1、 2002 Pratt & Whitney CanadaAll rights reserved, 1,問題根源糾正行動(RCCA),Training for Pilots and ACE Implementation Managers, 2002 Pratt & Whitney CanadaAll rights reserved, 2,益處Benefits Standardize intervention at root cause to prevent problems from reoccurring 標準化解決方法,從根本上防止問題重復(fù)出現(xiàn) 執(zhí)行Implementation Eight-

2、step process including tools 八個步驟 特征Characteristics Define the problem 定義問題 Analyze the problem 分析問題 Identify the root cause 確定根本原因 Apply mistake proofing 運用錯誤預(yù)防,Overview概述, 2002 Pratt & Whitney CanadaAll rights reserved, 3,Objectives 目標page 4 Introduction 簡介page 5 RCCA Steps 步驟page 18 Conclusion 結(jié)論

3、page 36,Table of contents目錄, 2002 Pratt & Whitney CanadaAll rights reserved, 4,Objectives目標,At the end of this module, you will be able to該單元學(xué)習完畢后,將能夠: 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

4、來消除在在生產(chǎn)和服務(wù)中發(fā)生于QCPC，設(shè)備停機和缺陷的重復(fù)問題。 Understand the 8 steps that form the RCCA process 了解組成RCCA 的8個步驟 Know when to use it 掌握何時運用RCCA。, 2002 Pratt & Whitney CanadaAll rights reserved, 5,Introduction簡介,Rptable,Efficace,Efficient,Mistake Proofing,1. Define定義,2. Measure衡量,3. Analyze分析,4. Improve改進 5. Contro

5、l控制,Chartered team,Process Management過程管理,Select opportunities,Standard Work,Root Cause Analysis,Why ? Why ? Why ?, 2002 Pratt & Whitney CanadaAll rights reserved, 6,What is it used for 使用目的? Correct a problem methodically系統(tǒng)地糾正問題: By determining its root cause 通過確定根源 By applying the best possible so

6、lutions通過應(yīng)用最佳方案 Prevent a problem from recurring 避免問題重復(fù)出現(xiàn): By following through 跟蹤全過程 By standardizing the solutions 使解決方案標準化,?,Introduction, 2002 Pratt & Whitney CanadaAll rights reserved, 7,When do we use 何時使用RCCA? We have a recurring problem 問題重復(fù)出現(xiàn).Or或 We are not sure of the causes 不能確定原因or 或 The

7、 problem is not constant (it comes and goes)or 問題不持續(xù)（時有時無） We want to take the time to solve the problem once and for all!我們需要花時間一次并徹底解決問題,Introduction, 2002 Pratt & Whitney CanadaAll rights reserved, 8,UTC 目前的思想狀態(tài)UTC Current Mindset,We must change the culture必須改變文化 “I have no time to address root c

8、ause, I must meet the delivery schedule!” “我沒有時間查找根源,我必須趕交付進度 !” “We have been doing this for 15 years with no substantial improvement, why is today going to be any different?” (George David, Ito University) “我們已經(jīng)如此工作了 15 年而沒有實質(zhì)性的改進，今天又會有什么區(qū)別?” (George David, 伊滕大學(xué)) “You continually develop and relea

9、se new products with known quality problems, why?” (UTC Customer) “你們不斷研制和生產(chǎn)的新產(chǎn)品存在已知的質(zhì)量問題，為什么?” (UTC 用戶) We must have a “new spirit” for the future of our business! 對于我們業(yè)務(wù)發(fā)展的未來必須具有“新的精神 ”！, 2002 Pratt & Whitney CanadaAll rights reserved, 9,UTC 渴望的思想狀態(tài)UTC Desired Mindset,The New Spirit of Management管

10、理新精神 “We must be actively involved to find root causes” “必須積極參與尋找問題根源” “We must fix defects by fixing the process, not by adding more manpower” “必須通過解決過程問題來解決缺陷，而不是通過增加人力” “85% of all quality problems are a result of the process, 15% are a result of the workers” (J. M. Juran) “85% 的質(zhì)量問題起源于過程， 15%的問題

11、來源于工人 ” (J. M. Juran)We must work to build a trusting environment! 我們必須建立一個可信賴的環(huán)境, 2002 Pratt & Whitney CanadaAll 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 r

12、ecurrence of the problem. 問題根源糾正行動是快速和持續(xù)跟蹤過程中斷和失敗的根本原因，一旦問題解決，就能避免重復(fù)發(fā)生。 Root cause analysis is like pulling weeds. 問題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，還會卷土重來, 2002 Pratt & Whitney CanadaAll rights reserved, 11,Philosophy,Each problem must be pursued and resolved rapidl

13、y 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

14、 is taken 每個問題必須迅速跟蹤和解決 解決問題需要警惕性高，思想開放，有耐心和頑強持久的精神 每個問題都是一塊金磚或財富 每個問題都是一個故事，告訴你為什么和怎樣發(fā)生的（沒有孤立的事件） 在采取行動之前，必須通過數(shù)據(jù)了解“真實” 的問題, 2002 Pratt & Whitney CanadaAll rights reserved, 12,Philosophy,問題遺漏造成的10倍規(guī)則,發(fā)現(xiàn)缺陷:,公司成本,對公司的影響,本工序,很小,下一道工序,短時延誤,加工結(jié)束,返工 重定進度,終檢,大返工 影響交付 額外檢驗,用戶,擔保費用管理費用名譽損失失去市場份額, 2002 Pratt

15、& Whitney CanadaAll 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 i

16、nspection,Customer,Warranty costAdmin. costReputationLoss of market share, 2002 Pratt & Whitney CanadaAll rights reserved, 14,Each problem is a golden nugget每個問題都是一塊金磚,Capacitor 電容器: $ 0.05,Circuit Board電路板: $ 34,Elevator 電梯: $ 350,000,Philosophy, 2002 Pratt & Whitney CanadaAll rights reserved, 15,E

17、ach problem is a golden nugget,Problem with capacitor電容器發(fā)生問題 Affected 10% of elevators in service影響10%的電梯在服務(wù)中受影響 (30,000),Cost of fixing problem修理費用 $ 454.00 每次 (Time and materials included包括時間和材料),Total cost for OTIS 總花費: $ 13,6 M,Philosophy, 2002 Pratt & Whitney CanadaAll rights reserved, 16,Each

18、problem is a golden nugget,If problem was addressed in-house .如果問題在內(nèi)部解決 .,Total cost for OTIS 總花費: $ 454,000,Cost of fixing problem修理費用 $ 15.00 每塊電板 (Time and materials included包括時間和材料),Philosophy, 2002 Pratt & Whitney CanadaAll rights reserved, 17,“低品質(zhì)費用”模型“Cost of Poor Quality” Model, 2002 Pratt &

19、 Whitney CanadaAll rights reserved, 18,Philosophy,Group Discussion小組討論 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? Qu

20、estion 4:Is best-in-class or simply beating your competitors quality levels good enough? 問題 1:采取行動之前相同的問題出現(xiàn)了多少次? 問題 2:采取行動與零件的成本有關(guān)嗎？ 問題 3:為什么將每個問題當作一塊金磚來處理很重要？ 問題 4:是做到最佳狀態(tài)還是略略超過競爭對手 就可以了？, 2002 Pratt & Whitney CanadaAll rights reserved, 19,8 Steps of Equal Importance同等重要的8個步驟,RCCA的步驟 Steps in the R

21、CCA Process, 2002 Pratt & Whitney CanadaAll rights reserved, 20,RCCA 的表格 P&WC #5532, 2002 Pratt & Whitney CanadaAll rights reserved, 21,Visit the site 現(xiàn)場調(diào)查 Collect the relevant information 收集相關(guān)信息 Describe the situation clearly in writing (Statement)以書面的方式詳細描述情況（綜述） Tools工具: Process mapping 過程圖表 Pare

22、to chart 排列圖,1.,Steps of RCCA RCCA的步驟,Describe and understand the situation描述和了解情況, 2002 Pratt & Whitney CanadaAll rights reserved, 22,RCCA步驟,Statement requirements陳述要求,陳述Statement,必須描述結(jié)果Must describe the effect,必須強調(diào)非一致性Must emphasize the non-conformance,必須是可衡量的Must be measurable,必須詳細 Must be specif

23、ic,必須明確Must be unambiguous, 2002 Pratt & Whitney CanadaAll 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 Ambi

24、guous Room for assumptions,Impact of a Bad Statement陳述不清楚的影響,不詳細和準確 界線不清 不可衡量 不知是否有改進 未強調(diào)非一致性 抓住錯誤問題 限制查究某些原因 未描述影響結(jié)果 缺乏目標 缺乏緊迫感 不明確 設(shè)想空間, 2002 Pratt & Whitney CanadaAll rights reserved, 24,2.,Assess the need for a team to complete the RCCA process評估完成RCCA過程是否需要一個小組 Identify the sectors affected by

25、the problem and the resource persons required for analysis確定該問題涉及到的部門及分析工作所需的人員 Tool工具:Team building 組隊,Steps of RCCA,Identify required resources確定所需資源, 2002 Pratt & Whitney CanadaAll rights reserved, 25,Practical Tip實踐經(jīng)驗點滴,Form an appropriate team to solve the problem組成一個適當?shù)男〗M來解決問題:,Form a small te

26、am 建立小規(guī)模團隊 Quick resolution is required Problem affects few departments 需快速做決議 問題影響少數(shù)部門,Form a bigger team 建立較大規(guī)模團隊 The problem crosses multiple boundaries The solution will require buy-in from multiple organizations 該問題跨度范圍很大 問題解決需要多個組織機構(gòu)參與, 2002 Pratt & Whitney CanadaAll rights reserved, 26,3.,Loo

27、k for the real causes of the problem尋找問題的真正原因: Be relentless 持續(xù)不斷地! 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 問為什么，為什么，為什么，為什么，為什么? 堅持事實核對數(shù)據(jù) 克服主觀性 不要僅止于人為的錯誤. 挑戰(zhàn)業(yè)務(wù)實踐,Steps of RCCA,Identify, select

28、 and prioritize probable root causes 確定問題可能的根源原因并進行選擇和排序, 2002 Pratt & Whitney CanadaAll rights reserved, 27,3.,Look for the real causes of the problem尋找問題的真正原因: Tools工具:Brainstorming 頭腦風暴 Cause & Effect Diagram 因果圖 The 5 Whys 5個為什么 Pictogram 象形圖,Steps of RCCA,Identify, select and prioritize probabl

29、e root causes 確定問題可能的根源原因并進行選擇和排序, 2002 Pratt & Whitney CanadaAll rights reserved, 28,因果圖是: 用來確定和分析情況或問題的一切可能原因Used to identify and analyze all possible causes of a situation or problem Also known as the Ishikawa or fishbone diagram也稱為魚骨圖,質(zhì)量,環(huán)境,方法,人力,材料,機器,原因,結(jié)果,測量,Cause & Effect Diagram因果圖, 2002 Pr

30、att & Whitney CanadaAll rights reserved, 29,Cause & Effect Diagram因果圖,問題PROBLEM 不合格產(chǎn)品Sub-standard product,WHY? 操作員的錯誤The operator made a mistake,WHY? 刀具被更換The cutting tools were changed,WHY? 更換了供應(yīng)商We changed suppliers,WHY? 新的更便宜The new one is less expensive,WHY? 質(zhì)量不合格The quality isnt there, 2002 Pra

31、tt & Whitney CanadaAll rights reserved, 30,證實原因的可靠性: 加倍核對消息來源 該原因?qū)栴}的影響程度? 工具:機械能力 (檢查) 統(tǒng)計過程控制 象形圖 清單 調(diào)查表,4.,Validate probable root causes 驗證可能的根源原因,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

32、 (check) Statistical Process Control Pictogram Validation ListSurvey, 2002 Pratt & Whitney CanadaAll rights reserved, 31,Look for the best possible correction action尋找最可能的糾正行動 Prioritize 優(yōu)先處理,5.,Steps of RCCA,Identify, select and prioritize potential solutions確定潛在的解決方案并進行選擇和排序,Criteria,解決方案 # 1,解決方案

33、 # 2,解決方案# 3,Decision Matrix 決策矩陣,Effectiveness of C / A 效力,Benefits / Cost Ratio 利益/成本比率,Delay of implementation 執(zhí)行延遲,Criteria標準, 2002 Pratt & Whitney CanadaAll rights reserved, 32,This is definitely the best solution!,6.,To choose the appropriate corrective action 選擇適當?shù)募m正行動 Prototype 原形 Test 測試 Is

34、 the solution mistake-proofed是否防錯的解決方法? Try-storm 嘗試風暴 Nasty test 錯誤測試 Tools工具: Statistical Process Control統(tǒng)計過程 控制,Steps of RCCA,Validate the potential solutions 驗證潛在的解決方案, 2002 Pratt & Whitney CanadaAll rights reserved, 33,6.,根源是否可以控制? 是! 能否再問一次 “為什么?” 獲取另一個可控根源？ 否! 確定的根源是否為過程失敗的基本原因？ 是! 如果我們糾正/改進我

35、們確定的根本原因，能否保證確定的問題 不再發(fā)生？ 是! 是否檢查過我們確定的根源適合于多個零件/過程？ 是!,Steps of RCCA,Validate the potential solutions 確認潛在解決方案,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 pr

36、ocess? 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 CanadaAll rights reserved, 34,7.,Develop an action plan 制定行動計劃 Target dates 目標日期 Implementation steps 執(zhí)行步驟 Actionees / resources 責任人/資源 When and how the solution effectiveness w