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TP ON DU KH VIT NAM

CNG TY C PHN HA DU V X SI DU KH

HNG DN
PHN TCH NGUYN NHN S C V BIN PHP KHC PHC
(Ban hnh theo Quyt nh s

/Q-TG ngy

M S TI LIU
BAN HNH LN
NGY BAN HNH
TNG S TRANG

Ngi vit

ca Tng Gim c)

:
:
:
:

Ngi kim tra

Ngi ph duyt

LCH S TI LIU
Ngy
ban hnh

Ni dung thay i
Ti liu mi, ban hnh ln u

Ban hnh
ln
01

HNG DN
HNG DN PHN TCH NGUYN NHN S
C V BIN PHP KHC PHC

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DANH SCH PHN PHI TI LIU


TT

n v, c nhn

S
lng

TT

Tng gim c

01

Ban ISO (bn gc)

01

Phng Qun l Sn xut

01

01

01

10

4
5

Vn th (lu, bn gc)

n v, c nhn

S
lng

MC LC
Mc

Ni dung

Trang

Mc ch

Phm vi p dng

Ti liu lin quan

nh ngha, thut ng v cc t vit tt

Lu trnh thc hin

Hng dn thc hin

HNG DN
HNG DN PHN TCH NGUYN NHN S
C V BIN PHP KHC PHC

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1. MC CH
Mc ch ca on iu tra l "xc nh nguyn nhn v a cc gii php phng nga
ngn chn cc s c tng t". Kt qu ca iu tra s c l nhn din cc hnh ng
khng an ton v iu kin khng an ton (cc mi nguy) v xc nh nhng hn ch ca
h thng qun l (cc nguyn nhn gc r).
2. CC LU QUAN TRNG TRONG QU TRNH IU TRA S C

a s cc nguyn nhn dn n s c l do li ca con ngi, thit b v vt t.

iu tra s c l xc nh ti sao s c xy ra v xy ra nh th no.

iu tra s c l ngn chn s c tng t xy ra.

iu tra s c khng phi kt ti ai .

3. TI LIU LIN QUAN

HNG DN
HNG DN PHN TCH NGUYN NHN S
C V BIN PHP KHC PHC

4. LU TRNH
Xy ra s c

Bo v hin trng

Thu thp thng tin

Phn tch cc d liu

Xc nh nguyn nhn trc


tip v nguyn nhn c bn

Hnh ng khc phc

Bo co iu tra s c

Dng v kt thc

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

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5. Hng dn phn tch nguyn nhn s c v bin php khc phc


Trnh t
Bo v
hin
trng
Thu thp
thng tin

Cng vic thc hin


1. Bo v hin
trng

Cch thc hin/Lu

- Thu thp nhng thng tin chnh xc

2. Chun b cc
dng c lien quan 3. Quan st hin
trng

B ly mu iu tra s c
My nh
My ghi m
Thc o loi chiu di 25 v 50 ft
Kp giy, giy, bt ch
Ti nha
ke, thc o gc
Trang thit b bo h c nhn (knh an
ton, m an ton, qun o bo h
Thit b, cng c, vt liu, my mc, cu
trc cng trnh ti hin trng
S c nh b v, h hng, try xc, vt
lm, vt bn
Kim tra ng di chuyn v cc du
hiu trt ca xe
Tm nhng bt thng trn b mt hin
trng
S c trn cht lng, vt bn, vt liu b
nhim hoc cc mnh vn
iu kin bt li do thi tit
Thi gian xy ra s c, a im, iu
kin nh sang
a hnh ti khu vc xy ra s c (bng
phng, g gh, vv.)
Hot ng no din ra xung quanh hin
trng s c
Nhng ngi c lin quan n s c,
nhng ngi khng lin quan
o khong cch v xc nh v tr ca
bt c iu g v tt c mi th m tin l
c gi tr iu tra

Xc
nhn

Ngi
thc hin

HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

- Yu cu nhn chng m t li mt cch


trnh t din bin ca s c

- Tn ca cc nhn chng khc nu c


4. Ly li khai

5. Chp hnh hin


trng s c

phng vn tip theo.


Tn ca cc nhn vin cu h hoc
nhm cu h.
Cc vt liu, thit b, dng c c di
chuyn hoc b xo trn trong qu trnh
ng cu/cu h.
Chp nh cc gc khc nhau
thy c chi tit ca hin trng
Ghi ch trn mi bc nh. Ngy, gi, a
im, ch , iu kin thi tit, kch
thc
t mt vt bit kch thc trc
trong cc bc nh nu cc i tng kh
khn o kch thc trong qu trnh
chp nh.
Xc nh ngi chp nh.
Ch ra hnh nh ca cc a im
c thc hin trn bn phc tho hin
trng s c.

- Ngy, thi gian, a im, cc vt


6. Phc tho hin
trng s c

dng c, nn nhn
- Cc kch thc
- V tr ca cc bc nh

7. Kim tra, r sot


cc ti liu

- H s bo tr, bo dng- xc nh
lch s bo tr, bo dng ca cc thit
b, dng c, my mc lin quan n s
c.
- H s o to - xc nh s lng v
cht lng o to cho cc nn nhn v
nhng ngi khc
- Quy trnh vn hnh- xc nh cc
bc vn hnh c thit lp trong
cc quy trnh, check list, check sheet,
nht k vn hnh.
- Cc chnh sch, k hoch, quy tc an
ton- xc nh s hin din v y
cc hng dn an ton.

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

- Lch lm vic- xc nh nn nhn c


th b mt mi hoc lm vic qu sc.

- H s k lut-xem xt cc h s k lut
-

8. Thu thp d liu


thng qua phng
vn

trc nu c
H s y t (nu cho php)- xc nh
yu t v th cht / tinh thn c th gp
phn gy ra s c
H s ng ph s c khn cp- xc
nh cht lng ca cc quy trnh ng
ph s c khn cp
D liu v s c- xc nh cc s c
tng t xy ra trc cha
Cc bin bn v hp hi ng bo h lao
ng- xc nh lch s ca cc cuc
tho lun lin quan n cc iu kin
nguy him, cc hnh vi khng an ton
hoc cc chng trnh hnh ng.
H s bnh n- xc nh nguyn nhn
trc tip gy ra chn thng gy t vong
Nn nhn. bit cc s kin trc, sau
v trong qu trnh xy ra s c.
Cc ng nghip. bit cc hnh ng
thc hin c ph hp vi cc quy
trnh ang c p dng hay khng
Gim st trc tip. c c thng tin
c bn v nn nhn. Anh ta hoc c ta c
th cung cp cc quy trnh v nhng
nhim v c thc hin.
Lnh o phng. xc nh cc ngun
thng tin lin quan n cc h thng
qun l
Phng o to. c c thng tin v
s lng v cht lng o to cho nn
nhn
B phn qun l nhn s. bit c
thng tin v nh gi cng vic, chuyn
mn, v cc cng vic trc ca nn
nhn.
B phn bo dng bo tr. bit c
lch s ca cc thit b my mc.
Nhn vin ng cu. tm hiu nhng
g h nhn thy khi h n v trong qu
trnh ng cu
Nhn vin y t. c c cc thng tin

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

9. Kt ni trnh t
cc s kin lien
quan

v y t (nu c php).
C th l mt ngun thng tin c gi tr
quyt nh loi / nguyn nhn gy t
vong
Ngi lin quan khc. Bt c ai lin
quan n s c c th l mt ngun
thng tin c gi tr iu tra s c
V hoc chng v gia nh ca nn
nhn. H c th hiu bit su sc v tnh
trng tinh thn hay cc vn v cng
vic khc ca nn nhn.
Xc nh cc hot ng hoc cc s kin
trc khi xy ra s c
Nghin cu tng s kin xc nh s
kin lin quan n s c
iu kin khng an ton. L cc nguyn
nhn trc tip gy ra s c
Hnh ng khng an ton. L thc hin
cc hnh ng khng an ton / khng
thc hin cc hnh ng ngn chn dn
n gp phn vo xy ra s c.

- Nguyn nhn c bn hoc hn ch ca


Phn tch
cc d
liu

10. Tm hiu nguyn


nhn c bn hoc
hn ch ca h
thng

h thng

- Nguyn nhn xy ra s c do khng


cung cp y hoc thiu cc chng
trnh, k hoch, chnh sch, cc quy trnh
cng ngh v quy trnh khc.

- M t cc hnh ng trc khi m t

11. M t v sp xp
cc hnh ng

nhng din bin ca s vic do hnh


ng gy ra.
- M t r rng chui cc s kin xy
ra.
- Cn lu tt c nhng thng tin nn
nhn /nhn chng ni, lm trc v
sau khi s c xy ra, thm ch trong qu
trnh ang iu tra v nh gi.
- Sp xp cc chui s kin/hnh ng
xy ra theo thi gian.

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

Xc nh
nguyn
nhn trc
tip v
nguyn
nhn c
bn

12. Cc nguyn nhn


trc tip

Nguyn nhn trc tip l


nhng iu kin khng an ton
v hnh ng khng an ton
trc tip gy ra hoc gp phn
gy ra s c.
iu kin khng an ton l
nhng vt hay nhng iu kin
khng an ton gy ra thng
tch hoc bnh tt:
Vt liu
My mc
Thit b
Dng c lm vic
Ha cht
Mi trng
Ni lm vic
iu kin lm vic
Con ngi
Khi lng cng vic
- V d v cc iu kin khng an ton:
Thiu cnh bo hoc ro chn
Khng v khng ng trang
thit b bo h
Li thit b, dng c hoc vt
liu s dng
Cc hnh ng thiu nhn thc
Thiu cc h thng cnh bo an
ton
Nhng mi nguy v chy n
V sinh khng tt
Cc loi kh/ bi/ hi kim loi/
hp cht bay hi/khi
Ting n
Tip xc vi phng x
Nhit
Chiu sng khng hoc qu
mc
Thng gi khng m bo
- Mt s v d v hnh ng khng an
ton

Khng tun th cc ni quy,

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

quy nh
S dng cc phng php lm
vic khng an ton
t chy giai on
a nghch
Khng thng bo/bo co khi
b thng
Khng thng bo/bo co cc
mi nguy, nguy him
Chp nhn cc hnh vi khng
an ton
Khng hoc thiu o to cho
cng vic
Thiu s gim st
Thiu hnh ng khc phc
Cng vic qu nhiu
Khng quan tm n s cng
thng ca nhn vin
Thiu s m bo
Vn hnh thit b khng ng
theo quy nh
t cc thit b an ton vo
trng thi vn hnh khng
chnh xc
Tho b cc thit b an ton
S dng cc thit b, dng c
b li
Khng s dng ng thit b
bo h hoc s dng khng
ph hp
Khng ng ti trng
Khng ng v tr
Nng d khng ng cch
V tr khng ng cho cng
vic
Sa cha cc thit b khi ang
hot ng
S dng ru bia hoc cht
kch thch
Vn hnh thit b cha c php
Thiu cnh bo

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

- Cc nguyn nhn c bn/gc r gy ra


s c l nhng im cha ph hp ca
h thng gp phn vo s hin din ca
iu kin khng an ton v hnh ng
khng an ton
- V d v cc h thng an ton

13. Cc nguyn nhn


c bn

o to
Qun l/gim st/hng dn
nhn vin
La chn v gim st nh thu
K thut/thit k
Hoch nh cng vic
Mua bn, kim sot v qun l
vt t
Dng c v thit b
Ni quy, quy nh, quy trnh v
cc tiu chun cho cng vic
Thng tin lin lc
- Cc v d v nguyn nhn c bn

Khng nng lc
Thiu hiu bit/kin thc
Thiu k nng
B p lc
Thiu ng c lm vic
Thiu s ch o/gim st/
hng dn
Thiu ht v vn k thut
(vd: thit k k thut cng
ngh)
Thiu thng tin v vt t,
thng tin t nh cung cp
Thiu bo dng phng nga
Thiu dng c, thit b lm
vic
Thiu quy trnh, hng dn
lm vic
Hao mn
Lm dng

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

- Loi b hoc lm gim cc mi

14. Gii php k


thut

Hnh
ng khc
phc

nguy/nguy him l cch hiu qu nht


lm gim cc nguyn nhn gy ra s c.
iu ny c th c thc hin trong
mt s cch khc nhau, bao gm:
Thit k li loi b mi
nguy. V d - Ch to li
bo v chng li tip xc gia
ngi vn hnh vi b phn
chuyn ng.
Thay th cc dng c, thit b
khng an ton bng cc dng
c, thit b an ton hn. V d Thay th mt my xay cht
lng km vi mt my xay
cht lng cao.
C lp mi nguy.
Gii php thay th V d Thay th mt ha cht c hi
bng mt ha cht khng c
hi.

- L a ra cc bin php qun l, kim


sot loi b hoc lm gim tn sut v
thi gian tip xc vi cc mi nguy/nguy
him, iu ny c th thc hin thng
qua cc bin php sau:
Qun l cng vic a ra v
thc hin theo check list, check
15. Gii php qun l
sheet v cc quy trnh lm vic
an ton v c tnh hp l.
Qun l lch lm vic k
hoch qun l ny bao gm
lun chuyn cng vic, b tr
thi ngh ngi hp l, lm vic
theo ca
16. Trang thit b bo - Khi cc gii php v k thut v/hoc
h c nhn
cc bin php v qun l khng loi
b hoc gim bt nguy him/mi nguy
ca cng vic, th gii php v trang
thit b bo h cc nhn (PPE) s c
s dng.
- Hy nh, PPE khng loi b hoc gim

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

thiu nhng mi nguy, n ch n thun


l lm gim bt hu qu.

- Vn an ton phi c cp trong


17. Ci tin h thng

Bo co
iu tra
s c

18. M t v s c

19. Hnh ng phng


nga

20. Thit hi

21. Chng c-thu

thng tin theo th


t ca cc s
kin, s vic

cc bin php lm vic


Ci thin chnh sch an ton thit lp
r rng nhim v v trch nhim.
Thay i qu trnh lm vic sao cho s
dng danh sch kim nh k (check list)
bao gm kim tra an ton.
Sa i chnh sch mua sm bao gm c
cn nhc v an ton v chi ph.
Thay i qu trnh kim tra an ton
bao gm tt c cc gim st vin v nhn
vin c tham gia.
M t tm tt qu trnh xy ra s c v
cc bng chng tm c mt cch trnh
t theo thi gian ( dng li hin
trng s c). Bn tm tt cn nu r
nhng ci g xy ra, xy ra u, khi
no v thit hi do s c gy ra.
M t cc hnh ng c thc hin
gim thiu thit hi v trnh s c leo
thang. V d nh chm sc y t cho
ngi b thng, hoc kch hot cc thit
b bo chy, cha chy v cc i ng
cu khn cp, hoc dng thit b hoc
khi ng cc thit b ca phn xng
M t v cc thit hi do s c gy ra
nh thit hi v ngi, mt sn phm,
thit hi cho mi trng, v h hng ti
sn. Chi ph thit hi c tnh phi c
tnh ton v bo co iu tra s c.
M t nhng nguyn nhn trc tip v
v nguyn nhn c bn m bn pht
hin ra trong qu trnh iu tra. Mi m
t nguyn nhn trc tip v nguyn nhn
c bn nn l gii v pht hin ny. Cc
l gii ny s gii thch kt lun ca bn.
M t cc s kin, s vic: iu kin
khng an ton quy trnh lm vic khng
an ton, khng y hoc thiu chnh
sch an ton, o to, trch nhim, vv
phi c m t trong bo co.

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

- Trnh by nhng pht hin/chng c da


trn quan st hin trng, phng vn,
kim tra ti liu. Nhng pht hin/chun
c phi m t chi tit trnh t ca cc s
kin trc, trong v sau khi v vic xy
ra. Thi gian ca mi s kin phi chnh
xc. Nhng hnh ng (hoc c thc
hin hoc khng thc hin) ca nhng
ngi tham gia hoc c lin quan n v
vic phi c nu chi tit.
- kin ca chuyn gia (nu c) c
xem l chng c xem xt. Pht hin
v s h hi ca thit b, thit b iu
khin, ha cht, qu trnh cng ngh, v
nhng yu t khc phi c phn tch
v nhn mnh trong bo co.

- Hy chc chn rng nguyn nhn trc


22. Cc nguyn
nhn- Nhng mi
nguy n trc
s c v li h
thng qun l
23. Hnh ng khc
phc v phng
nga (khuyn
ngh)

tip (hnh ng khng an ton v iu


kin) v nguyn nhn c bn (im yu
ca h thng qun l) c lit k ring
bit. Tham kho cc v d v cc nguyn
nhn trc tip hoc gin tip ti mc D
ca hng dn ny.

- Cc khuyn ngh nn gii quyt tt c


cc nguyn nhn c xc nh vi mc
tiu ngn chn s lp li s c tng t.
- M t lm th no khc phc nhng
iu kin khng an ton v hnh ng
khng an ton trc tip dn n s c.
Tham kho cc bin php kim sot mi
nguy nh bin php k thut, bin php
qun l, bin php PPE hoc kt hp ca
cc bin php trn khi a ra cc hnh
ng khc phc v phng nga.
- Quan trng hn ht l cc khuyn ngh
nn gii quyt cc nguyn nhn gc r
hoc hn ch ca h thng. Thng
thng, cc h thng nh chng trnh
o to, tiu chun / chnh sch / quy
trnh, quy trnh qun qun l nh thu, ,
quy trnh mua bn, thng tin lin lc v
nhng h thng khc l nhng h thng,

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HNG DN
HNG DN PHN TCH NGUYN NHN S C V
BIN PHP KHC PHC

nu c lin quan n s c phi c


kim tra mt cch y .
- Tt c cc hnh ng khc phc phng
nga phi c thi hn hon thnh v
ngi thc hin c th. Ngi thc hin
nn l c nhn hoc ngi c v tr c
th. V d nh ngi hnh ng: Trng
Phng sn xut ch khng phi l Phng
sn xut, hoc Trng phng HSE ch
khng phi l Phng HSE
- Nhng khuyn ngh phi c th, va
phi, c th t c, thc t v kp thi
(SMART). Khng nn a ra cc
khuyn ngh khng c thi gian hon
thnh hoc mang tnh chung chung kh
xc nh.

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