佳保事故调查培训讲义 根源分析

IncidentInvestigationRootCauseAnalysis事故调查与根源分析JobSafetySolutionsLtd.佳保安全管理咨询徐伟东开场Opening源自海油服务社会背景Background徐伟东佳保安全董事长安全工程博士生DavidXuChairmanofJobSafetySolutionsSafetyEngineeringPHDCandidateAboutme:2005.8–CURRENT:SHENZHENJOBSAFETYSOLUTIONSCHAIREMANOFDIRACTORS2003.1–2005.7:BPChina&VietnamLPG,EuropeBU,HSSEManager1999.7–2002.12:BPGroup,ARCOChinaInc.HSSESeniorEngineer1997.7–1999.6:ChinaNationalOffshoreOilCo.HSEEngineer1992.10–1993.8:CityWaterConservancyProjectDevelopmentCo.BusinessManager1990.8–1992.9:CityWaterConservancyandElectricProjectBureau,HRSecretary迈克尔查普曼业务顾问MichaelChapmanBusinessAdvisor吉姆查斯科业务顾问JimTruscottBusinessAdvisor2341我们的使命MissionStatement與人為善HelpPeopleCareforSafety2010佳保安全–人本安全系列（2010第2版）（2006第1版）课程设计与大纲Outline培训内容1.案例分析2.事故特点3.事故调查基本概念4.如何开展事故调查5.根源分析培训目的•明确职责•了解事故的引发机制•事故调查与收集证据的技巧•学会实用《根源分析表》•如何制定整改措施•报告的内容与形式•制定和跟踪整改人非圣贤孰能无过Toerrorishuman,todivineisGod条分缕析前车可鉴Tomakearootcauseanalysis,tolearnlessonsfromthepast事故调查的目的？1案例分析案例BPTexasRefineryButanesplitterCorrosionThicknessfrom22mmto3mmBP德克萨斯炼油厂丁烷罐腐蚀壁厚由22mm减到3mmInsufficientmaintenanceoftheinsulation&inspection保护层维护和检查不够ShellTankcollapseRainwatergetsintolegsAndcausecorrosion壳牌罐倒塌雨水进到支撑造成腐蚀Poormaintenance&inspection维护质量和检查差案例客户槽车翻车与死人事故-3rdroadtruckrollover&fatalityaccident2003年6月4日晚11:00,一辆客户槽车浙GC5826(25吨车)在宁波大榭库区充装完LPG离开大榭在去浙江义乌的途中,于凌晨2:30左右在新昌沙溪一拐弯山路翻车。造成2人死亡重大交通事故。案例ThiseventandtheBhopaldisastertriggeredthedevelopmentofthePSMstandardPhillips66HoustonChemicalComplexPasadena,Texas–Oct.23,1989OnOctober23,1989,atapproximately1:00p.m.,anexplosionandfirerippedthroughthePhillips66CompanyHoustonChemicalComplexinPasadena,Texas.Twenty-threeworkerswerekilledandmorethan130wereinjured.Propertydamagewasnearlythree-quartersofabilliondollars.Theaccidentresultedfromareleaseofextremelyflammableprocessgasesthatoccurredduringregularmaintenanceoperationsononeoftheplant'spolyethylenereactors.Theevidenceshowedthatmorethan85,000poundsofhighlyflammablegaseswerereleasedthroughanopenvalve.Avaporcloudformedandtraveledrapidlythroughthepolyethyleneplant.Within90to120seconds,thevaporcloudcameintocontactwithanignitionsourceandexplodedwiththeforceof2.4tonsofTNT.LessonsLearned•ManagementofChanges变更管理•EmergencyPreparedness应急响应•OperatorTraining员工培训•ProceduralDevelopment程序•PermitSystems作业许可MOC-It’snotenoughtojusthaveasystemtomanagechanges.Thesystemhastobealiveandwell.Atthefirstsuggestionofaproceduralchange,thesystemshouldhavebeentriggered.Audityourownprogramstoensureyourmanagingchanges(thisincludesequipment,proceduresevenmanpowerissues)EmergencyPreparedness-Reviewyouremergencyoperatingprocedures-dotheycoverallthecredibleevents.(PHA’sshouldcoverthisindetailandflushoutthedeficiencies)Operatortraining-Isthetrainingadequate.Dooperatorsknowthetruehazardsoftheprocessthey’reoperating.Whataboutrespondingtoupsetsandunusualoperatingconditions.Procedures-Aretheycurrentandaccurate?Havetheybeeneffectivelycommunicatedtooperations?PermitSystems-Ifyoudon’thavethem,developthem.Inthiscasethesystemwasseriouslyflawed.Itwasacknowledgedthatdrumparameterswereadequateforunheadingwhentheyreallyhadnowayofknowingthetemperature案例CaseStudy2005年3月23日，BP德克萨斯城炼油厂发生爆炸事故，造成15人死亡、170多人受伤。案例CaseStudyKeyOrganizationalFindings1.Cost-cutting,failuretoinvestandproduction.2.TheBPBoardofDirectorsdidnotprovideeffectiveoversightofBP‟ssafetycultureandmajoraccidentpreventionprograms.3.Relianceonthelowpersonalinjuryrate11atTexasCityasasafetyindicatorfailedtoprovideatruepictureofprocesssafetyperformanceandthehealthofthesafetyculture.4.DeficienciesinBP‟smechanicalintegrityprogramresultedinthe“runtofailure”ofprocessequipmentatTexasCity.5.A“checkthebox”mentalitywasprevalentatTexasCity,wherepersonnelcompletedpaperworkandcheckedoffonsafetypolicyandproceduralrequirementsevenwhenthoserequirementshadnotbeenmet.6.BPTexasCitylackedareportingandlearningculture.Personnelwerenotencouragedtoreportsafetyproblemsandsomefearedretaliationfordoingso.7.Safetycampaigns,goals,andrewardsfocusedonimprovingpersonalsafetymetricsandworkerbehaviorsratherthanonprocesssafetyandmanagementsafetysystems.Whilecompliancewithmanysafetypoliciesandprocedureswasdeficientatalllevelsoftherefinery,TexasCitymanagersdidnotleadbyexampleregardingsafety.8.Numeroussurveys,studies,andauditsidentifieddeep-seatedsafetyproblemsatTexasCity,buttheresponseofBPmanagersatalllevelswastypically“toolittle,toolate.”9.BPTexasCitydidnoteffectivelyassesschangesinvolvingpeople,policies,ortheorganizationthatcouldimpactprocesssafety.德州爆炸事故的管理原因：1.控制费用2.事故预防与监管3.依赖数字忽略系统4.工艺安全缺失5.程序执行流于形式6.隐患报告与管理7.缺乏安全领导力8.领导反馈太少太迟9.变更管理案例CaseStudy2010年4月20日晚上22:00左右，BP公司位于墨西哥湾的“深水地平线（DeepwaterHorizon）”钻井平台井发生井喷爆炸着火事故，造成11人死亡，17人受伤，造成人类历史上最严重的海洋污染。案例CaseStudy深水地平线爆炸事故管理原因：1.机械故障2.人因判断失误3.工艺设计缺陷4.操作执行不力5.团队沟通•mechanicalfailures•humanjudgments•engineeringdesign•operationalimplementation•teamcommunication过去？如何管理安全?现在？区别在哪里？安全理念的演变ChangeofsafetyPrinciples传统安全管理特征发现问题事故警察解决问题增加程序或修订程序培训与复培纪律处罚企业安全管理国际最新趋势：①由政府“法规