RCCA(C)根因分析.ppt

2002 Pratt & Whitney Canada All rights reserved, 1,问题根源纠正行动 (RCCA),Training for Pilots and ACE Implementation Managers, 2002 Pratt & Whitney Canada All rights reserved, 2,益处Benefits Standardize intervention at root cause to prevent problems from reoccurring 标准化解决方法,从根本上防止问题重复出现 执行Implementation Eight-step process including tools 八个步骤 特征Characteristics Define the problem 定义问题 Analyze the problem 分析问题 Identify the root cause 确定根本原因 Apply mistake proofing 运用错误预防,Overview概述, 2002 Pratt & Whitney Canada All rights reserved, 3,Objectives 目标 page 4 Introduction 简介 page 5 RCCA Steps 步骤 page 18 Conclusion 结论 page 36,Table of contents目录, 2002 Pratt & Whitney Canada All rights reserved, 4,Objectives目标,At the end of this module, you will be able to该单元学习完毕后,将能够: Use a method that will enable you to eliminate turnbacks identified through QCPC, equipment downtimes and defects in your products and services.使用方法来消除在在生产和服务中发生于QCPC，设备停机和缺陷的重复问题。 Understand the 8 steps that form the RCCA process 了解组成RCCA 的8个步骤 Know when to use it 掌握何时运用RCCA。, 2002 Pratt & Whitney Canada All rights reserved, 5,Introduction简介,Rptable,Efficace,Efficient,Mistake Proofing,1. Define定义,2. Measure衡量,3. Analyze分析,4. Improve改进 5. Control控制,Chartered team,Process Management过程管理,Select opportunities,Standard Work,Root Cause Analysis,Why ? Why ? Why ?, 2002 Pratt & Whitney Canada All rights reserved, 6,What is it used for 使用目的? Correct a problem methodically系统地纠正问题: By determining its root cause 通过确定根源 By applying the best possible solutions通过应用最佳方案 Prevent a problem from recurring 避免问题重复出现: By following through 跟踪全过程 By standardizing the solutions 使解决方案标准化,?,Introduction, 2002 Pratt & Whitney Canada All rights reserved, 7,When do we use 何时使用RCCA? We have a recurring problem 问题重复出现. Or或 We are not sure of the causes 不能确定原因 or 或 The problem is not constant (it comes and goes) or 问题不持续（时有时无） We want to take the time to solve the problem once and for all!我们需要花时间一次并彻底解决问题,Introduction, 2002 Pratt & Whitney Canada All rights reserved, 8,UTC 目前的思想状态UTC Current Mindset,We must change the culture必须改变文化 “I have no time to address root cause, I must meet the delivery schedule!” “我没有时间查找根源,我必须赶交付进度 !” “We have been doing this for 15 years with no substantial improvement, why is today going to be any different?” (George David, Ito University) “我们已经如此工作了 15 年而没有实质性的改进，今天又会有什么区别?” (George David, 伊滕大学) “You continually develop and release new products with known quality problems, why?” (UTC Customer) “你们不断研制和生产的新产品存在已知的质量问题，为什么?” (UTC 用户) We must have a “new spirit” for the future of our business! 对于我们业务发展的未来必须具有“新的精神 ”！, 2002 Pratt & Whitney Canada All rights reserved, 9,UTC 渴望的思想状态UTC Desired Mindset,The New Spirit of Management管理新精神 “We must be actively involved to find root causes” “必须积极参与寻找问题根源” “We must fix defects by fixing the process, not by adding more manpower” “必须通过解决过程问题来解决缺陷，而不是通过增加人力” “85% of all quality problems are a result of the process, 15% are a result of the workers” (J. M. Juran) “85% 的质量问题起源于过程， 15%的问题来源于工人 ” (J. M. Juran) We must work to build a trusting environment! 我们必须建立一个可信赖的环境, 2002 Pratt & Whitney Canada All rights reserved, 10,Philosophy理念,Root Cause Corrective Action is the rapid and persistent pursuit of the fundamental breakdown or failure of the process that, when resolved, prevents a recurrence of the problem. 问题根源纠正行动是快速和持续跟踪过程中断和失败的根本原因，一旦问题解决，就能避免重复发生。 Root cause analysis is like pulling weeds. 问题根源分析就象拔草除根。 If you dont get the root, the weed comes back! 拔草不除根，还会卷土重来, 2002 Pratt & Whitney Canada All rights reserved, 11,Philosophy,Each problem must be pursued and resolved rapidly Solving problems requires a mindset that is alert, open-minded, patient, tenacious and persistent Each problem is a golden nugget or treasure Each problem tells a story about why and how it occurred (there are no isolated incidents) The “true” problem must be understood from the data before action is taken 每个问题必须迅速跟踪和解决 解决问题需要警惕性高，思想开放，有耐心和顽强持久的精神 每个问题都是一块金砖或财富 每个问题都是一个故事，告诉你为什么和怎样发生的（没有孤立的事件） 在采取行动之前，必须通过数据了解“真实” 的问题, 2002 Pratt & Whitney Canada All rights reserved, 12,Philosophy,问题遗漏造成的10倍规则,发现缺陷:,公司成本,对公司的影响,本工序,很小,下一道工序,短时延误,加工结束,返工 重定进度,终检,大返工 影响交付 额外检验,用户,担保费用 管理费用 名誉损失 失去市场份额, 2002 Pratt & Whitney Canada All rights reserved, 13,Philosophy,Problem Escapes and the Rule of 10,Defect found at:,Cost to the Company:,Impact to the Company:,Own process,Very minor,Next process,Minor delays,End of line,Rework Reschedule of work,Final inspection,Significant rework Delay of delivery Additional inspection,Customer,Warranty cost Admin. cost Reputation Loss of market share, 2002 Pratt & Whitney Canada All rights reserved, 14,Each problem is a golden nugget 每个问题都是一块金砖,Capacitor 电容器: $ 0.05,Circuit Board电路板: $ 34,Elevator 电梯: $ 350,000,Philosophy, 2002 Pratt & Whitney Canada All rights reserved, 15,Each problem is a golden nugget,Problem with capacitor电容器发生问题 Affected 10% of elevators in service影响10%的电梯在服务中受影响 (30,000),Cost of fixing problem修理费用 $ 454.00 每次 (Time and materials included包括时间和材料),Total cost for OTIS 总花费: $ 13,6 M,Philosophy, 2002 Pratt & Whitney Canada All rights reserved, 16,Each problem is a golden nugget,If problem was addressed in-house .如果问题在内部解决 .,Total cost for OTIS 总花费: $ 454,000,Cost of fixing problem修理费用 $ 15.00 每块电板 (Time and materials included包括时间和材料),Philosophy, 2002 Pratt & Whitney Canada All rights reserved, 17,“低品质费用”模型“Cost of Poor Quality” Model, 2002 Pratt & Whitney Canada All rights reserved, 18,Philosophy,Group Discussion小组讨论 Question 1: How many times does the same problem have to occur before action is taken? Question 2: Should an action be dependent on the cost of the part? Question 3: Why is it important to treat each problem like a golden nugget? Question 4: Is best-in-class or simply beating your competitors quality levels good enough? 问题 1: 采取行动之前相同的问题出现了多少次? 问题 2: 采取行动与零件的成本有关吗？ 问题 3: 为什么将每个问题当作一块金砖来处理很重要？ 问题 4: 是做到最佳状态还是略略超过竞争对手 就可以了？, 2002 Pratt & Whitney Canada All rights reserved, 19,8 Steps of Equal Importance 同等重要的8个步骤,RCCA的步骤 Steps in the RCCA Process, 2002 Pratt & Whitney Canada All rights reserved, 20,RCCA 的表格 P&WC #5532, 2002 Pratt & Whitney Canada All rights reserved, 21,Visit the site 现场调查 Collect the relevant information 收集相关信息 Describe the situation clearly in writing (Statement)以书面的方式详细描述情况（综述） Tools工具: Process mapping 过程图表 Pareto chart 排列图,1.,Steps of RCCA RCCA的步骤,Describe and understand the situation描述和了解情况, 2002 Pratt & Whitney Canada All rights reserved, 22,RCCA步骤,Statement requirements陈述要求,陈述Statement,必须描述结果Must describe the effect,必须强调非一致性Must emphasize the non-conformance,必须是可衡量的Must be measurable,必须详细 Must be specific,必须明确Must be unambiguous, 2002 Pratt & Whitney Canada All rights reserved, 23,Not specific Scope creep Not measurable Dont know if we are improving Not emphasizing the non-conformance Focused on wrong problem Limit search to some causes Not describing the effect Lack of purpose Lack of urgency Ambiguous Room for assumptions,Impact of a Bad Statement陈述不清楚的影响,不详细和准确 界线不清 不可衡量 不知是否有改进 未强调非一致性 抓住错误问题 限制查究某些原因 未描述影响结果 缺乏目标 缺乏紧迫感 不明确 设想空间, 2002 Pratt & Whitney Canada All rights reserved, 24,2.,Assess the need for a team to complete the RCCA process 评估完成RCCA过程是否需要一个小组 Identify the sectors affected by the problem and the resource persons required for analysis 确定该问题涉及到的部门及分析工作所需的人员 Tool工具: Team building 组队,Steps of RCCA,Identify required resources确定所需资源, 2002 Pratt & Whitney Canada All rights reserved, 25,Practical Tip实践经验点滴,Form an appropriate team to solve the problem组成一个适当的小组来解决问题:,Form a small team 建立小规模团队 Quick resolution is required Problem affects few departments 需快速做决议 问题影响少数部门,Form a bigger team 建立较大规模团队 The problem crosses multiple boundaries The solution will require buy-in from multiple organizations 该问题跨度范围很大 问题解决需要多个组织机构参与, 2002 Pratt & Whitney Canada All rights reserved, 26,3.,Look for the real causes of the problem寻找问题的真正原因: Be relentless 持续不断地! Ask why, why,why, why, why? Stick to facts - Check your data Beware of subjectivity Do not stop at human error . Challenge the business practices 问为什么，为什么，为什么，为什么，为什么? 坚持事实核对数据 克服主观性 不要仅止于人为的错误. 挑战业务实践,Steps of RCCA,Identify, select and prioritize probable root causes 确定问题可能的根源原因并进行选择和排序, 2002 Pratt & Whitney Canada All rights reserved, 27,3.,Look for the real causes of the problem寻找问题的真正原因: Tools工具: Brainstorming 头脑风暴 Cause & Effect Diagram 因果图 The 5 Whys 5个为什么 Pictogram 象形图,Steps of RCCA,Identify, select and prioritize probable root causes 确定问题可能的根源原因并进行选择和排序, 2002 Pratt & Whitney Canada All rights reserved, 28,因果图是: 用来确定和分析情况或问题的一切可能原因Used to identify and analyze all possible causes of a situation or problem Also known as the Ishikawa or fishbone diagram也称为鱼骨图,质量,环境,方法,人力,材料,机器,原因,结果,测量,Cause & Effect Diagram 因果图, 2002 Pratt & Whitney Canada All rights reserved, 29,Cause & Effect Diagram 因果图,问题PROBLEM 不合格产品Sub-standard product,WHY? 操作员的错误The operator made a mistake,WHY? 刀具被更换The cutting tools were changed,WHY? 更换了供应商We changed suppliers,WHY? 新的更便宜The new one is less expensive,WHY? 质量不合格The quality isnt there, 2002 Pratt & Whitney Canada All rights reserved, 30,证实原因的可靠性: 加倍核对消息来源 该原因对问题的影响程度? 工具: 机械能力 (检查) 统计过程控制 象形图 清单 调查表,4.,Validate probable root causes 验证可能的根源原因,Steps of RCCA,To make sure the causes are credible: Double-check the source How much does the cause contribute to the problem? Tools: Machine capability (check) Statistical Process Control Pictogram Validation List Survey, 2002 Pratt & Whitney Canada All rights reserved, 31,Look for the best possible correction action寻找最可能的纠正行动 Prioritize 优先处理,5.,Steps of RCCA,Identify, select and prioritize potential solutions确定潜在的解决方案并进行选择和排序,Criteria,解决方案 # 1,解决方案 # 2,解决方案# 3,Decision Matrix 决策矩阵,Effectiveness of C / A 效力,Benefits / Cost Ratio 利益/成本比率,Delay of implementation 执行延迟,Criteria标准, 2002 Pratt & Whitney Canada All rights reserved, 32,This is definitely the best solution!,6.,To choose the appropriate corrective action 选择适当的纠正行动 Prototype 原形 Test 测试 Is the solution mistake-proofed是否防错的解决方法? Try-storm 尝试风暴 Nasty test 错误测试 Tools工具: Statistical Process Control统计过程 控制,Steps of RCCA,Validate the potential solutions 验证潜在的解决方案, 2002 Pratt & Whitney Canada All rights reserved, 33,6.,根源是否可以控制? 是! 能否再问一次 “为什么?” 获取另一个可控根源？ 否! 确定的根源是否为过程失败的基本原因？ 是! 如果我们纠正/改进我们确定的根本原因，能否保证确定的问题 不再发生？ 是! 是否检查过我们确定的根源适合于多个零件/过程？ 是!,Steps of RCCA,Validate the potential solutions 确认潜在解决方案,Is the root cause controllable? Yes! Can we ask “why?” one more time and get another controllable root cause? No! Is the identified root cause the fundamental breakdown or failure of the process? Yes! If we correct/improve the root cause we have identified, will that ensure that the identified problem will not recur? Yes! Have we checked to see if our identified root cause is applicable to more than one part/process? Yes!, 2002 Pratt & Whitney Canada All rights reserved, 34,7.,Develop an action plan 制定行动计划 Target dates 目标日期 Implementation steps 执行步骤 Actionees / resources 责任人/资源 When and how the solution effectiveness will