RCCA(C)根因分析

2001Pratt&WhitneyCanada-Tousdroitsrservs,1,问题根源纠正行动(RCCA),TrainingforPilotsandACEImplementationManagers,2001Pratt&WhitneyCanada-Tousdroitsrservs,2,益处BenefitsStandardizeinterventionatrootcausetopreventproblemsfromreoccurring标准化解决方法,从根本上防止问题重复出现执行ImplementationEight-stepprocessincludingtools八个步骤特征CharacteristicsDefinetheproblem定义问题Analyzetheproblem分析问题Identifytherootcause确定根本原因Applymistakeproofing运用错误预防,Overview概述,2001Pratt&WhitneyCanada-Tousdroitsrservs,3,Objectives目标page4Introduction简介page5RCCASteps步骤page18Conclusion结论page36,Tableofcontents目录,2001Pratt&WhitneyCanada-Tousdroitsrservs,4,Objectives目标,Attheendofthismodule,youwillbeableto该单元学习完毕后,将能够:UseamethodthatwillenableyoutoeliminateturnbacksidentifiedthroughQCPC,equipmentdowntimesanddefectsinyourproductsandservices.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。Understandthe8stepsthatformtheRCCAprocess了解组成RCCA的8个步骤Knowwhentouseit掌握何时运用RCCA。,2001Pratt&WhitneyCanada-Tousdroitsrservs,5,Introduction简介,Rptable,Efficace,Efficient,MistakeProofing,1.Define定义,2.Measure衡量,3.Analyze分析,4.Improve改进5.Control控制,Charteredteam,ProcessManagement过程管理,Selectopportunities,StandardWork,RootCauseAnalysis,Why?Why?Why?,2001Pratt&WhitneyCanada-Tousdroitsrservs,6,Whatisitusedfor使用目的?Correctaproblemmethodically系统地纠正问题:Bydeterminingitsrootcause通过确定根源Byapplyingthebestpossiblesolutions通过应用最佳方案Preventaproblemfromrecurring避免问题重复出现:Byfollowingthrough跟踪全过程Bystandardizingthesolutions使解决方案标准化,?,Introduction,2001Pratt&WhitneyCanada-Tousdroitsrservs,7,Whendoweuse何时使用RCCA?Wehavearecurringproblem问题重复出现.Or或Wearenotsureofthecauses不能确定原因or或Theproblemisnotconstant(itcomesandgoes)or问题不持续（时有时无）Wewanttotakethetimetosolvetheproblemonceandforall!我们需要花时间一次并彻底解决问题,Introduction,2001Pratt&WhitneyCanada-Tousdroitsrservs,8,UTC目前的思想状态UTCCurrentMindset,Wemustchangetheculture必须改变文化“Ihavenotimetoaddressrootcause,Imustmeetthedeliveryschedule!”“我没有时间查找根源,我必须赶交付进度!”“Wehavebeendoingthisfor15yearswithnosubstantialimprovement,whyistodaygoingtobeanydifferent?”(GeorgeDavid,ItoUniversity)“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?”(GeorgeDavid,伊滕大学)“Youcontinuallydevelopandreleasenewproductswithknownqualityproblems,why?”(UTCCustomer)“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)Wemusthavea“newspirit”forthefutureofourbusiness!对于我们业务发展的未来必须具有“新的精神”！,2001Pratt&WhitneyCanada-Tousdroitsrservs,9,UTC渴望的思想状态UTCDesiredMindset,TheNewSpiritofManagement管理新精神“Wemustbeactivelyinvolvedtofindrootcauses”“必须积极参与寻找问题根源”“Wemustfixdefectsbyfixingtheprocess,notbyaddingmoremanpower”“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%ofallqualityproblemsarearesultoftheprocess,15%arearesultoftheworkers”(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)Wemustworktobuildatrustingenvironment!我们必须建立一个可信赖的环境,2001Pratt&WhitneyCanada-Tousdroitsrservs,10,Philosophy理念,RootCauseCorrectiveActionistherapidandpersistentpursuitofthefundamentalbreakdownorfailureoftheprocessthat,whenresolved,preventsarecurrenceoftheproblem.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。Rootcauseanalysisislikepullingweeds.问题根源分析就象拔草除根。Ifyoudontgettheroot,theweedcomesback!拔草不除根，还会卷土重来,2001Pratt&WhitneyCanada-Tousdroitsrservs,11,Philosophy,EachproblemmustbepursuedandresolvedrapidlySolvingproblemsrequiresamindsetthatisalert,open-minded,patient,tenaciousandpersistentEachproblemisagoldennuggetortreasureEachproblemtellsastoryaboutwhyandhowitoccurred(therearenoisolatedincidents)The“true”problemmustbeunderstoodfromthedatabeforeactionistaken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,2001Pratt&WhitneyCanada-Tousdroitsrservs,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,2001Pratt&WhitneyCanada-Tousdroitsrservs,13,Philosophy,ProblemEscapesandtheRuleof10,Defectfoundat:,CosttotheCompany:,ImpacttotheCompany:,Ownprocess,Veryminor,Nextprocess,Minordelays,Endofline,ReworkRescheduleofwork,Finalinspection,SignificantreworkDelayofdeliveryAdditionalinspection,Customer,WarrantycostAdmin.costReputationLossofmarketshare,2001Pratt&WhitneyCanada-Tousdroitsrservs,14,Eachproblemisagoldennugget每个问题都是一块金砖,Capacitor电容器:$0.05,CircuitBoard电路板:$34,Elevator电梯:$350,000,Philosophy,2001Pratt&WhitneyCanada-Tousdroitsrservs,15,Eachproblemisagoldennugget,Problemwithcapacitor电容器发生问题Affected10%ofelevatorsinservice影响10%的电梯在服务中受影响(30,000),Costoffixingproblem修理费用$454.00每次(Timeandmaterialsincluded包括时间和材料),TotalcostforOTIS总花费:$13,6M,Philosophy,2001Pratt&WhitneyCanada-Tousdroitsrservs,16,Eachproblemisagoldennugget,Ifproblemwasaddressedin-house.如果问题在内部解决.,TotalcostforOTIS总花费:$454,000,Costoffixingproblem修理费用$15.00每块电板(Timeandmaterialsincluded包括时间和材料),Philosophy,2001Pratt&WhitneyCanada-Tousdroitsrservs,17,“低品质费用”模型“CostofPoorQuality”Model,2001Pratt&WhitneyCanada-Tousdroitsrservs,18,Philosophy,GroupDiscussion小组讨论Question1:Howmanytimesdoesthesameproblemhavetooccurbeforeactionistaken?Question2:Shouldanactionbedependentonthecostofthepart?Question3:Whyisitimportanttotreateachproblemlikeagoldennugget?Question4:Isbest-in-classorsimplybeatingyourcompetitorsqualitylevelsgoodenough?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？,2001Pratt&WhitneyCanada-Tousdroitsrservs,19,8StepsofEqualImportance同等重要的8个步骤,RCCA的步骤StepsintheRCCAProcess,2001Pratt&WhitneyCanada-Tousdroitsrservs,20,RCCA的表格P&WC#5532,2001Pratt&WhitneyCanada-Tousdroitsrservs,21,Visitthesite现场调查Collecttherelevantinformation收集相关信息Describethesituationclearlyinwriting(Statement)以书面的方式详细描述情况（综述）Tools工具:Processmapping过程图表Paretochart排列图,1.,StepsofRCCARCCA的步骤,Describeandunderstandthesituation描述和了解情况,2001Pratt&WhitneyCanada-Tousdroitsrservs,22,RCCA步骤,Statementrequirements陈述要求,陈述Statement,必须描述结果Mustdescribetheeffect,必须强调非一致性Mustemphasizethenon-conformance,必须是可衡量的Mustbemeasurable,必须详细Mustbespecific,必须明确Mustbeunambiguous,2001Pratt&WhitneyCanada-Tousdroitsrservs,23,NotspecificScopecreepNotmeasurableDontknowifweareimprovingNotemphasizingthenon-conformanceFocusedonwrongproblemLimitsearchtosomecausesNotdescribingtheeffectLackofpurposeLackofurgencyAmbiguousRoomforassumptions,ImpactofaBadStatement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,2001Pratt&WhitneyCanada-Tousdroitsrservs,24,2.,AssesstheneedforateamtocompletetheRCCAprocess评估完成RCCA过程是否需要一个小组Identifythesectorsaffectedbytheproblemandtheresourcepersonsrequiredforanalysis确定该问题涉及到的部门及分析工作所需的人员Tool工具:Teambuilding组队,StepsofRCCA,Identifyrequiredresources确定所需资源,2001Pratt&WhitneyCanada-Tousdroitsrservs,25,PracticalTip实践经验点滴,Formanappropriateteamtosolvetheproblem组成一个适当的小组来解决问题:,Formasmallteam建立小规模团队QuickresolutionisrequiredProblemaffectsfewdepartments需快速做决议问题影响少数部门,Formabiggerteam建立较大规模团队TheproblemcrossesmultipleboundariesThesolutionwillrequirebuy-infrommultipleorganizations该问题跨度范围很大问题解决需要多个组织机构参与,2001Pratt&WhitneyCanada-Tousdroitsrservs,26,3.,Lookfortherealcausesoftheproblem寻找问题的真正原因:Berelentless持续不断地!Askwhy,why,why,why,why?Sticktofacts-CheckyourdataBewareofsubjectivityDonotstopathumanerror.Challengethebusinesspractices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,StepsofRCCA,Identify,selectandprioritizeprobablerootcauses确定问题可能的根源原因并进行选择和排序,2001Pratt&WhitneyCanada-Tousdroitsrservs,27,3.,Lookfortherealcausesoftheproblem寻找问题的真正原因:Tools工具:Brainstorming头脑风暴Cause&EffectDiagram因果图The5Whys5个为什么Pictogram象形图,StepsofRCCA,Identify,selectandprioritizeprobablerootcauses确定问题可能的根源原因并进行选择和排序,2001Pratt&WhitneyCanada-Tousdroitsrservs,28,因果图是:用来确定和分析情况或问题的一切可能原因UsedtoidentifyandanalyzeallpossiblecausesofasituationorproblemAlsoknownastheIshikawaorfishbonediagram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&EffectDiagram因果图,2001Pratt&WhitneyCanada-Tousdroitsrservs,29,Cause&EffectDiagram因果图,问题PROBLEM不合格产品Sub-standardproduct,WHY?操作员的错误Theoperatormadeamistake,WHY?刀具被更换Thecuttingtoolswerechanged,WHY?更换了供应商Wechangedsuppliers,WHY?新的更便宜Thenewoneislessexpensive,WHY?质量不合格Thequalityisntthere,2001Pratt&WhitneyCanada-Tousdroitsrservs,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.,Validateprobablerootcauses验证可能的根源原因,StepsofRCCA,Tomakesurethecausesarecredible:Double-checkthesourceHowmuchdoesthecausecontributetotheproblem?Tools:Machinecapability(check)StatisticalProcessControlPictogramValidationListSurvey,2001Pratt&WhitneyCanada-Tousdroitsrservs,31,Lookforthebestpossiblecorrectionaction寻找最可能的纠正行动Prioritize优先处理,5.,StepsofRCCA,Identify,selectandprioritizepotentialsolutions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,DecisionMatrix决策矩阵,EffectivenessofC/A效力,Benefits/CostRatio利益/成本比率,Delayofimplementation执行延迟,Criteria标准,2001Pratt&WhitneyCanada-Tousdroitsrservs,32,Thisisdefinitelythebestsolution!,6.,Tochoosetheappropriatecorrectiveaction选择适当的纠正行动Prototype原形Test测试Isthesolutionmistake-proofed是否防错的解决方法?Try-storm尝试风暴Nastytest错误测试Tools工具:StatisticalProcessControl统计过程控制,StepsofRCCA,Validatethepotentialsolutions验证潜在的解决方案,2001Pratt&WhitneyCanada-Tousdroitsrservs,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!,StepsofRCCA,Validatethepotentialsolutions确认潜在解决方案,Istherootcausecontrollable?Yes!Canweask“why?”onemoretimeandgetanothercontrollablerootcause?No!Istheidentifiedrootcausethefundamentalbreakdownorfailureoftheprocess?Yes!Ifwecorrect/improvetherootcausewehaveidentified,willthatensurethattheidentifiedproblemwillnotrecur?Yes!Havewecheckedtoseeifouridentifiedrootcauseisapplicabletomorethanonepart/process?Yes!,2001Pratt&WhitneyCanada-Tousdroitsrservs,34,7.,Developanactionplan制定行动计划Targetdates目标日期Implementationsteps执行步骤Actionees/resources责任人/资源Whenandhowthesolutioneffectivenesswillb