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1、深圳市佳保安全股份有限公司深圳市佳保安全股份有限公司 Shenzhen Job Safety Solutions Company Ltd. 新三板挂牌：831231 风险风险管理基础及管理基础及BowTieBowTie技巧技巧培训培训 授课人：崔文彩 CGE荷兰风险管理公司授权讲师 安全工程硕士 国家注册安全工程师 国家安监总局职业健康协会会员 Help People Care for Safety 课程课程安排安排 第一天第一天: : 风险管理基础风险管理基础 BowtieBowtie分析方法介绍分析方法介绍 基础：风险因素基础：风险因素、危险类别危险类别、屏障有效性和关键屏障屏障有效性和关
2、键屏障 第二天第二天: : BowtieBowtie XPXP 后台各种参数的设置后台各种参数的设置 编辑编辑BowBowt tieie图表图表 方法与练习方法与练习 行业案例练习行业案例练习 设计一个设计一个 BowtieBowtie 链接链接BowtieBowtie图表图表、导出数据与形成报告导出数据与形成报告 屏障性能监控屏障性能监控 Help People Care for Safety 课程回顾课程回顾 Help People Care for Safety Application Overview应用预览 图表区 树视图 预览 Help People Care for Safety
3、 第一步：识别危险源 Activity or state that has the potential to cause harm可能导致危险的活动或状态可能导致危险的活动或状态 Hazard 危险源 Help People Care for Safety 危险源是什么？ 一种活动或状态，一旦故障或失效，可能导致负面结果 该活动或状态是正常业务组成部分 经常涉及到能源您行业涉及哪些？ - Chemical化学能 - Kinetic动能 - Gravitational重力能 - Nuclear原子能 - Thermal热能 - Pressure高压能 - Biological生物能 - ? 也涉
4、及如社会、金融、服务、组织等等 目标：建立及定义Bowtie图表的范围 Hazard Help People Care for Safety 第二步：定义顶级事件 The point in time when control over the Hazard is lost 对危害的控制失效的时间节点 Top Event 顶级事件 Help People Care for Safety Top Event顶级事件 Help People Care for Safety 第三步：确定威胁 A possible cause for the Top Event Threat威胁 导致顶级事件导致顶级事
5、件 的可能原因的可能原因 Help People Care for Safety 威胁 威胁：直接导致顶级 事件发生 人 设备 环境 交叉作业 Help People Care for Safety 第四步：确定后果 由顶级事件导致的意外事件由顶级事件导致的意外事件 Consequence 后果 Help People Care for Safety 损害 vs 事件 受伤或死亡 设备损坏 环境破坏 声誉受损 就是风险矩阵中的“后果 ” 烟尘吸入/钝器撞击 物体撞击到设备上 海面溢油 Help People Care for Safety 第 5 & 6步：确定屏障 预防或减缓事件的措施预防或
6、减缓事件的措施 Barrier屏障 Help People Care for Safety 屏障功能 消除消除/替代替代危险 缺乏控制 能量释放 屏障功能： 消除、降低危害 消除威胁 预防顶级事件发生 分解后果 降低后果 正常情况正常情况 初始阶段初始阶段 结束阶段结束阶段 伤害阶段伤害阶段 失去控制 Step 5 & 6. Defining Barriers Measures taken to prevent, reduce or mitigate events. Also used to prevent or reduce degradation of barriers 15 Barrie
7、r Examples Execute the plan Airbags, ABS Apply defensive driving techniques Cover the hole to prevent dropped object Having a plan Right wording - balanced barriers Begin with common word e.g. “Maintenance of.” Dont just say “Training” or “Alarms” training in what? Be concise, clear and consistent i
8、n wording Usually aim for maximum of three lines or 6 words 16 The Three Barriers Too wordy Just right Too Help People Care for Safety 小组练习 -孩子从秋千摔下 -上班迟到 -从梯子上坠落 -电脑丢失 -狮子从笼子逃脱 Help People Care for Safety 第7步： 确定干扰因素 降低或干扰降低或干扰屏障有效性的状态或条件、因素屏障有效性的状态或条件、因素 干扰因素 Step 7. Define Escalation Factors A co
9、ndition that defeats or reduces the effectiveness of a Barrier 19 Escalation Factor Causality in the BowTie CAUSE Threat or initiating event Top Event Outcome or Consequence as a Threat Escalation or Defeating Factor (UNWANTED) EFFECT Top Event loss of contr ol of the hazard Outcome or Consequence T
10、op Event in another BowTie diagram Failed Barrier 20 March 2016 Help People Care for Safety 干扰因素 EF considerations Should not directly cause the Top Event ( = a Threat!) Temperature sensor failure doesnt cause overheating Miscalibrated scales dont cause dropped objects Identify the real cause of fai
11、lure: “Why might the emergency services not be available?” “Why did the detector not work?” “Are we using contractors who are not trained?” “Use of non-approved spare parts” Sometimes relate to root causes of why the Threat occurs (e.g. Design does not consider site conditions) 22 Help People Care f
12、or Safety 四大主要类别四大主要类别 干扰因素的四个主要类别 Human Factors人因 Mechanical Failures机械故障 Abnormal Conditions异常情况 Loss of Critical Services关键维护缺失 Four main EF categories Categories: Examples Human Factors Mechanical Failures Loss of Critical Services Abnormal Conditions 24 No qualified personnel during breaks Non-
13、standard equipment / procedures Concurrent tasks no restricted area Procedural violations / omissions Equipment can be off-line for maint. Bypassed safety devices in shutdown Loss of critical power services Abnormal conditions exceed limits Failure in verbal communications Contractors not fully site
14、-trained Help People Care for Safety 卸压阀 泄漏200桶 原油 油罐满溢 储罐原油 1.泄压阀拆除 拿去维修 1 练习：练习： 确定以下图表中的干扰因素因素： Help People Care for Safety 第8步. 确定EF（干扰因素）屏障 针对干扰因素的控制措针对干扰因素的控制措 施和屏障施和屏障 干扰因素EF 屏障 Escalation Factor Barrier guidelines 27 Escalation Factor Barriers Address the barrier decay only. Block the holes
15、in the cheese. Are not primary barriers that stop the Top Event or Consequence. If they are, put them on the primary line! Usually reflect what we are continuously doing anyway (Maintenance, inspections, training, audits, supervision, spare parts, redundancies, etc.) Can also be contingencies “If th
16、is happens, then we have a backup plan” such as “Engage contractors or alternative services” EFBs can also have escalation factors, but this should be rare Could identify the real cause of barrier failure Help People Care for Safety 干扰因素屏障 Help People Care for Safety 火灾 LPG泄漏 不许吸烟政策 炼化厂的LPG 1. 2. 2 1 练习： 定义以下图表中的干扰因素干扰因素及干扰因素屏障干扰因素屏障： He
