rootcauseanalysis事故根源分析

rootcauseanalysis事故根源分析内容摘要：

etter question? 怎样更好的提问。 – What did you see the operator do? 你看到这个工人当时如何做呢 ? Interview Quiz 面谈中的小测试 • Is this a good question? 这个问题问的好不好 ? – Did you realize that Ed was angry before he got the fork truck? 你注意到 Ed在得到叉车前很生气吗 ? • Leading question that assumes: 引导性的问题这里有： – Ed was angry Ed很生气 • What would be a better question? 怎样更好的提问。 – How would you describe Ed’s behavior before he got the fork truck? 你能描述一下 Ed在得到叉车前的表现吗 ? Bucket of Bricks 桶装砖事故 A Series of Unfortunate Events 一连串的不幸事件 THE BUCKET OF BRICKS STORY (Interviewing Technique Reinforcer) The following letter is a reprint of an actual letter sent by an employee to the PetrolaneUtah Gas Service. I am writing in response to your request for additional information. In the accident reporting form, I put “trying to do the job alone” as the cause of the accident. You said in your letter that I should explain more fully and I trust that the following information will be sufficient. I am a bricklayer by trade. On the date of the accident, I was working alone on the roof of a new six story building. When I pleted my work, I discovered that I had about 500 pounds of bricks left over. Rather than carry the bricks by hand, I decided to lower them in a barrel by using a pulley which fortunately was attached to the side of the building at the sixth floor. Securing the rope at ground level, I went up to the roof, swung the barrel out and loaded the bricks into it. Then I went ba ck to the ground and untied the rope, holding it tightly to ensure a slow descent of the 500 pounds of brick. You will note in the accident report that I weigh 165 pounds. Due to my surprise at being jerked off the ground so suddenly, I lost my present state of mind and fot to let go of the rope. Needless to say, I proceeded at a rather rapid rate up the side of the building. In the vicinity of the third floor, I met the barrel ing down. This explains the fractured skull and broken collarbone. Slowed only slightly, I continued my rapid ascent, not stopping until the fingers of my right hand were two knuckles deep into the pulley. Fortunately, by this time, I had regained my present state of mind and was able to hold tightly to the rope in spite of my pain. At approximately the same time, however, the barrel of bricks hit the ground and the bottom fell out of the barrel. Devoid of the weight of the bricks, the barrel now weighed approximately 50 pounds. I refer you again to my weight. As you might imagine, I began a rapid descent of the building. In the vicinity of the third floor, I met the barrel ing up. This accounts for the two fractured ankles and the lacerations of my legs and lower body. The encounter with the barrel slowed me enough to lessen my injuries when I fell on the pile of bricks. Fortunately, only three vertebrae were cracked. I am sorry to report, however, that as I lay there on the bricks in pain, unable to stand, and watching the empty barrel six stories above me, I again lost my present state of mind and let go of the rope. The empty barrel weighed more than the rope, so it c ame back down. And that accounts for my two broken legs. I hope I have furnished the information you required as to how the accident occurred. Sincerely, Joe Schmoe • 桶装砖事故 • （免谈技巧强化） • 下面这封信是一名 PetrolaneUtah Gas Service的员工的真实来信。 • 应您的要求，我向您写这封信，想让您了解更多关于事故的真实情况。 在事故报告书中，我写的事故原因是“设法自己独立完成工作”。 您在信中提到要我将当天事故发生的经过描述的更详细些，所以我给您写 来这封信，告诉您更多当时的情况。 • 我是一名搬砖工。 出事那天，我当时正一个人沿着一幢新建六层楼房的房顶走。 当我干完活后，我发现还 有大约 500磅重的砖块要搬。 这时我正巧在六楼一角落处发现 一个滑轮。