Incident Reporting & Investigation
事故报告与事故调查
EHS Training/安全培训
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What Is an Incident什么是事故
Fire火灾
Explosion爆炸
Injury/illness人员受伤或疾病
Environmental excursion环保超标排放
Quality incident质量事故
Mechanical failure设备故障
Other upset from normal desired operations其他导致正常生产过程被中断的事件
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What Is an Incident事故类型
Process Safety Incident 工艺流程安全事故
Personal Injury and Illness 人员受伤或疾病
Security Event保安事件
Transportation Incident运输事故
Quality Incident质量事故
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Process Safety Incidents
工艺流程安全事故
Fire/explosion 火灾或爆炸事故
Equipment failure 设备故障
Reactive Chemical 非期望的化学反应
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Personal Injury Incident
人员伤害或疾病
Near Miss无伤事故
First Aid急救
Medical Treatment医疗处置事故
Recordable Medical Treatment需记录的医疗处置事故
Restricted Work Case限制工作事故
Day Away from Work Case损失工伤事故
Fatality死亡事故
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Environmental Excursion环保超标
LOPC (Loss of Primary Containment) 化学泄漏事故
Spills溅出
leakage渗漏
overflow溢出
Odor Complaint气味抱怨
Wastes discharged out of specification废弃物排放超过限制标准
Waste treatment facilities failure废弃物处理设施故障
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Security Incident保安事故
Crime犯罪
Fraud诈骗
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Why Report Incident
为什么要求所有的事故必须报告
F: Fatality/死亡
DAWC: Day Away from Work Case损时工伤
RWC: Restricted Work Case限制工作
RMTC: Recordable Medical Treatment Case需记 录的医疗处置
First Aid: 急救（轻微伤害）
Near Miss: 无伤事故
Unsafe Behavior: 不安全行为
Unsafe behaviors
Near Miss
First Aid
MTC
RMTC
RC
DAWC
F
Recordable
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Why Report Incidents 为什么发生事故需要报告
Incident is undesired system output事故是一种不期望的系统输出/产品
Uncover contributing causes揭露造成事故的原因
Prevent similar accidents预防类似事故的发生
Stop incident level aiming to high防止小事故向大事故演变
Promote Safety提高安全表现
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How Report Incident如何报告事故
Incident reporting form事故报告表
Emailing电子邮件
Verbal口头报告
Report Incident immediately发生事故需要立即报告
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Why Investigate Incidents?
为什么要开展事故调查
Incident investigation is integral to a total safety and health program事故调查构成完全安全和健康计划的不可或缺的部分
Continuous Improvement持续改进的要求
Determines direct causes确定直接原因
Uncover contributing causes揭露根本原因
Prevent similar incidents预防类似事故
Promote safety提升安全表现
Legal requirements required政府法规要求
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How investigate incidents?
如何调查事故
Type 1 第一种
traditional传统型
Informal非正式
One-On-One, immediate supervisor with injured一对一，直接主管与受伤人员
Type 2 第二中
Committee会议
Brainstorming头脑风暴
Use expert judgment采用专家的判断意见
Multiple causes多种原因
use of investigation tools (RCI, Fishbone Checklist, etc.) 使用调查工具如根本原因分析，鱼骨图等
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Outputs of an investigation
事故调查获得的结果
Root causes of the incident 该事故发生的根本原因
Corrective and Preventative actions事故预防和纠正措施
Responsible personnel 措施落实人
completion date of each action items措施完成日期
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Discipline of incident investigation
事故调查的纪律
Immediately-as soon as victims have received medical attention and the area has been secured立即，当受伤人员接受了医疗救护后以及现场恢复安全后立即开始调查
The longer the delay, the greater the possibility of erroneous or incomplete information. The accident scene changes, memories fade, and people discuss what has happened, that can lead to people altering their impressions to agree with others越晚开展调查，获得正确完整的信息的可能性越小。因为事故现场会改变，记忆会退化，其他人员的讨论和猜测使得事故发生时在场的人的最初认识发生改变并有可能同意和接受别人的猜测
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Discipline of Incident investigation
事故调查纪律
To find root causes, not censure开展事故调查的目的是发现事故发生的根本原因而不是为了谴责某人
Censure can lead people to conceal the fact from investigator指责会引导员工在调查过程中隐瞒真相
The purpose of conducting investigation is to prevent the similar incident from happening, not to find the mistake of a person事故调查是为了预防类似事故的再次发生，不是为了发现是谁犯了错
If an incident was caused by a person who disregarded operating procedure, it also indicated the insufficient of training or pre-employment process如果事故是由于人为忽视操作程序造成，这也同样反映了在人员培训或人员招募过程中的不足
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公司领导层责任
确保所有的事故包括无伤事故都得到及时地报告
确保所有的事故都被调查和分析
确保所有的事故报告和调查分析报告都与所有员工共享
确保所有的整改行动及时地完成
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员工的责任
严格遵守操作程序，佩戴正确的个人保护设备以避免事故的发生
所有的事故立即报告
参与事故的调查并提供详实的事故发生信息。
与同事共享事故中获得的经验教训。
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Suggested incident investigation tool推荐的事故调查工具
Apollo Root Cause Investigation 阿波罗根本原因调查
Apollo Cause and Effect Analysis is a simple tool used for investigating incidents, analyzing events, and troubleshooting problems to ultimately reach effective solutions. It can be used by individuals to troubleshoot recurring problems in their jobs or by a team of people led by a Root Cause Investigation (RCI) Team Leader in the investigation of incidents or significant business issues 阿波罗原因和结果分析工具是一个简单实用的用来调查事故，分析事件和解决问题的工具。他可以帮助最终获得有效的解决方案。
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