RCCAC根因分析学习课程

1、 2002 Pratt & Whitney CanadaAll rights reserved 1 益处BenefitsStandardize 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ImplementationEight-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

2、cause 确定根本原因Apply mistake proofing 运用错误预防第1页/共38页第一页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 2 Objectives 目标page 4 Introduction 简介page 5 RCCA Steps 步骤page 18 Conclusion 结论page 36Table of contents目录目录第2页/共38页第二页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights re

3、served 3Objectives目标目标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 R

4、CCA process 了解组成RCCA 的8个步骤Know when to use it 掌握何时运用RCCA。第3页/共38页第三页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 4Introduction简介简介RptableEfficaceEfficientMistake Proofing1. Define定义2. Measure衡量3. Analyze分析4. Improve改进 5. Control控制Chartered teamProcess Management过程管理Select opp

5、ortunitiesStandard WorkRoot CauseAnalysisMap processCollect dataSelect best opportunitiesQCPC & MFASurvey customersObjectives320 %65 %510 %415 %220 %130 %ProcessGFEDCBAHighMediumLowWhy ?Why ?Why ?第4页/共38页第四页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 5What is it used for

6、 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?第5页/共38页第五页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaA

7、ll rights reserved 6When 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第6页/共38页第六页，编辑于星期六：十八点

8、 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 7UTC 目前的思想状态目前的思想状态UTC Current MindsetWe 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

9、 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 fu

10、ture of our business!对于我们业务发展的未来必须具有对于我们业务发展的未来必须具有“新的精神新的精神 ”！第7页/共38页第七页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 8UTC 渴望的思想状态渴望的思想状态UTC Desired MindsetThe 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

11、 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我们必须建立一个可信赖的

12、环境第8页/共38页第八页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 9Philosophy理念理念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.问题根源纠正行动问题根源纠正行动是快速和持续跟踪过

13、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，还会卷土重来第9页/共38页第九页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 10PhilosophyEach problem must be pursued and resolved rapidlySolving problem

14、s requires a mindset that is alert, open-minded, patient, tenacious and persistent Each problem is a golden nugget or treasureEach 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

15、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 第10页/共38页第十页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 11Philosophy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1 $10 $100 $1 000 $10 000 $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

16、失去市场份额第11页/共38页第十一页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 12PhilosophyProblem Escapes and the Rule of 10Defect found at:Cost to the Company:Impact to the Company:1 $10 $100 $1 000 $10 000 $Own processVery minorNextprocessMinor delaysEnd of lineReworkReschedule of workFi

17、nalinspectionSignificant reworkDelay of deliveryAdditional inspectionCustomerWarranty costAdmin. costReputationLoss of market share第12页/共38页第十二页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 13Each problem is a golden nugget每个问题都是一块金砖每个问题都是一块金砖Capacitor 电容器: $ 0.05Circuit Board

18、电路板: $ 34 Elevator 电梯: $ 350,000第13页/共38页第十三页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 14Each 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 inclu

19、ded包括时间和材料)Total cost for OTIS 总花费: $ 13,6 M第14页/共38页第十四页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 15Each 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:$ 454,000Cost of fixing problem修理费用$ 15.00 每块电板(Time and materials inc

20、luded包括时间和材料)第15页/共38页第十五页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 16“低品质费用低品质费用”模型模型“Cost of Poor Quality” ModelExtra InspectionWarrantyEscapesScrapReworkEngineering ChangesLong Cycle TimesExtra SetupsExpediting CostsLost SalesLate Delivery ChargesLost Customer LoyaltyEx

21、cess InventoryNon - Visible5-8 % of SalesVisible2-3 % of SalesRepairRecurringService BulletinsRecurringEngineering NoticesNon-Contractual WarrantySupplier QualityLost CredibilityHidden?第16页/共38页第十六页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 17PhilosophyGroup Discussion小组讨论Q

22、uestion 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 leve

23、ls 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？第17页/共38页第十七页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 188 Steps of Equal Importance同等重要的8个步骤第18页/共38页第十八页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll

24、 rights reserved 19第19页/共38页第十九页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 20Visit 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.Describe and underst

25、and the situation描述和了解情况第20页/共38页第二十页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 21Statement 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第21页/共38页第二十一页

26、，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 22Not specificScope creepNot measurableDont know if we are improvingNot emphasizing the non-conformanceFocused on wrong problemLimit search to some causesNot describing the effectLack of purposeLack of urgencyAmbiguousRoom for assu

27、mptions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第22页/共38页第二十二页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 232.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 person

28、s 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Identify required resources确定所需资源第23页/共38页第二十三页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 24Form 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

29、 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!第24页/共38页第二十四页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 253.Look for t

30、he 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 dataBeware 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Identify, select and prioritize probable root ca

31、uses确定问题可能的根源原因并进行选择和排序第25页/共38页第二十五页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 263.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Identify, select and prioritize probable root causes确定问题

32、可能的根源原因并进行选择和排序第26页/共38页第二十六页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 27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 problemAlso 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第27页/共38页第二十七页，编辑于星期六：十八点 三十五分。

33、2002 Pratt & Whitney CanadaAll rights reserved 28问题PROBLEM 不合格产品Sub-standard productWHY? 操作员的错误The operator made a mistakeWHY? 刀具被更换The cutting tools were changedWHY? 更换了供应商We changed suppliersWHY? 新的更便宜The new one is less expensiveWHY? 质量不合格The quality isnt there第28页/共38页第二十八页，编辑于星期六：十八点 三十五分。

34、2002 Pratt & Whitney CanadaAll rights reserved 29 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 To make sure the causes are credible: Double-check the sourceHow much does the cause contribute to the problem?Tools:Machine capability (check)Stati

35、stical Process ControlPictogramValidation ListSurvey第29页/共38页第二十九页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 30Look for the best possible correction action寻找最可能的纠正行动Prioritize 优先处理5.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

36、解决方案# 3Decision 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标准第30页/共38页第三十页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 31This is definitelythe best solution!6.To choose the appropriate corrective action选择适当的纠正行动 Protot

37、ype 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Validate the potential solutions验证潜在的解决方案第31页/共38页第三十一页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 326.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

38、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! 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 t

39、he 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! 第32页/共38页第三十二页，编辑于星期六：十八点 三十五分。 2002 Pratt & Whitney CanadaAll rights reserved 337. 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 be verified 何时, 如何核实解决方法效果Verify the effectiveness of the solution核实解决方案的效果Tools工具:Monitoring log监测记录Measur