Things The System Does Physical Conditions Production Pressure Policies Procedures Training Authority …etc.
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Accident Pyramid
Fatality Serious Injuries Minor Injuries Near Misses At Risk Behaviors Values/Culture
Heinrich: 1 Major Injury 29 Minor Injuries 300 No-Injury Events
CoreAdvantageSM
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Identifying Root Causes
• Root Cause is the most basic source or origin of the Causal Factors • Root Causes are the reasons “why” the Causal Factors existed.
Operator pushed start button
Table Saw started
Blade strikes scrap wood
Op struck by scrap
CoreAdvantageSM
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Event & Causal Factor Charting
Conditions – Descriptors that provide amplifying information about the event step. Place in Ovals, e.g., “operator had never operated equipment before”.
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Interdependence of Culture-Behavior & Attitudes
Culture Attitudes Behavior
What is your cycle driving? (Is it Positive or Negative?) CoreAdvantageSM
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Root Causes will Resurface in Additional Incidents if left Unaddressed!
Symptoms
Incident
Incident
Incident Incident
Same Group of Root Causes
CoreAdvantageSM
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Example
E&CF Chart
CoreAdvantageSM
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Identifying Causal Factors
• Causal Factors are conditions that could have prevented the incident • Ask the question: “if this condition was controlled or did not occur would the incident have occurred?”
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Culture - Behavior - Management Systems
Culture Behaviors Risk Mtg S&HMS Behaviors Culture
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Slide 2
Purpose of Incident Investigation
To fix blame or prevent the reoccurrence?
Prevent the reoccurrence
Prevent the reoccurrence
Prevent the reoccurrence!