12/8/20104:47 PM
Evaluator Employee ID
Problem statement
工作人员在电子舱的坠落防护 Fall protection for working in E/E bay open
526
Discription Process A/C Daily Maintenance Employees Exposed 1 to 2 Sub-process open the E/E Bay hatch Frequency of Exposure Once a year 1 Treament the injury Containme site specific pro Plane Job Title 2 Report the safety nt Location Cabin Property A/C Mechanic 3 Briefing on site Nature Dept. lectronics/Electrical Tec 4 People Production Publish a instruction of pre work
ChenSheng
aluator Na
who
Discript who ion
where
HuangMingLCabin Eric HM Eric HM Eric HM
Other index Related MET item
where
5 6 7 8
100736 Hazard Id 10
Poll Results Identified Risks
KNOT Date Quantitative
Further control acton
Existing controls described & evaluated
4
3
4
3
4
3
12
Procedure or Process re- 发布新的有关机上工作注意事项的指引 assessment
M
N
N
N/A
Y
3
2
3
2
3
2
7.2
M
N
N
N/A
Y
4
4
4
3
4
3
4
4
4
4
4
4
14.4
M
N
N
N/A
Y
4
3
3
3
3
3
4
3
4
3
4
3
10.8
3
3
3
3
3
3
3
3
3
3
3
3
9
3
4
4
4
4
4
3
4
3
4
3
4
13.6
Procedure or Process re- 发布新的有关机下（电子舱）工作注意 assessment 事项的指引 Training 安全教育-公司级及部门安全教育 Safety Awareness 定期宣扬-daily meeting,现场开工前会议 training / consciously Training 安全教育-公司级及部门安全教育 Audit 质量系统自我评估，查找漏洞，编制质 量系统日常检查单的具体项目。
7
0
0
0
0
0
8
0
0
0
0
0
9
0
0
0
0
0
10
0
0
0
0
0
11
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
3
4
2
4
2
3
3
3
3
3
3
8.84
2
2
2
2
2
2
2
2
2
2
2
2
4
0
2
3
3
3
3
2
3
2
3
2
3
5.6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
community with the onsite mechanic community with the onsite mechanic community with the onsite mechanic
安全意识不够高 3 Attitude Quality/Workmanship/Safety 4 Communication Breakdown 现场协调不好 5 Schedule/Time/Deadline 现场协调不好(控制人员协调) Detection System Fault 质量系统没有发现这个风险源
6
Or add a new current h d
Sele Select Potential Hazard: 1t Attitude Quality/Workmanship/Safety 2 Procedure/Policy Human Performance
Detail discript about the Harzard
Detail discript about the Harzard
Before inprovement-Risk After inprovement-Risk
VH
18.44
H
L
2
飞机没有推梯 子，直接从客 舱进入飞机
电子舱口 盖未关闭
3 E/E bay fall down injury
电子舱，打开 后没有人负责 关闭
3W 飞机准备推出机 库，没有打开照明 飞机准备推出机 库，工作人员不选 择从机身下部进入 电子舱 工作者以为后面没 有人跟进，应客户 要求保留电子舱口 盖打开
没有设置 4 警告装置 现场操作 人员没有 通知后续 5 人员电子 舱口盖已 打开
现场操作人不 知道后面有人 进入客舱
现场协调不好
6 当事人没 想到
没有人提醒
这是班组人员的一 贯做法
N
N/A
Y
N
N/A
Y
M
N
N
N/A
N
Dec. Dec. 10 30 2010 Dec. 30 Dec. 30 Dec. 30 Dec. 30 Dec. 30
Dec. 10 Xian QS Dec. ghua 10 JR HM Dec. 10 Dani Oper Dec. el ation 10 Xian QS Dec. ghua 10
0
67
M
2W 飞机没通电， 无客舱照明
N N
HM HM
Potential control if appropriate
一线人员宣扬的效果，安全意识的有效 提高 质量系统的检查单是否能涵盖所有日常 的风险源 执行效果
1W 当事人没 1 有看到
M M
JR JR
4W
5W 没有明确规定客舱工作需 要打开客舱照明
没有明确的程序要求需要 从飞机下部进入电子舱
安全意识不够高
质量系统没有发现这个风 险源
Page 1 of 13
Evaluation Date： Future Review date:
程序及工作指引发布 程序及工作指引发布 培训宣讲纪录 定期抽查 定期抽查 质量系统的自我审核
chen shen g chen shen chen shen chen shen chen shen Xue Che
Date
3 3
Measurement of Effectiveness （MOE）
Due Date
4 3
Validation and Audit
Assigned To
3 3
Date
4 3
Due Date
3 2
Procedure/Policy
Dept。
4
1
没有明确规定客舱工作需要打开客舱照 明 没有明确的程序要求需要从飞机下部进 入电子舱
W h at w e wi ll d o to
Assigned To
Cost to implement?
Accept Risk (Yes or No)
Difficulty to implement?
Detail discription about the control action
Solution creates new problems?
Risk level
Solution to problem accuracy?
What we do now to manage this risk.
3
Procedure/Policy
3
Action Taken to validation
Likelihood
know
(L, M, H or VH - see Sheet 1)
on
Consequence
w
(1, 2, 3, 4 or 5 - see Sheet 1)
w
Likelihood
Kno
Lack of q uality attitude
(1, 2, 3, 4, or 5 - see Sheet 1)
Hang er constructio n limitation
Lack of quality attitud e
(1, 2, 3, 4 or 5 - see Sheet 1)
Lack of saf ety training
we
Likelihood
Lack of safety training
Consequence
Lack of safety sense Walkie-talkie is in - op eration Not follow the procedure (Industry standard)
Kno
5 th Why
Short of skill traini ng
(1, 2, 3, 4 or 5 - see Sheet 1)
Lack of saf ety sense
Entry HIDRA Average Risk Lever
shane (1, 2, 3, 4, or 5 - see Sheet 1)
4th Why
Likelihood
Not fol low th e procedu re manual
Lack of insp ection skill
Consequence
Not use the communica tio n tool No communicati on between team
D o not tag o n warning tag
Staff not be assig n
(1, 2, 3, 4 or 5 - see Sheet 1)
Lack of communicati on
3rd Why
shane (1, 2, 3, 4, or 5 - see Sheet 1)
O ver sign th e mistake
Likelihood
Lack of onsite monito r
Consequence
No 6 slat PNL D amag ed
2nd Why
Likelihood
Lack of Observation
Consequence
1st Why
Problem Stat ement
Consequence
5-Why Analysis
(1, 2, 3, 4 or 5 - see Sheet 1)
Think
d to Opini
(1, 2, 3, 4 or 5 - see Sheet 1)
Nee KInde Risk Description x method selection
(1, 2, 3, 4, or 5 - see Sheet 1)
T-
XiaoFen g Dawei (1, 2, 3, 4, or 5 - see Sheet 1)
O-
(1, 2, 3, 4, or 5 - see Sheet 1)
N-
shane
Jan. Jan. 5 5 Jan. 5 Jan. 5 Jan. 5 Jan. 5 Jan. 5
Jan. 5 Jan. 5 Jan. 5 Jan. 5 Jan. 5
12/8/20104:47 PM
Evaluator Employee ID
B747/767尾架移动撞击东航设备
luator N HeGe
396
who
Discription Process A/C Daily Maintenance Employees Exposed 25 to 35 employees Sub-process The 747 tail docking impacting Frequency of Exposure Once a year 1 Containm site specific pro Plane Job Title 2 ent Location Apron Property Facilities Maintenance 3 Nature People Dept. A/C Mechanic 4 Production
Problem statement
Discri who ption
where
Other index Related MET item
where
100722
5 6 7 8
Evident
10
Pic Pic 2 invest Modi
Poll Results Identified Risks
KNOT Date Quantitative
4
3
4
3
10.4
Engineering Controls
在此工作梯上明显位置注明移动梯架 M 时风速不超过30公里/小时。
N
N
4
4
4
4
4
3
11.4
Planning, Phasing
现场指挥者要及时注意当时天气变化 M （通过网络，机场塔台等）。
N
N
4
3
4
3
4
3
4
3
4
3
4
3
12
Procedure
3
3
3
3
3
3
3
3
3
3
3
9.6
Engineering Controls
按照pro-04-m08r3规定梯架停滞进行 M 现场开工程序培训（口述，文本签字. 与供应商协调，在安全的范围里重新 H 设计梯架，减轻重量，或改为自动式
N
4
N
0
0
0
0
0
Engineering Controls
在使用上，梯架固定在机库内某一区 M 域减少移动距离
0
0
0
0
0
Engineering Controls
梯架支撑脚脱卸式摇把改成固定式
M
0
0
0
0
0
Procedure
在支撑脚锁 定前用轮挡刹住轮子防止移动
M
8
0
0
0
0
0
9
0
0
0
0
0
10
0
0
0
0
0
11
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
修理坞改装效果，成本
3
2
3
2
3
2
3
3
3
3
3
2
7.2
effective of procedudre implementation
2
2
2
1
2
2
2
2
2
2
2
2
3.6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
梯架设计不合理－支撑脚锁定过程繁 琐 Attitude 现场人员决断力及判断力不够（应急 4 Quality/Workmanship/Safety 处置，安全意识） Tools
3
interview with the onsite mechanic
5 6 7
Or add a new current hazard:
Detail discript about the Harzard
Sele Select Potential Hazard: 1t Equipment Human Performance
Detail discript about the Harzard
storm stronger on apran
2W
43.4
VH
After inprovement-Risk
10.8
H
3W
4W
5W 工作者在移动梯架时没有 及时预判风速变大
2 Storm impact docking moving
现场人员 3 无法控制 修理坞
梯架设计不合理－梯架庞 大重量重
4
梯架设计不合理－支撑脚 锁定过程繁琐
现场保护 措施不足梯架停放 时锁定支 5 撑脚未全 部锁定， 未设置轮 档
N
N/A
Y
Y
much Y
N
Y
N/A
N
N
10000 Y
N
N
N/A
Y
Y
供应 Bac Dec 商 ksh 0 op 201 PPC Eng Dec 0 、 201 MO Zon HM Dec e 0 Mik Faci Dec lity 0 e Zh 201 JR HM Dec 0 201 Mik Faci Dec e lity 0 JR HM Dec 0
Dec ， 30 Dec ， 30 Dec ， Dec ， 30 Dec
现场人员决断力及判断力 不够（应急处置，安全意 识） Page 3 of 13
铭牌在位 相应程序建立，并发布 相应程序建立，并发布 修理坞改装完成
相应程序建立，并发布 ， 30 修理坞改装完成 Dec Dec 相应程序建立，并发布 ，
0
Before inprovement-Risk
L
1W
Y
Potential control if appropriate
M
1
500 Y N/A
Evaluation Date： Future Review date:
Date
3
3
Measurement of Effectiveness （MOE）
Due Date
4
4
Validation and Audit
Assigned To
2
2
Date
4
3
Due Date
2
2
Dept。
4
4
W h a t w e w i l l
Assigned To
3
梯架设计不合理－梯架庞大重量重
Cost to implement?
4
Design/Architecture
Accept Risk (Yes or No)
Difficulty to implement?
Solution creates new problems?
Detail discription about the control action
工作者在移动梯架时没有及时预判风 速变大
2
2
Solution to problem accuracy?
What we do now to manage this risk.
Environmental Conditions 1
Further control acton
Existing controls described & evaluated
Risk level
Likelihood
Action Taken to validation
(L, M, H or VH - see Sheet 1)
know
Consequence
ion
(1, 2, 3, 4 or 5 - see Sheet 1)
w
Likelihood
w
(1, 2, 3, 4, or 5 - see Sheet 1)
Kno
Lack of q uality attitude
(1, 2, 3, 4 or 5 - see Sheet 1)
Hang er constructio n limitation
Lack of quality attitud e
Likelihood
Lack of saf ety training
k we
Consequence
Kno
(1, 2, 3, 4 or 5 - see Sheet 1)
Lack of safety training
Entry HIDRA Average Risk Lever
HeGe (1, 2, 3, 4, or 5 - see Sheet 1)
Lack of safety sense Walkie-talkie is in - op eration Not follow the procedure (Industry standard)
5 th Why
Short of skill traini ng
Likelihood
Lack of saf ety sense
Consequence
Not fol low th e procedu re manual
4th Why
Lack of insp ection skill
(1, 2, 3, 4 or 5 - see Sheet 1)
Not use the communica tio n tool No communicati on between team
D o not tag o n warning tag
Staff not be assig n
HeGe (1, 2, 3, 4, or 5 - see Sheet 1)
Lack of communicati on
3rd Why
Likelihood
O ver sign th e mistake
Consequence
Lack of onsite monito r
(1, 2, 3, 4 or 5 - see Sheet 1)
No 6 slat PNL D amag ed
2nd Why
Likelihood
Lack of Observation
Consequence
1st Why
Problem Stat ement
Consequence
5-Why Analysis
(1, 2, 3, 4, or 5 - see Sheet 1)
Thin
d to Opin
(1, 2, 3, 4 or 5 - see Sheet 1)
Nee KInd Risk Description ex method selection
T-
XiaoFe ng DaWei (1, 2, 3, 4, or 5 - see Sheet 1)
O-
(1, 2, 3, 4, or 5 - see Sheet 1)
N-
Shane
HG Jan 5 201 HG Jan 5 201 HG Jan 5 HG Jan 5 201 HG Jan
Jan 5 201 Jan 5 201 Jan 5 Jan 5 201 Jan
5 201 HG Jan 5 HG Jan 5
5 201 Jan 5 Jan 5
12/8/20104:47 PM
Evaluator Employee ID
Process plane Maintenance - A Ch Employees Exposed Sub-process Close the side cowl Frequency of Exposure site specific pro 发动机勤务的恢复工作 Plane Location Hangar Bay 4 Property Nature Dept. People Heavy Maintenance
Problem statement
side cowl突然滑落导致人员受伤
who
Discription
3 to 6 Once a year Job Title
Containme 1 2 nt
A/C Mechanic Inspector
Other index
Disc who ripti
where
Treament the injury inspect the side cowl
where
Discription
who
where
Identified Risks
KNOT Date Quantitative
Existing controls described & evaluated
N
3 Knowledge 4 Design/Architecture
工作经验不足
3
3
3
3
4
3
4
3
4
3
11 Training
N
N
No
Y
configuration defferent
3
2
3
2
3
3
3
3
H 培训 OJT requires the sells to communication L ith t
Y
Y
n/A
Y
w
Action Taken to validation
9 Engineering Controls
Cost to implement?
on
Solution creates new problems?
w
2000 Y
司介 HM 忠
Dec.1 Dec. 梯子到位 0 30 read and sign training emaildrecord
Daw Jan Jan i 5 5
Risk level (L, M, H or VH - see Sheet 1)
N/A
w
Measurement of Effectiveness （MOE）
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
N
Lack of quality attitude
Lack of quality attitude
Detail discription about the control action
Future Risk Level Target (L, M, H or VH - see Sheet 1)
N
Hanger con stru ction limitation
Not follow the procedure (Indu stry stand ard )
kno
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
N
H
Walkie-talkie is in -operatio n
Kno
Date
N
重新review生产部门授权体制
Lack of saf ety training
Due Date
使用与机型匹配的现有梯架 采购 M /配置与不同机型相匹配的梯架
11 Procedure or Process re-
Short of skill trainin g
Lack of saf ety sense
What we do now to manage this risk.
10
Expected Risk After Improvements
Validation and Audit
Assigned To
17 Engineering Controls
3
Not follow th e procedure manual
Kno
Date
5
4
Not use th e co mmunica ti on tool No commun icati on between team
D o not tag on warn ing tag
Lack of safety trai ning
Due Date
4
3
Lack of insp ectio n skill
5 th Why
Dept。
5
3
O ver sig n the mistake
Lack of saf ety sen se
Accept Risk (Yes or No)
5
3
Lack of co mmu nicati on
4th Why
Staff not be assign
Difficulty to implement?
4
4
No 6 slat PNL D amaged
3rd Why
Lack of onsite mo nitor
Solution to problem accuracy?
4
3
Problem Statement
2nd Why
Risk level (L, M, H or VH - see Sheet 1)
4
3
Lack of O bservation
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
3
3
1 st Why
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
5
4
5-Why Analysis
Assigned To
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
3
授权限制比较多
Thin
d to Opini k we
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
没有合适的梯架－梯架与飞机型号不匹配
Nee
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
1 Equipment 2 Fatigue
KInde Risk Description x method selection
0 0 0 0
4
4
5
0
0
6
0
0
0
0
0
0
9
0
0
0
0
0
0
10
0
0
0
0
0
0
11 Or add a new current h d
Sele Select Potential H d Knowledge
1t 2
Other
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
T-
Further control acton
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
O-
Entry HIDRA Average Risk Lever
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
N-
DaWei Song
100863 Evident
Report MEDA
3 4
Poll Results XiaoFe Shane ng He Ge He
Related MET item
Fatigue
Detail discript about the H d
Detail discript about the H all the d employee can got not th t it f t i i 授权实施效果待确定
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
3
2
1
2
2
2
1
2
2
3
2
2
2
3
2
4
0
3
2
3
2
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9
VH
M L
1W
2W
3W
4W
5W
梯子不合 适
没有合适 的梯子 没有足够 的休息时 间
没买合适 的梯子
Equipment
站不稳
2 疲劳 3 经验不足 设计缺陷4 安全余度 不够
疲劳
人手不够
没有合适的 经授权的工 作人员 Knowledge Design/Arc hitecture
0 After inprovement-Risk
47
H
然滑落导 致人员受 伤
0 0
Potential control if appropriate
After inprovement-Risk
1
0 0
Before inprovement-Risk
side cowl 突
shan
授权限制 比较多
Page 4 of 13
Future Review date:
12/8/20104:47 PM
Evaluator Name
Evaluator Employee ID
Process A/C Daily Maintenance Employees Exposed Sub-process Frequency of Exposure Plane site specific pro Location Hangar Bay 3 Property Nature Dept. People Heavy Maintenance
Problem statement
飞机进场维修未接地
A Team Once a season Job Title A/C Mechanic Facilities Maintenance
Discription Containme 1 2 nt
reconnect the static ground
who
where
Discription who
Mechanic
Cabin HM HM HM
5 6 7 8
3 4
XiaoFeng where
Other who
Discription
where
Identified Risks
KNOT Date Quantitative
Existing controls described & evaluated
Buy new static wires
H
N
N
2
6 Training
associate with ground training
H
N
N
N/A
Y
3 Instruments, Controls, No checklist regarding A/C static lib ti 4
2
2
3
2
3
2
3
2
3
2
3
2
6 Procedure
update the checklist
H
N
N
N/A
Y
0
0
0
0
0
5
0
0
0
0
0
6
0
0
0
0
0
7
0
0
0
0
0
8
0
0
0
0
0
9
0
0
0
0
0
10
0
0
0
0
0
kno
Lack of q uality attitud e
L ack of q uality attitude
w
w
on
w
Action Taken to validation
12 Material handling device
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
B
0
0
0
0
0
C
0
0
0
0
0
D
0
0
0
0
0
E
0
0
0
0
0
1t
2
2
2
2
4
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11 A
Or add a new current Detail discript about the Harzard h d
Sele Select Potential H d Performance Human
Detail discript about the Harzard
After inprovement-Risk
2
1
2
2
2
2
24 4
M L
3W
4W
接地线不 够长 工作人员 2 不知道怎 么接 3 没有 checklist
5W Equipment The length of current cable does not satisfy to connect A/C and ground point
1
飞机进场 维修未接 地
没有受过 相应机型 接地培训
没有人提 出需要相 应培训
Facil facili Dec. it t 10 Eric HM Dec. QA QA 10 Dec. 10
After inprovement-Risk VH H
2W
1000 Y
No aircraft static ground training for junior mechanics Instruments No checklist , Controls, regarding calibration A/C static
Page 5 of 13
Measurement of Effectiveness （MOE）
Dec. static wire available 30 Dec. Training record 30 Dec. Checklist update 30
Potential control if appropriate
Before inprovement-Risk
1W
Detail discription about the control action
Cost to implement?
Hang er construction limita tion
Kno
0 Future Review date:
XF XF XF
Jan. Jan. 5 5 Jan. Jan. 5 5 Jan. Jan. 5
5
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
3
3
Lack of safety training
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
4
2
Walkie- talkie is in -op erati on Not follow the proced ure (Ind ustry standard )
Kno
5th Why
Short of skill training Lack of safety trai ning
Future Risk Level Target (L, M, H or VH - see Sheet 1)
4
3
Lack of safety sense
Date
3
2
No t follo w the proced ure manual
4th Why
Lack of safety sense
Due Date
3
3
No t use the communica tio n tool No communicati o n between team
Do not tag o n warning tag
Staff no t be assi gn Lack of i nspectio n skill
Expected R After Improvemen
Validation and Audit
Assigned To
3
2
Lack of communicati on
3rd Why
Date
3
4
Lack of onsite monitor Over si gn the mistake
Due Date
4
2
2nd Why
Dept。
Solution creates new problems?
3
3
Lack of Observation
What we will do to reduc e this risk
Assigned To
Solution to problem accuracy?
3
2
1st Why
No 6 sl at PNL Damaged
What we do now to manage this risk.
Accept Risk (Yes or No)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
3
3
d to Opini k we 5-Why Analysis Problem Statement
1 Equipment 2 Knowledge
Thin
Difficulty to implement?
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
5
No aircraft static ground training for junior mechanics
Inde Risk Description x method selection
Nee
Risk level (L, M, H or VH - see Sheet 1)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
The length of current cable does not satisfy to connect A/C and ground point
K-
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
Likelihood (1, 2, 3, 4 or 5 - see Sheet 1)
T-
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
O-
Further control acton
Consequence (1, 2, 3, 4, or 5 - see Sheet 1)
N-
Entry HIDRA Average Risk Lever
10071 Evident N/A N/A N/A N/A
Poll Results XiaoFe DaWei Shane ng He Ge He Song Other
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