<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全的监督（续）<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">没有纠正问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－工具箱里有无编号工具，并且被操作者<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">拿去使用。当螺刀头丢失后从接油盘里找<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">到一个，因无编号误认为已找到（该工具<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">箱有<SPAN lang=EN-US>26</SPAN>件无编号工具）。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">组织因素<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行过程<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－程序<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">工具管理程序涵盖不住公司所有部门（如<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">车间），缺乏归口统一管理。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－监督<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">缺乏有效地监督检查，没有及时纠正问<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">题。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在的问题<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">工具管理程序不完善<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">监督工作不落实<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的和潜在的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">警戒性不足<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线被突破或缺乏防线<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">组织因素<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全的监督<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">前提<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">摘自</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Reason (1990)<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">事故与损伤<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">打坏发动机<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">认知差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">使用无编号工具<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">由于丢失工具引发的一起地面维修事故<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">监督者违规<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">没有纠正问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">案例三<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">波音<SPAN lang=EN-US>747 APU</SPAN>电瓶接地线过热着火<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">事件综述<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate IsROCDate="False" IsLunarDate="False" Day="27" Month="12" Year="1999" w:st="on"><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">1999</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">年<SPAN lang=EN-US>12</SPAN>月<SPAN lang=EN-US>27</SPAN>日</SPAN></st1:chsdate><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在航后检查时，发现<SPAN lang=EN-US>5</SPAN>号门<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">附近有烟雾，并闻到烧焦的气味。经进一<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">步检查是<SPAN lang=EN-US>E33 APU</SPAN>电瓶及充电器设备架处<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">隔音棉表层保护膜烧损，隔音棉燎黑。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">事件综述（续）<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">经过调查和试验，查明导致此次失火事件<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的直接原因是在完成适航指令规定的<SPAN lang=EN-US>APU<o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">电瓶充电器接地线改装时，没有去掉接地<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">线支架上的漆层及氧化层，并且，少装了<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">两个垫片，造成接触电阻大，过热着火，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">并点燃了不阻燃的隔音棉表层保护膜。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">完成适航指令规定的改装是为了防止<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">APU</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">充电器接地线过热，改装后为什么<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">反而失火？<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全的行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">技能差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－专业知识和技能不足<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">工作者没有接受过标准工艺培训，不知<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">道如何查相关手册。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">人为因素分析<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">完成适航指令规定的改装是为了防止<SPAN lang=EN-US>APU<o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">充电器接地线过热，改装后为什么反而失<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">火？<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">223<o:p></o:p></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全的行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">技能差错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－专业知识和技能不足<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">工作者没有接受过标准工艺培训，不知道<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">如何查相关手册<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为的前提条件<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">操纵者低于标准条件<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">盲目性<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－操作者不熟悉飞机制造厂标准线路施工<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">手册中的工艺要求。<SPAN lang=EN-US>BSWPM20</SPAN>－<SPAN lang=EN-US>20</SPAN>－<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">00</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为的前提条件<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">信息和沟通<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－工作单、卡错误，对服务通告中关键词<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的翻译错误，在此<SPAN lang=EN-US>SB</SPAN>里“<SPAN lang=EN-US> Clean</SPAN>”应译为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">“ 去底漆”，而实际译为“ 清洁”，误导了工<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">作者。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">－改装工作由金工和电器人员共同完成，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">相互缺乏沟通，造成接地线漏装垫片。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P>想看看是什么培训资料</P>
<P> </P>
