最新The System - Induced Error Approach：引起的误差的方法系统课件PPT.ppt 37页

'TheSystem-InducedErrorApproach：引起的误差的方法系统 Somecommonassumptionsaboutprocedures‘Fullydocumentedstepbystepproceduresneedtobeactivelyreferredtowhenalltasksarecarriedout’ThetypeandlevelofdetaildependsonthelevelofexpertiseforthespecificoperatorsandtasksconcernedFamiliar,simpletasksusuallydonotrequirewrittenproceduresatthepointofuseTheMatrixprovidesguidelinesfortheappropriateformofproceduralsupportRisk,complexity,frequencyoftaskperformance2 ‘Youcannotwriteproceduresforeverything’ForroutinesituationsOPERAallowsbestpracticescanbedefinedanddocumentedasthemostcosteffectiveway(s)ofcarryingoutthetaskForabnormalsituations,jobaidsmustbeprovidedfordealingwithsituationsthatcanbeanticipatedForhighrisk,unpredictablesituations,needtodefinegenericprocedurestogetthesystemtoasafestateandbuytime3 7Blackbooksareausefulsourceofinformal,undocumentedknowledge7 HowtheConsensusProcessWorksTechnicalexpertsIseeaproblemFacilitator(Systemuserpeergroup)TechnicalquestionsProposedbestpracticeConsensusgroupBestPracticeAgreedbyallJobaidsTrainingspecificationDifferencesPracticalrealitiesFacilitatorstalktoallsystemuserswhodescribecurrentpracticeRiskscontrolled8TaskExpertsPeoplewhodothejob8 FacilitatorcollectsinformationanddevelopsprovisionalbestpracticeReviewedbyeachshift&modifiedifnecessary9 TaskanalysisinformationPotentialhazards/consequencesTrainingissuesHazardAdd.Info.GenericskillsSpecificknowledgeLevelofsupportReferenceProcedureformat10 MaintainingBestPracticeEncourageandusefeedbackfromusersMaintainchannelsofcommunicationwiththesharpendviafacilitatorReapplyOPERAtogeneratenewpracticesandsupportingjobaids&refreshertraining:plant/equipmentchangeschangesinworkingpracticesoperationalexperienceregulatorychange11 WhatareJobAids?“Anysourceofinformationusedtosupportthesuccessfulperformanceoftasks”(e.gremindersandmemoryaids)Intendedtocomplementbutnotreplaceskill12 Howoftenarewrittenproceduresactuallyneeded‘inhand’whenataskisperformed?13 TheMatrixfordeterminingappropriatelevelofsupportStepbyStepinstructionrequired(SBS)LowLowMediumHighNWINWINWINWINWINWINWINWIJANWINWIJANWIJAJASBSNWINWINWISBSNWIJAJAJANWIJASBSMediumHighFreqInfreqRareFreqInfreqRareFreqInfreqRareTaskCriticalityTaskFamiliarityTaskComplexity14JobAidrequirede.g.checklist/memoryaid(JA)NoWrittenInstructionrequired(NWI)14 ExamplesofJobAidFormatsStep-by-steplistsPostersFlowchartsLabelsSimplifieddrawingsDecisiontablesChecklistsheets15 CordGripBlueorBlackNGreen&YelloworGreenE13AFuseBrownorRed32mm12mm22mmFittedWithBS136213AFuseAlwaysFitBS1362ReplacementCartridgeFuse6mm6mm6mmLLUKPlugCoverJobAid Furnace/HotOil-LabelMaintainburnerpressureabove0.6barKeepoiltemperature170-225CFluegasO2Veryunsafe.DonotincreaseairUnsafe.IncreaseairgraduallyEmissionsIncreaseairTargetrangeWastedfuel1%2%5%6%17 FurnaceTripJobAidHowlongisfurnacelikelytobedown?FurnaceTripResetAlarmsIdentifyinitiatoreventTemporaryunitshutdownColumntemperatureandrefluxtomanualReducefeedStophotoiltocolumns5and7Bypasscolumn6steamraisersReducecolumnrefluxratesMaintaincolumnlevelsStoptank7and8importRundowntooffgradeStopoverheadpumpsascondenserlevelsfallMorethan1hourCommencefurnacestart-upprocedureReset98-DEA-80LightpilotflameReturnUnittonormalDidpilotflamelight?Attempttore-lightfurnaceYesYesIshotoiltemperatureabove150°C?NoLessthan1hourNo1818 PlanningJobAidsBasefinaldecisiononwhatuserswantandneed-listentofeedback!123LowLowMediumHighNWINWINWINWINWINWINWINWIJANWINWIJANWIJAJASBSNWINWINWISBSNWIJAJAJANWIJASBSMediumHighFreqInfreqRareFreqInfreqRareFreqInfreqRareCriticalityFamiliarityComplexityBaseinitiallyondecisionaidtableGetallthepotentialuserstogether19 CaseStudyImprovingProceduresComplianceataMajorMultinationalChemicalSiteFailuretomanageflarelineincidentalmostledtoacatastrophicfailureAnalysisofincidentshowedthatmaincausewasfailuretocomplywithprocedures(HSEinvestigation)HRAaskedtoinvestigateandproposesolutionsacrosssite(~1000employees)20 CaseStudyImprovingProceduresComplianceataMajorMultinationalChemicalSitePhase1:ProceduresculturesurveydevelopedandappliedacrosssitePhase2:ProceduresculturechangeprocessOPERA(OptimisingProceduresforEfficiencyandReducedAccidents)developedandpilotedacrosssitePhase3:OPERArolledoutacrossallproductionunitsonsiteover4yearperiod(Ownedbyworkforce,facilitatedbyHRA)21 34%Resentbeingtoldhowtodojob44%Tootimeconsuming19%Experiencedpeopledon’tneedthem47%Toorestrictive62%ToolongiffollowedtotheletterFindabetterwayofdoingthem72%Insteadrelyonskills&experience42%Moredifficulttodowork40%Don’tunderstandwhytheyarenecessary%agreeProceduresarenotusedbecause…70%Assumehaveknowledge37%Nopolicyonwhenshouldbeused42%22 Mostproceduresmanualswererarelyaccessed2323 +52%Don"tunderstandwhytheyarenecessary+18%Notawaretheyexist+17%Identificationdifficult+21%Toocomplex+19%Notbestpractice+52%UnworkableImprovementover3yearperiodOpinions:Proceduresare…ResultsofapplyingOPERAovera3yearperiodChangesinopinionsofworkforceStatisticallysignificantchanges24 CaseStudyConcludedWastheprocesssuccessful?Plantstart-uptimesubstantiallyreduced,giving~500,000poundssavinginfirstyearManycostreductionsduetoreducedtimeneededtoconductyearlystart-ups/shutdownsGenerallyproceduresfollowedasdocumented25 CaseStudyConcludedWastheprocesssuccessful?ReducedeffluentemissionsImprovedsafetyrecordAfter5yearssavingsof~3MillionpoundsproducedSitenowhasthehighestproductionlevelsperemployeeofanysiteworldwide(Formerlybottomoftheinternationalleaguetable)26 SummaryofRecommendedStrategyStartwiththemostcriticaltasks(fromTaskInventory&Criticalityanalysis)MayuseexistingproceduresasstartingpointbutneedtoverifyagainstactualworkingpracticesDevelopReferenceProceduresfortheCriticalTasks(dependingonresources)DevelopJobaids,trainingandcompetencyspecificationstocontrolrisksProceedtoothertasksasresourcesbecomeavailable27 RealMenDon’tUseProcedures!2828 1.长方体和正方体有什么相同点和不同点。长方体有_____个面，相对的面_____；有_____条棱，相对的棱_____；有_____个顶点。正方体有_____个面，每个面_______；有_____条棱，每条棱_______；有_____个顶点。 2.分别说一说什么是长方体或正方体的棱长总和和表面积。长高宽棱棱棱 为迎接“五一”国际劳动节，工人叔叔要在工人俱乐部的四周装上彩灯(地面的四边不装)。已知工人俱乐部的长90m，宽50m，高20m，工人叔叔至少需要多长的彩灯线? 1.做一个微波炉的包装箱(如右图)，至少要用多少平方米的硬纸板?0.5m0.5m0.4m这里要求的是这个长方体包装箱的表面积。2.一个正方体礼品盒，棱长2dm，包装这个礼品盒至少用多少平方分米的包装纸? 3.一个无盖玻璃鱼缸的形状是正方体，棱长3分米。制作这个鱼缸时至少需要玻璃多少平方分米? 乒乓球台的长度为2m，宽度为1m，台面厚度为0.1m，它的表面喷上了漆，喷漆的面积是多少平方米? 如何把这个长方体木块分成两个棱长为4cm的正方体?8cm4cm4cm两个棱长为4cm的正方体的总表面积与这个长方体的表面积相等吗? 亮亮家要给一个长1m，宽0.5m，高1.5m的简易衣柜换成布罩(如下图，没有底面)。至少需要用布多少平方米?1.6m0.5m0.75m 学校要粉刷新教室。已知教室的长是8m，宽是6m，高是3m，扣除门窗的面积是11.4m2。如果每平方米需要花4元涂料费，粉刷这个教室需要花费多少元?'