rootcauseanalysis事故根源分析.ppt

Root Cause Analysis事故根源分析 Objectives 目标 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 Why Investigate Incidents?为什么要进行事故调查？ Find the causes 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重视） Every Imerys employee is a valuable asset. 每个Imerys的员工都是公司的重要财富 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 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。 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 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 Before You Discipline (5 Questions)在你开始严肃纪律前 （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 Incident Investigation Process事故调查过程 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能对所涉及到的组织的影响 Before the Interview在面谈之前 Have prepared questions, just in case 事先准备好一些问题，以防万一 Meet on interviewees’ turf or