事故调查
一、事故分类 | Incident Classification
二、调查流程 | Investigation Process
三、根因分析 | Root Cause Analysis
四、整改与预防 | Corrective & Preventive Actions
五、事故统计与报告 | Incident Statistics & Reporting
Characters: Safety Manager (安全经理 SM) / Site Supervisor (现场主管 SS) · Characters: Investigation Lead (调查组长 IL) / Project Manager (项目经理 PM)
We just had a scaffolding collapse. Has the area been cordoned off?
刚发生了脚手架坍塌。现场封锁了吗?
Yes, the area is secured. No one is allowed in without authorization.
是的,现场已警戒。未经授权任何人不得进入。
Good. We need to preserve the scene before the investigation team arrives. Take photos from all angles. Don't move anything yet.
好。调查组来之前必须保护现场。各角度拍照,先什么都不要动。
Understood. I've already taken photos of the collapsed scaffolding and surrounding area. The workers involved are waiting for interviews.
明白。已经拍了倒塌脚手架和周边环境的照片。涉事工人正在等问询。
We need to interview them separately while memories are fresh. Also, pull the pre-start briefing record, work permit, and inspection checklist.
趁记忆清晰,我们要分别问询。另外把班前会记录、作业许可证和检查表都调出来。
Copies are ready. The permit was valid and the inspection was done this morning with no issues found.
复印件已备好。许可证有效,今天早上检查也没有发现问题。
Then we need to look deeper. Was the scaffold properly tagged? Who was the competent person that signed off? Let's start the timeline now.
那需要深挖。脚手架挂牌了吗?签字的资质人员是谁?现在开始梳理时间线吧。
We've completed the RCA using the Five Whys method. The direct cause was an unsecured ledger, but the root cause goes deeper than that.
我们已用五问法完成根因分析。直接原因是横杆未固定,但根本原因更深。
Walk me through it. What did you find?
说说看,你们发现了什么?
First why: the ledger slipped. Second: the wedge was loose. Third: the scaffolder didn't use a hammer to tighten it properly. Fourth: he was rushed because we are behind schedule. Fifth: there was no independent inspection after erection.
一问:横杆滑脱。二问:楔子松动。三问:架子工没用锤子拧紧。四问:进度滞后 赶工期导致仓促。五问:搭设后没有独立第三方检查。
So it's not just one person's mistake. It's a system failure — schedule pressure plus missing inspection.
所以不是一个人的错,是体系问题——工期压力加上检查缺失。
Exactly. We're proposing three corrective actions: mandatory independent scaffold inspection before use, a stop-work policy when schedule rushes safety, and refresher training for all scaffolders. Preventive actions include rolling this case study out across all project sites.
对。我们建议三项整改:使用前强制独立脚手架检查、进度冲刺时停工授权政策、 全体架子工复训。预防措施包括将本案横向推广到所有项目现场。
Agreed. Set the CARs with clear deadlines. I want the scaffold refresher done within one week and the policy draft on my desk by Friday.
同意。开整改通知单,明确期限。一周内完成架子工复训,周五前政策草案放我桌上。
Noted. We'll track all actions to close-out and share the lessons learned at the next project safety meeting.
收到。我们会跟踪全部整改到关闭,并在下次项目安全会上分享经验教训。