5Why分析工具实例讲解

1、Dei_F>lII5-WHY PROBLEM SOLVING PROCESSAutorViotix/t SystemsPRACTICAL PROBLEM SOLVING实际问题解决In troducti on介绍In the Delphi orga ni zati on, a com mon problem solvi ng process is used to an alyze and solve quality problems. 在德尔福组织里，一个共同的问题解决过程是用于分析和解决质量问题。这有过程中四个主要部分预防错误There are four major parts of

2、the process:* Grasp the Situation 掌握情况* Cause In vestigati on 调查情况« Problem Correcti on问题纠正* Preve nti on through Errorproofi ng+ Grasp the Situation掌握情况During the first part of the process, you:在过程的第一部分，你要：Ide ntify the Problem识别问题* Clarify the Problem 阐明问题* Locate the Poi nt of Cause (PoC)查找发

3、生事故的地点+ Cause In vestigati on原因调查In the sec ond part of the process, you:在过程的第二步你要：* Con duct a-W/hy, in vestigati on to ide ntify the root cause 进行"5-WHY "调查以识别问题根源。for the specific problem特殊问题for why the problem was n ot detected为什么问题没有被发现。for why the “ system ” allowed the problem to oc

4、c为什么系统允许问题发生+ Problem Correction 问题纠正In the third part of the process, you:在过程的第三部分，你要：* Take specific acti on to correct the problem. At a mini mum, short-term temporary measures are required to protect the customer.采取特殊措施改正问题，至少，要求用短期暂时的方法去保护顾客。+Preve nti on Thru Errorproofi ng预防错误In the fourth pa

5、rt of the process, you:在过程的第四部分，你要：* Take specific acti on to make sure the problem cannot recur, typically through errorproofi ng Capture Less ons Lear ne采取特殊措施以保证问题不在发生，代表性的错误论据取得课程学习。Page 1Dei_F>lII5-WHY PROBLEM SOLVING PROCESSAutomotivta SyiitertisPRACTICAL PROBLEM SOLVING MODEL 实际问题解决模型5 Why

6、 Funnel 5个为什么漏斗PROBLEM IDENTIFIED问题识别(Large, Vague, Complicated)Problem Clarified i（大的，含糊的，复杂的）阐明问题SITUATIONGRASP THE查找问题范围Area of Cause LocatedPoint of Cause(PoC)Why? 1Cause为什么?原因发生事故的地点Where in the process is problem occurri ng?了解问题“ Go See”the problem过程里问题发生在哪?基本原因/结果调查Why? 2CauseBasic Cause/Effe

7、ct Inv estigati onCAUSEINVESTIGATIONWhy? 3CauseWhy? 4CauseWhy? 5Root Cause5WHY ？问题根源的调查5 Why?Inv estigati on of Root CauseWhy did wehave the problem?为什么我们会有 这种问题？Corrective Acti on纠正措施Less ons Lear ned课程学习问题根源Why did it get to the customer?为什么对顾客有影响？Why did“丄”our system为什么我们的系统失效？fail?Page 3Dei_F>

8、;lII5-WHY PROBLEM SOLVING PROCESSAutorViotix/t SystemsBASIC STEPS OFPRACTICAL PROBLEM SOLVING时间问题解决的基本步骤Part I -Grasp the Situation 第一部分掌握情况。+ Step 1: Ide ntify the Problem第一步：识别问题In the first step of the process, you become aware of a problem that may be large, vague, or complicated. You have some

9、in formati on, but do not have detailed facts. Ask:在过程的第一步，你可以意识到问题可能是大的、含糊的或是复杂的，你有一些信息，但是没有详细事实。问：What do I kn ow? 我了解什么?+ Step 2: Clarify the Problem 第二步：阐明问题。The next step in the process is to clarify the problem. To gain a more clear understanding, ask: 过程的下一步是阐明问题，为了得到一个更清楚的认识，问：What is actual

10、ly happe ning?What should be happe ning?实际发生了什么？ 什么应发生？+ Step 3: Break Dow n the Problem第三步：分解问题At this point, break the problem down into smaller, individual elements, if necessary. 在这一点，如有必要，把问题分解成更小的单个元素。What else do I know about the problem?我还要对问题了解什么？Are there other sub-problems?那里还有其它问题吗？+ Ste

11、p 4: Locate the Poi nt of Cause (PoC)第四步；查找事故发生的地点。Now, the focus is on locati ng the actual point of cause of the problem. You n eed to track back to see the point of cause first-ha nd. Ask:现在，中心是查找问题的根源的实际地点，你需要追踪直接的事故点。问：Where do I n eed to go?我们需要去哪里？What do I n eed to see?我们需要了解什么？Who might hav

12、e in formation about the problem?谁可能会有有关此问题的信息？+ Step 5: Grasp the Ten de ncy of the Problem第五步；掌握问题倾向To grasp the tendency of the problem, ask:为了掌握问题倾向，问：Who?谁？Which?那一个？When?什么时候？How often?(单位时间发生的频率)多少？How much?多少？It is importa nt to ask these questi ons before ask ing“ Why?'在问“ WHY ”之前问这些问题是

13、很重要的。AutorViotix/t SystemsPart II: Cause In vestigatio n第U部分：原因调查。+ Step 6: Ide ntify and con firm the direct cause of the abn ormal occurre nee.第六步：识别和确认反常事件的直接原因。If the cause is visible, verify it. If the cause is not visible, consider potential causes and check the most likely causes. Confirm the

14、 direct cause based on fact. Ask:如果原因明显，验证它。如果原因不明显，考虑潜在的原因和检查类似事故，以事实为基础确认直接原因。问：Why is the problem occurri ng?问题为什么发生？Can I see the direct cause of the problem?我能看到问题的直接原因吗？If not, what do I suspect as pote ntial causes?如果不能，我猜想潜在原因是什么？How can I check the most likely pote ntial causes?我怎么检查类似的潜在的原

15、因？How can I co nfirm the direct cause?我怎么确认直接原因？+ Step 7: Use 5-Why in vestigati on to build a cha in of cause/effect relati on ships that lead to the rootcause. Ask:第七步：利用5Why调查以建立一通向问题根源的原因/结果的关系链。问：Will addressi ng the direct cause preve nt recurre nee?查明直接原因预防再发生了吗？If not, can I see the next lev

16、el of cause?如果没有，我能看到下次再发生的机率吗？If not, what do I suspect as the next level of cause?如果没有，对于下次再发生的机率我觉察到什么？How can I check and confirm the n ext level of cause?我怎样检查和确认下次再发生的机率？Will address ing this level of cause preve nt recurre nee?查明事故级别预防再发生了吗？If not, continue aski ng“ Why?' un til you find

17、the root cau如果没有，继续问为什么直到你找到了问题根源。Stop at the cause that must be addressed to preve nt recurre nee. Ask:停止这些，预防事故再发生。问：Have I fou nd the root cause of the problem?我找到问题的原因根源了吗？Can I preve nt recurre nee by addressi ng this cause?我根据找到的原因，预防再发生吗？Is this cause lin ked to the problem by a cha in of cau

18、se/effect relati on ships that are based on fact?根据基于事实的原因/结果关系链，这个原因与问题有联系吗？Does the chain pass the“ therefore 这个链能通过"因此"测试吗？If I ask “ Why?" agai n, will I be into ano ther problem如果我再次问"为什么"，我会深入到另一个问题之 中吗？Be sure you have used 5-Why Investigation to answer these question

19、s:确信你会用 5-Why 调查回答这些问题：Why did we have the problem?为什么我们会有这种问题？Why did the problem get to the customer?为什么问题会对顾客有影响？Why did our “ system " allow it to occ为什么我们的系统"允许"它发生？AutorViotix/t Systems5 WHY CAUSE INVESTIGATION5Why原因调查Abno rmal Occurre nee 反常事件Why?(cause/effect relationship)原因 /

20、结果关系Direct Cause直接原因Why?(cause/effect relationship)原因 /结果关系Cause原因Why?(cause/effect relati on ship)CauseWhy?(cause/effect relati on ship)1 CauseWhy?Page 6Dei_F>lII5-WHY PROBLEM SOLVING PROCESSPage #Dei_F>lII5-WHY PROBLEM SOLVING PROCESS* Root Cause问题根源ThereforeTest因果测试Page #Dei_F>lII5-WHY P

21、ROBLEM SOLVING PROCESSAutorViotix/t SystemsStep 8: Take Specific Acti on to Address the Problem第八步：采取特殊措施解决问题Use temporary measures to eliminate the abnormal occurrence until the root cause can be addressed. Ask: 使用临时方法消除反常事件直到问题根源被找岀。Does it contain the problem until a permanent solution can be imp

22、lemented?Impleme nt corrective acti ons to address the root cause to preve nt recurre nce. Ask:在执行一项持久解决方案之前，它可以解决问题吗？实施纠正措施以标明问题根源防止再发生。问：Does it preve nt the problem?它能预防问题发生吗？Follow-up and check results. Ask:跟踪和检查结果，问：Is the solution worki ng?此解决方案运行了吗？How do I know? 我怎么知道？Page 7Dei_F>lII5-WHY

23、 PROBLEM SOLVING PROCESSAutorViotix/t SystemsPRACTICAL PROBLEM SOLVING CHECKLIST实际的问题解决检查表To be sure you have followed the problem solv ing model, use this checklist as you complete the problem solv ing process.确信你遵循了问题解决模型，当你完成问题解决过程时使用这项检查表：| Grasp the situatio n掌握情况Pick-up the problem.提取问题Clarify

24、 the problem.阐明问题Break dow n the problem.分解问题Locate the Poi nt of Cause (PoC).查找发生事故的地点Grasp the tendency of the problem.掌握问题倾向Cause In vestigati on原因调查Ide ntify/c on firm the direct cause.识别/确认直接原因Ask 5 Why's to identify the root cause.提问 5Why 去识别问题根源Ask 5 Why's for“ Why the problem was n o

25、t detected and reached the customer? 提问5Why中的为什么问题没有被顾客发现和传达。Ask 5 Why's for “ Why did the system allow the problem to occur? 提问5Why中为什么系统允许问题发生？Problem Correction问题纠正Impleme nt corrective acti on; at a mi ni mum, impleme nt temporary measures 实施纠正措施；至少实施临时方法。Preve nti on 预防Errorproof the root c

26、ause.错误论证问题根源Capture Less ons Lear ned.取得课程学习Page 9Dei_F>lII5-WHY PROBLEM SOLVING PROCESSAutorViotix/t SystemsACTIVITY:活动FLEX INDUSTRIES CASE STUDY弯曲工业事例研究Directio ns:说明Use the Delphi Problem Solving Process to evaluate the Flex Industries Case Study below and on the following pages. Review the 5

27、-Why In vestigati on results on Page 11.使用德尔福问题解决过程，评价页底及下页的弯曲行业事例研究。评审第11页的5-Why调查结果。Use the worksheets on Pages 13 and 14 to record your work.使用第 13、14页的工作表记录你的工作Use only the in formatio n provided.仅用于假设信息Do not try to re-engineer the rivets or solve the technical problems in the case study. The p

28、urpose of this activity is to use the Problem Solving model to organize the given data.在这个事例研究中，不要试图模仿设计铆钉或解决技术问题。这项行动的目的是使用问题解决模型去组织特定 数据。FLEX INDUSTRIES CASE STUDY弯曲工业事例研究Backgrou nd背景Jake Ryan is the Quality Manager at Flex Industries. Flex is a component supplier that manufactures metal stamp in

29、 gs a nd light assembly products. The compa ny has a reputati on for suppl ying high quality parts on a con siste nt basis. Seldom has there bee n a customer compla int. Flex has Quality represe ntatives called Customer Support Engineers (CSE ' s) at every customer assembly plant. The CSE' s

30、 report any problems to Jake forin vestigati on and follow-up.JackeRyan是弯曲行业的质量经理，弯曲是生产金属冲压件和照明装配产品的供应商的组成部分。此公司在提供高 质量产品上享有声誉。很少有客户抱怨，Flex的每个顾客装配厂都有称为顾客支持工程师(CSE )的质量代表，顾客支持工程师给Jacke报道大量问题，以调查和跟踪。At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the Winding River Assembly Plant. Ja

31、net in formed him that the customer had found five defective stabiliz ing brackets on sec ond shift last ni ght. She checked the remaining inventory and there were no defects in the remaining 326 pieces. The manufacturing sticker on the back of the brackets in dicated that they were made by the sec

32、ond shift operator. Normally, the stabilizing bracket is fastened to the regulator motor with three rivets. The five defective brackets had only two rivets in them. The lower set of rivets on all five brackets was missing a rivet. This was the first time that the problem occurred.早上7: 00Jake接到了 Jane

33、tWandingRiver装配厂的CSE， Janet的电话，告诉他昨天晚上在第二轮班，顾客发现五个有缺陷的固定支架，她检查了剩余的存货且剩余的3 2 6个产品没有缺陷。支架背部的生产标签显示，它们是 第二轮班操作工制造的。通常固定支架用三个铆钉固定在发动机调整器上。这五个支架上较底位置的铆钉缺少了一 个，这个问题是第一次发生。AutorViotix/t SystemsJake set-up containment procedures at the plant warehouse to sort for discrepant materials. As of this morning, tw

34、o more defective brackets had been found in the remaining 2019 pieces of inventory at Flex.Jake对仓库施行围堵政策程序，以挑选差异原料。就在今天早上，在Flex剩余2019个存货中发现了不至两个缺陷支架。Cause In vestigati on原因调查Jake went out to the floor to talk with the team leader of the two rivet lines (East and West) and the area quality assura nce

35、 auditor. He in formed Sam (the team leader) of the quality problem and asked him to ide ntify the line which runs the stabiliz ing bracket assembly. Sam directed Jake to the East line which runs Winding River assembly brackets only.Jake去基层与东西两个铆钉生产线的领导组和区域质量保证审核员谈话。他告诉Sam (本组领导)这个质量问题。并且要求他 验证是哪个线进

36、行固定支架装配的。Sam直接告诉Jake仅东线进行 WindingRiver支架装配。At the East Line, he spoke with Judy (the QA Auditor for the area) and asked to see the quality log sheets. Jake andJudy reviewed the Nov. 11 log sheet and could not find any thi ng out of the ordin ary. He asked her to set-upin-house containment procedures

37、 to sort for any discrepant material in the finished goods area.在东线，他与Judy (此区域QA审核员)讲话并且要求去看质量日志表。Jake和Judy评审了 11月11号的日志表，并没有发现任何异于平常的事情。他要求她去建立内部围堵政策程序在成品区挑选任何差异原料。Next, Jake tried to locate the sec ond shift operator whose clock n umber was on the defective parts. Since that operator was gone, Ja

38、ke spoke with the current machine operator (Ben). He asked Ben about any recent difficulties with the rivet machi ne. Ben said that he had n' t no ticed an yth ing out of the ord in ary. Ben also men ti oned,however, that there had n ever bee n any quality bullet ins posted in the two years that

39、 this particular part has bee n running.接着，Jake试着查找工作时间在出现缺陷零件的第二轮班操作工，操作工走之后，Jake与当前操作员Ban谈话，他问Ben近来在铆钉加工有什么困难。Ban说他没有发现任何异与平常的事。然而，Ben也提起在用精确零件运行的两年内，那里没有任何的质量报告。Jake decided to stay in the area to watch the machine run for a while. After about 15 minutes, he watched Ben dump rivets into the feede

40、r bowl to prepare for the n ext run.AutorViotix/t SystemsShortly after restart ing rivet operati ons, Ben walked over to ano ther riveter and came back with a steel rod. Ben poked arou nd the rivet chute and the n con tin ued work ing. Jake approached Ben and asked him about the steel rod. Ben repli

41、ed that from time to time the chute gets jammed and he has to clear it out. This happens two or three times during a shift. He didn' t mention this in his earlier conversation with Jake because the problem has existed eversince he started working with this machine. The previous operator showed h

42、im how to clear the chute. All the rivet machi nes are like this.Jake决定暂时呆在这监视机器运转。大约15分钟后，他观察到 Ben把铆钉倒入进料钵，准备下此运转。很快重新开始铆钉操作。Ben走到另一个打铆机并且带了一个钢棒回来，Ben捅了捅铆钉斜槽，然后继续工作。Jake靠近Ben问他关于钢棒的事。Ben回答说有时这个斜槽被堵塞，并且他必须清除它，一个轮班岀现两三次。在同Jake的早期谈话中，他没有提及这件事，因为从他开始在这台机器工作以来，这个问题一直存在。先前的操作工教给他怎样清 除斜槽。所有的铆钉机器都是这样。Jake

43、called the Mach ine Repair Departme nt and asked that some one look at the rivet track. A slight gap in the track was found and removed, and Ben con ti nued to work.Jake叫来机器修理部且要求看这个铆钉通道，通道中一个微小的缺口被发现，除去后，Ben继续工作。Two hours later, Jake got a call from Ben saying that the track was still jamming. As f

44、ar as Jake could see, only rivets were in the bowl. Next, Jake looked into the rivet supplier containers. There was some foreign material in the blue contain er, but none in the red contain er. The label on the blue container showed that it was from Ajax Rivet, In c., and the label on the red contai

45、ner in dicated that it was from FrankObvRastlyi ehs. foreig n materialwas entering the rivet feeder bowl and jamming the track.两个小时以后，Jake接到Ben的电话说通道仍然堵塞。至到 Jake看到仅铆钉在钵内。接着， Jake看到铆钉厂商的箱 子，蓝色箱子里有一些杂质材料，但是红色箱子没有。蓝色箱子的标签显示它来自Ajax Rivet公司并且红色箱子的标签显示它来自Frank' s Fasteners，明显的，杂质材料进入铆钉进料器，并且阻塞了通道。Jake

46、 called Maintenance and requested that the bowl be clea ned. He also added the clea ning operati on to the preventive maintenance schedule on the equipment. He then called both Ajax Rivet, Inc. and Frank' s Fasteners.He asked about the cleaning procedures on the returnable containers. Frank'

47、 s did a full container purge and clean.Ajax just re-i ntroduced the contain ers back into their system. When Jake asked why Ajax did not clea n their contain ers, he was told that Ajax was not aware that such a policy was n eeded.Jake命令维修并要求清扫钵，他也把清扫工作加到预防性维护时间表上。然后他打电话给Ajax RivetI公司和Franks Fastene

48、rs ，他要求在 可退回的箱子上有清洁程序。Frank公司做了一次全面的清除和清扫。Ajax正好重申退回这些箱子。当JAKE问Ajax为什么不清扫他们的箱子时，他被告之Ajax没有意识到诸如这个方针是必要的。Upon further investigation, Jake learned that Frank' s Fasteners supplies otheraratgoirotive companies. Sincethese compan ies require that all returnable containers be cleaned, Frank' s in

49、stituted the purge as part of itspractice for all customers. Ajax Rivet, however, depends primarily on Flex as its major customer. No such policy has ever bee n required of them.在更深的调查上，JAKE认识到Frank' s Fasteners供应其它的重大汽车公司，自从这些公司要求清扫所有的可退回的箱子之后。Frank'开始将清除作为为顾客实践的一部分，诸如这样的方针以前从来没有被要求过。（以下为方框

50、中 的译文）：JAKE号召材料控制部门起草一项适用于他们所有厂商的包装箱维护政策，他也要求修正机器以能判断铆钉的存在。JakeQuality Man agerJa netCSE, Win di ng River Pla ntSamTeam Leader, East LineJudyQA Auditor, East LineBenMach ine OperatorKEY PLAYERSJake called the Material Control Department and requested that a container maintenance policy be drafted wh

51、ich would apply to all their suppliers. He also asked that a machi ne modificati on be developed to sense for the prese nee of rivets. Hopefully, this would error-roof the process.Page 135-WHY PROBLEM SOLVING PROCESSAcitomotive Systems5-Why Cause In vestigati on5WHY原因调查Reference No. _ 参考号(Spill, PR/

52、R )Date:纠正措施Corrective ActionsDateDefine Problem明确问题校订包装规范以反映没有杂质 材料的要求A - Revise pack ing specificati on for dunn age to reflect no foreig n material requireme ntB & C - Revise scope of PFMEA to in clude en tire process from dock to dockB&C-校订PFMEA范围包括从一方到另一方运送整个过程B - Update PFMEA and Con trol Pla n to reflect con ti nu ous sampli ng pla n for bracketsB - Modify machine to sense for prese nce of rivets更新PFMEA和控制计划以反映持续 支架抽样检验方法修正机器以判断铆钉存在Page 155-WHY PROBLEM SOLVING PROCESSLess ons Le