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1、Root Cause Analysis 事故根源分析,Best Practice techniques for conducting effective root cause analysis 分析事故根源时常用的有效技巧 Identifying Countermeasures, Hierarchy of Control 确定相应的对策并实施有层次的控制手段 Examples of how techniques can be applied to incidents and near misses. 举例说明如何利用技巧分析事故和未遂事件的原因,Objectives 目标,Find the c
2、auses 找出事故原因 There will typically be several causes to an incident. 一般来说事故是由多方面的原因造成的 Prevent similar incidents 避免类似事故的发生 Performing an incident investigation, and communicating the results, will prevent similar incidents. 开展事故调查并传达事故调查的结果以可以避免类似事故的发生 Protect company interests 维护公司的利益（表明公司对员工生命安全的高度
3、重视） Every Imerys employee is a valuable asset. 每个Imerys的员工都是公司的重要财富,Why Investigate Incidents? 为什么要进行事故调查？,.Working Safely Is! 但工作安全是可以自觉控制的!,Getting hurt is not generally a conscious decision. 受伤都是意外的，不是自觉的,3,000 FIRST AID 急救 (Minor 轻伤),30,000 NEAR MISSES 未遂事件 (Unsafe acts-Unsafe conditions 不安全的行为和
4、状态),1 FATAL 死亡,30 DISABLING 残疾 (Severe 重伤),300 MEDICAL 需要治疗 (Serious 受伤),Because we dont get to pick where we land 因为我们无法预知事情的结果。,?,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。,Effort 努力方向,Why Investigate Incidents and Near misses? 为什么要调查事故和未
5、遂事件？,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),1 FATAL 身亡,30 DISABLING 残疾 (Severe 重伤),300 MEDICAL 疗伤 (Serious 受伤),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 5 minutes 5分钟时间,Responsi
6、bility 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。,Responsibility 职责,Investigate every accident! 调查每次事故的原因 Major 重大事故 Minor 小事故 Property 财产损失 Near Miss 未遂事件,KEY INVESTIGATION POINT 调查的重点,Do
7、 Not Look for Someone to Blame! 调查不是为了追究责任！,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 训练员工注意行走区域,Before You Discipline (5 Questions) 在你开始严肃纪律前
8、（问自己5个问题）,Leadership requires discipline when justified! 即使理由充分，领导也需要严肃纪律！ Before you discipline ask yourself “Have I”: 在你开始推行纪律前，问问你自己“我是否”： set an example by following safety rules/policies 以身作则了？ 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,provided adequate training 是否提供了足够的培训 i
9、nsisted on compliance by enforcing safety rules in the past 在过去是否坚持遵守安全法规 provided adequate supervision by identifying and correcting hazards before someone got hurt 在发生事故之前就安排足够的监管力量，发现和消除事故隐患,Before You Discipline (5 Questions) 在你开始严肃纪律前 （问自己5个问题）,Incident Investigation Process 事故调查过程,Follow-Up 整改
10、跟进,Corrective Action 改进措施,Response 回应,Fact-Finding 实情调查,Analysis 分析事故原因,Notification 通告,Before the Interview 在面谈之前,Preparation 准备 Who should do the interview? 谁应当负责面谈工作？ Interviewer should have credibility with the interviewee 面谈组织者应当得到受访者的信任 Interviewer should be aware of group dynamics 面谈组织者应当认识到可
11、能对所涉及到的组织的影响,Have prepared questions, just in case 事先准备好一些问题，以防万一 Meet on interviewees turf or neutral location 站在被访者的或中立的立场上考虑问题 Preferably were the incident occurred 面谈最好仅针对刚发生的事件（“就事论事”）,Before the Interview 在面谈之前,Who Should be Interviewed? 哪些人应该受访？,Injured and others directly involved 受伤者及其他直接当事
12、人 Witnesses 目击证人 Others who do the same job 其他相同工作人员 Maintenance personnel 设备维护人员 Engineering 工程人员 Those who set up the equipment 设备装配人员 Other experts 其他专家,Fact Finding: The Interview 实情调查：面谈,Interview Tips (put the interviewee at ease) 面谈技巧 （使受访人处于轻松的状态） Create a positive environment 营造一个积极的面谈环境 As
13、k questions without being aggressive 在较为平和的气氛下提出问题 Be patient, do not talk too much 保持耐心，不要说过多的话 Show interest in the interviewee 对受访者的回答表现出兴趣 Avoid criticism 避免批评受访者,You are investigating the incident/accident, not the person 你是在调查事故，不是在调查人,Interview Questions 面谈问题,Open 开放性 vs. Closed 封闭性,Primary a
14、nd Secondary 首要和其次问题,Leading 引导性 vs. Neutral 公正性,Individual 个人 vs. Group 小组,What techniques can you use for more effective interviews? 有效的面谈可采用哪些技巧？,During the Interview 在面谈中,As soon as possible and at the scene 尽可能快当场面谈 Put at ease 营造轻松的气氛 fact finding, not fault finding 调查事故情况，不是调查当事人的过失 start wit
15、h easily answered questions (conditions, etc.) 以容易回答的问题开始提问（受访者身份等） seek privacy 面谈情况应保密 ask for prevention ideas 寻问预防安全事故的建议,During the Interview 在面谈中,Ask open questions (what, when, where) 询问开放性的问题（发生什么事情，何时，在哪里） One-on-One and One at a time 每次面谈时采用一对一的方式,Fact Finding: Interview Questions 事件调查：面谈的
16、问题,Ask open ended questions (not yes/no) 提开放性的问题（不要只提用是/否就可以回答的问题） No 避免问 Have you received safety training? 你接受过安全培训吗？ Yes 应该问 What safety training have you received? 你接受过哪些安全培训？,Dont ask leading questions 别提对答案有诱导性的问题 No 避免 Does your supervisor discuss safety with you? 你们的主管与你们讨论安全生产的问题吗？ Yes 应该 Who discusses safety with you? 谁与你们讨论安全生产问题？,Fact Finding: Interview Questions 事件调查：面谈的问题,During the Interview 面谈过程中,Phrases to remember 记住适用下列用语 “Please help me
