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••CollectEvidence收集证据•••People,Parts,PositionsandPaper人证、物证、位置和文件•••PreserveEvidence保护证据•可能的直接原因Possibleimmediatecauses123456工具、设备及车辆Tools,Equipment&Venires781-12-13-14-15-16-1设备有缺陷Defectiveequipment7-18-11-22-23-24-25-26-2设备不足Inadequateequipment7-28-21-32-33-34-35-36-3设备准备不够Improperlyprepared7-38-31-42-43-44-45-46-4工具缺陷Defectivetools7-48-41-52-53-54-55-56-5工具欠妥inadequatetools7-58-51-62-63-64-65-66-6工具准备不妥Improperlypreparedtools7-61-72-73-74-75-76-7车辆有缺陷DefectiveVehicle7-71-82-83-84-85-86-8车型和用途不符Inadequatevehicleforthepurpose7-81-93-94-95-96-9车辆准备欠妥Improperlypreparedvehicle7-91-105-106-10其它因素Others7-101-117-118-67-12可能的系统原因Possiblesystemcauses1体力PhysicalCapability2身体状况Physicalcondition3精神状态MentalState4精神压力MentalStress5行为Behavior6技术水平SkillLevel7训练/知识转换Training/Knowledgetransfer8管理/监督/员工的领导关系Management/supervision/Employee9承包商的选择和审查contractorselection&oversight10工程/设计Engineering/Design11工作计划WorkPlanning12采购、材料处理及材料控制Purchasing,Materialhanding&Material13工具和设备Tools&Equipment14工作规程/政策/标准/程序（PSP）WorkRules/Policies/Standards/Procedures(PSP)15沟通Communication1-1视力低下Visiondeficiency2-1原先受伤或得病Previousinjuryorillness3-1判断力差Poorjudgment4-1全神贯注于别的问题Preoccupationwithproblems5-1不合格的操作近观到奖赏Improperperformanceisrewarded6-1对所需求技术没有充分评估Inadequateassessmentofrequiredskills7-1没有进行充分的知识转换inadequateknowledgetransfer8-1角色和职责冲突Conflictingroles/responsibilities9-1承包商未进行资格预审Lackofcontractorpre-qualifications10-1技术设计欠妥inadequatetechnicaldesign11-1工作计划欠妥Inadequateworkplanning12-1收货项目与订购项目不符Incorrectitemreceived13-1需求和风险评估欠妥Inadequateassessmentofneedsandrisks14-1执行任务缺乏PSPLackofPSPforthetask15-1在同伴间水平沟通不完善Inadequatehorizontalcommunicationbetweenpeers1-2听力低下Hearingdeficiency2-2疲劳Fatigue3-2记忆力丧失Memoryfailure4-2受到挫折Frustration•节省时间努力savestimeoreffort6-2缺乏技术实践Inadequatepracticeofskill•不能领会inabilitytocomprehend•报告关系不明确unclearreportingrelationship9-2承包商资格预审欠妥inadequatecontractorper-qualifications•设计输入陈旧designinputobsolete11-2预防性保养欠妥Inadequatepreventivemaintenance•给供应商的规范不正确Inadequatespecificationtovendor13-2人的因素及人机控制考虑欠缺Inadequatehumanfactors/ergonomicsconsiderations•缺乏PSP的详细职责lackofdefinedresponsibilityforPSP15-2上下级间垂直沟通不完善Inadequateverticalcommunicationbetweensupervisorandperson1-3基它感觉缺陷OtherSensoryDeficiency•由于工作量Duetoworkload3-3协调不好或反应时间长Poorcoordinationorreactiontime4-3对工作方向及要求模糊不清ContusingDirections/demands•避免不便avoidsdiscomfort6-3不经常操作的技术Infrequentperformanceofskill•导师资格欠缺inadequateinstructorqualifications•报告关系矛盾conflictingreportingrelationship9-3承包商选用欠妥inadequatecontractorselection•设计输入不正确designinputnotcorrect•维护需求评估assessmentofneeds•订购书上的规范不明确inadequatespecificationonrequisition13-3标准和堆满不合适Inadequatestandardsorspecifications•缺乏作业安全分析lackofjobsafetyanalysis15-3不同机构间沟通不完善Inadequatecommunicationbetweendifferentorganizations1-4肺活量下降ReducedRespiratoryCapacity•由于缺乏休息duetolackofrest3-4情绪干扰Emotionaldisturbance4-4目标或要求相冲突Conflictingdirections•哗众取宠gainsattention6-4缺乏技术指导Lackofcoachingonskill•培训设备不够Inadequatetrainingequipment•职责分配不清unclearassignmentofresponsibility9-4雇用未经审核批准的承包商useofnon-approvedcontractor•设计输入不可用designinputnotavailable•润滑/维修lubrication/servicing•对订单修改控制不当inadequatecontrolonchangestoorders13-4不适当的可用性Inadequateavailability•作业安全分析不当inadequatejobsafetyanalysis15-4工作组之间沟通不完善Inadequatecommunicationbetweenworkgroups1-5其它良久性身体残疾OtherPermanentPhysicaldisabilities•由于感官超载duetosensoryoverload3-5恐惧Fearsorphobias4-5无意义的或品味低的活动Meaninglessordegradingactivities5-2没有适当的监督示范impropersupervisoryexample6-5没有充分温习训练以巩固技术Instructiontoestablishskill•误解指令说明misunderstoodinstructions•职责分配矛盾conflictingassignmentofresponsibility9-5无工程监管Lackofjoboversight•设计输入不妥designoutputinadequate•调整/装配adjustment/assembly•供应商未经批准擅自更换替代品unauthorizedsubstitution13-5调节、修理、保养欠妥Inadequateadjustment/repair/maintenance14-2PSP工作展开不力InadequatedevelopmentofPSP15-5班组之间沟通不完善Inadequatecommunicationbetweenshifts1-6暂时残疾Temporarydisabilities2-3操作能力降低Diminishedperformance3-6缺乏机械知识Lowmechanicalaptitude4-6情绪超负荷Emotionaloverload5-3对关键的安全行为没有充分的认识inadequateidentificationofcriticalsafe6-6其它因素Other7-2不能充分回想起训练内容inadequaterecalloftrainingmaterial•授权不清或不妥improperorinsufficientdelegationofauthority9-6工程监管欠妥inadequateoversight•设计输入不可行designinputinfeasible•清洁/涂层deaning/resurfacing•产品验收不完善inadequateproductacceptancerequirements13-6废旧物品和再次利用物资处理不妥Inadequatesalvageandreclamation•程序和设备设计不相一致inadequatecoordinationwithprocess/equipmentdesign15-6沟通方法不完善inadequatecommunicationmethods1-7无力支撑身体姿势Inabilitytosustainbodypositions•由于温度极限duetotemperatureextremes3-7理解能力差Lowlearningaptitude4-7过渡的评价/决定要求Extremejudgment/decisiondemands5-4没有充分强调养分的安全行为inadequatereinforcementcriticalsafebehaviors□不适用NotApplicable•缺乏强化培训Trainingnotreinforcedonthejob8-2不适宜的领导关系Inadequateleadship9-7其它因素Other•设计输出不清designoutputnuclear11-3维护性保养欠缺Inadequaterepair•未进行产品验收noacceptanceverificationperformance13-7不合适部件白拆卸和更换欠妥Inadequateremoval/replacementofunsuitableitems•员工参与PSP制定安排不当Inadequateemployeeinvolvementinthedevelopment15-7沟通手段缺乏Nocommunicationmethodavailable1-8身体活动范围受限Restrictedrangeofbodymovement•由于缺氧duetooxygendeficiency3-8受药物影响Infected