1、 2001 Pratt & Whitney Canada - Tous droits rservs, 1,問(wèn)題根源糾正行動(dòng)(RCCA),Training for Pilots and ACE Implementation Managers, 2001 Pratt & Whitney Canada - Tous droits rservs, 2,益處Benefits Standardize intervention at root cause to prevent problems from reoccurring 標(biāo)準(zhǔn)化解決方法,從根本上防止問(wèn)題重復(fù)出現(xiàn) 執(zhí)行Implementation Ei

2、ght-step process including tools 八個(gè)步驟 特征Characteristics Define the problem 定義問(wèn)題 Analyze the problem 分析問(wèn)題 Identify the root cause 確定根本原因 Apply mistake proofing 運(yùn)用錯(cuò)誤預(yù)防,Overview概述, 2001 Pratt & Whitney Canada - Tous droits rservs, 3,Objectives 目標(biāo)page 4 Introduction 簡(jiǎn)介page 5 RCCA Steps 步驟page 18 Conclus

3、ion 結(jié)論page 36,Table of contents目錄, 2001 Pratt & Whitney Canada - Tous droits rservs, 4,Objectives目標(biāo),At the end of this module, you will be able to該單元學(xué)習(xí)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 servi

4、ces.使用方法來(lái)消除在在生產(chǎn)和服務(wù)中發(fā)生于QCPC，設(shè)備停機(jī)和缺陷的重復(fù)問(wèn)題。 Understand the 8 steps that form the RCCA process 了解組成RCCA 的8個(gè)步驟 Know when to use it 掌握何時(shí)運(yùn)用RCCA。, 2001 Pratt & Whitney Canada - Tous droits rservs, 5,Introduction簡(jiǎn)介,Rptable,Efficace,Efficient,Mistake Proofing,1. Define定義,2. Measure衡量,3. Analyze分析,4. Improve改進(jìn)

5、 5. Control控制,Chartered team,Process Management過(guò)程管理,Select opportunities,Standard Work,Root Cause Analysis,Why ? Why ? Why ?, 2001 Pratt & Whitney Canada - Tous droits rservs, 6,What is it used for 使用目的? Correct a problem methodically系統(tǒng)地糾正問(wèn)題: By determining its root cause 通過(guò)確定根源 By applying the best

6、 possible solutions通過(guò)應(yīng)用最佳方案 Prevent a problem from recurring 避免問(wèn)題重復(fù)出現(xiàn): By following through 跟蹤全過(guò)程 By standardizing the solutions 使解決方案標(biāo)準(zhǔn)化,?,Introduction, 2001 Pratt & Whitney Canada - Tous droits rservs, 7,When do we use 何時(shí)使用RCCA? We have a recurring problem 問(wèn)題重復(fù)出現(xiàn).Or或 We are not sure of the causes

7、不能確定原因or 或 The problem is not constant (it comes and goes)or 問(wèn)題不持續(xù)（時(shí)有時(shí)無(wú)） We want to take the time to solve the problem once and for all!我們需要花時(shí)間一次并徹底解決問(wèn)題,Introduction, 2001 Pratt & Whitney Canada - Tous droits rservs, 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 t

8、o address root cause, I must meet the delivery schedule!” “我沒(méi)有時(shí)間查找根源,我必須趕交付進(jìn)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(méi)有實(shí)質(zhì)性的改進(jìn)，今天又會(huì)有什么區(qū)別?” (George David, 伊滕大學(xué)) “You continually d

9、evelop and release 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(wèn)題，為什么?” (UTC 用戶(hù)) We must have a “new spirit” for the future of our business! 對(duì)于我們業(yè)務(wù)發(fā)展的未來(lái)必須具有“新的精神 ”！, 2001 Pratt & Whitney Canada - Tous droits rservs, 9,UTC 渴望的思想狀態(tài)UTC Desired Mindset,The New Spi

10、rit of Management管理新精神 “We must be actively involved to find root causes” “必須積極參與尋找問(wèn)題根源” “We must fix defects by fixing the process, not by adding more manpower” “必須通過(guò)解決過(guò)程問(wèn)題來(lái)解決缺陷，而不是通過(guò)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%

11、的質(zhì)量問(wèn)題起源于過(guò)程， 15%的問(wèn)題來(lái)源于工人 ” (J. M. Juran)We must work to build a trusting environment! 我們必須建立一個(gè)可信賴(lài)的環(huán)境, 2001 Pratt & Whitney Canada - Tous droits rservs, 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 re

12、solved, prevents a recurrence of the problem. 問(wèn)題根源糾正行動(dòng)是快速和持續(xù)跟蹤過(guò)程中斷和失敗的根本原因，一旦問(wèn)題解決，就能避免重復(fù)發(fā)生。 Root cause analysis is like pulling weeds. 問(wèn)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(huì)卷土重來(lái), 2001 Pratt & Whitney Canada - Tous droits rservs, 11,Philosophy,Each problem must be pursu

13、ed 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

14、the data before action is taken 每個(gè)問(wèn)題必須迅速跟蹤和解決 解決問(wèn)題需要警惕性高，思想開(kāi)放，有耐心和頑強(qiáng)持久的精神 每個(gè)問(wèn)題都是一塊金磚或財(cái)富 每個(gè)問(wèn)題都是一個(gè)故事，告訴你為什么和怎樣發(fā)生的（沒(méi)有孤立的事件） 在采取行動(dòng)之前，必須通過(guò)數(shù)據(jù)了解“真實(shí)” 的問(wèn)題, 2001 Pratt & Whitney Canada - Tous droits rservs, 12,Philosophy,問(wèn)題遺漏造成的10倍規(guī)則,發(fā)現(xiàn)缺陷:,公司成本,對(duì)公司的影響,本工序,很小,下一道工序,短時(shí)延誤,加工結(jié)束,返工 重定進(jìn)度,終檢,大返工 影響交付 額外檢驗(yàn),用戶(hù),擔(dān)保費(fèi)用管理費(fèi)

15、用名譽(yù)損失失去市場(chǎng)份額, 2001 Pratt & Whitney Canada - Tous droits rservs, 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 Dela

16、y of delivery Additional inspection,Customer,Warranty costAdmin. costReputationLoss of market share, 2001 Pratt & Whitney Canada - Tous droits rservs, 14,Each problem is a golden nugget每個(gè)問(wèn)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, 2001 Pratt & Whitney Can

17、ada - Tous droits rservs, 15,Each problem is a golden nugget,Problem with capacitor電容器發(fā)生問(wèn)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(fèi)用 $ 454.00 每次 (Time and materials included包括時(shí)間和材料),Total cost for OTIS 總花費(fèi): $ 13,6 M,Philosophy, 2001 Pratt & Whitney Canad

18、a - Tous droits rservs, 16,Each problem is a golden nugget,If problem was addressed in-house .如果問(wèn)題在內(nèi)部解決 .,Total cost for OTIS 總花費(fèi): $ 454,000,Cost of fixing problem修理費(fèi)用 $ 15.00 每塊電板 (Time and materials included包括時(shí)間和材料),Philosophy, 2001 Pratt & Whitney Canada - Tous droits rservs, 17,“低品質(zhì)費(fèi)用”模型“Cost of

19、 Poor Quality” Model, 2001 Pratt & Whitney Canada - Tous droits rservs, 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 e

20、ach problem like a golden nugget? Question 4:Is best-in-class or simply beating your competitors quality levels good enough? 問(wèn)題 1:采取行動(dòng)之前相同的問(wèn)題出現(xiàn)了多少次? 問(wèn)題 2:采取行動(dòng)與零件的成本有關(guān)嗎？ 問(wèn)題 3:為什么將每個(gè)問(wèn)題當(dāng)作一塊金磚來(lái)處理很重要？ 問(wèn)題 4:是做到最佳狀態(tài)還是略略超過(guò)競(jìng)爭(zhēng)對(duì)手 就可以了？, 2001 Pratt & Whitney Canada - Tous droits rservs, 19,8 Steps of Equal Impo

21、rtance同等重要的8個(gè)步驟,RCCA的步驟 Steps in the RCCA Process, 2001 Pratt & Whitney Canada - Tous droits rservs, 20,RCCA 的表格 P&WC #5532, 2001 Pratt & Whitney Canada - Tous droits rservs, 21,Visit the site 現(xiàn)場(chǎng)調(diào)查 Collect the relevant information 收集相關(guān)信息 Describe the situation clearly in writing (Statement)以書(shū)面的方式詳細(xì)描

22、述情況（綜述） Tools工具: Process mapping 過(guò)程圖表 Pareto chart 排列圖,1.,Steps of RCCA RCCA的步驟,Describe and understand the situation描述和了解情況, 2001 Pratt & Whitney Canada - Tous droits rservs, 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(qiáng)調(diào)非一致性Must emphasize the non-conformance,必

23、須是可衡量的Must be measurable,必須詳細(xì) Must be specific,必須明確Must be unambiguous, 2001 Pratt & Whitney Canada - Tous droits rservs, 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 t

24、he effect Lack of purpose Lack of urgency Ambiguous Room for assumptions,Impact of a Bad Statement陳述不清楚的影響,不詳細(xì)和準(zhǔn)確 界線(xiàn)不清 不可衡量 不知是否有改進(jìn) 未強(qiáng)調(diào)非一致性 抓住錯(cuò)誤問(wèn)題 限制查究某些原因 未描述影響結(jié)果 缺乏目標(biāo) 缺乏緊迫感 不明確 設(shè)想空間, 2001 Pratt & Whitney Canada - Tous droits rservs, 24,2.,Assess the need for a team to complete the RCCA process評(píng)估完成

25、RCCA過(guò)程是否需要一個(gè)小組 Identify the sectors affected by the problem and the resource persons required for analysis確定該問(wèn)題涉及到的部門(mén)及分析工作所需的人員 Tool工具:Team building 組隊(duì),Steps of RCCA,Identify required resources確定所需資源, 2001 Pratt & Whitney Canada - Tous droits rservs, 25,Practical Tip實(shí)踐經(jīng)驗(yàn)點(diǎn)滴,Form an appropriate team t

26、o solve the problem組成一個(gè)適當(dāng)?shù)男〗M來(lái)解決問(wèn)題:,Form a small team 建立小規(guī)模團(tuán)隊(duì) Quick resolution is required Problem affects few departments 需快速做決議 問(wèn)題影響少數(shù)部門(mén),Form a bigger team 建立較大規(guī)模團(tuán)隊(duì) The problem crosses multiple boundaries The solution will require buy-in from multiple organizations 該問(wèn)題跨度范圍很大 問(wèn)題解決需要多個(gè)組織機(jī)構(gòu)參與, 2001 Pr

27、att & Whitney Canada - Tous droits rservs, 26,3.,Look for the real causes of the problem尋找問(wèn)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(wèn)為什么，為什么，為什么，為什么，為什么? 堅(jiān)持事實(shí)核對(duì)數(shù)據(jù) 克服主

28、觀(guān)性 不要僅止于人為的錯(cuò)誤. 挑戰(zhàn)業(yè)務(wù)實(shí)踐,Steps of RCCA,Identify, select and prioritize probable root causes 確定問(wèn)題可能的根源原因并進(jìn)行選擇和排序, 2001 Pratt & Whitney Canada - Tous droits rservs, 27,3.,Look for the real causes of the problem尋找問(wèn)題的真正原因: Tools工具:Brainstorming 頭腦風(fēng)暴 Cause & Effect Diagram 因果圖 The 5 Whys 5個(gè)為什么 Pictogram 象形圖

29、,Steps of RCCA,Identify, select and prioritize probable root causes 確定問(wèn)題可能的根源原因并進(jìn)行選擇和排序, 2001 Pratt & Whitney Canada - Tous droits rservs, 28,因果圖是: 用來(lái)確定和分析情況或問(wèn)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(chēng)為魚(yú)骨圖,質(zhì)量,環(huán)境

30、,方法,人力,材料,機(jī)器,原因,結(jié)果,測(cè)量,Cause & Effect Diagram因果圖, 2001 Pratt & Whitney Canada - Tous droits rservs, 29,Cause & Effect Diagram因果圖,問(wèn)題PROBLEM 不合格產(chǎn)品Sub-standard product,WHY? 操作員的錯(cuò)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

31、 less expensive,WHY? 質(zhì)量不合格The quality isnt there, 2001 Pratt & Whitney Canada - Tous droits rservs, 30,證實(shí)原因的可靠性: 加倍核對(duì)消息來(lái)源 該原因?qū)?wèn)題的影響程度? 工具:機(jī)械能力 (檢查) 統(tǒng)計(jì)過(guò)程控制 象形圖 清單 調(diào)查表,4.,Validate probable root causes 驗(yàn)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 t

32、he cause contribute to the problem? Tools:Machine capability (check) Statistical Process Control Pictogram Validation ListSurvey, 2001 Pratt & Whitney Canada - Tous droits rservs, 31,Look for the best possible correction action尋找最可能的糾正行動(dòng) Prioritize 優(yōu)先處理,5.,Steps of RCCA,Identify, select and prioriti

33、ze potential solutions確定潛在的解決方案并進(jìn)行選擇和排序,Criteria,解決方案 # 1,解決方案 # 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(biāo)準(zhǔn), 2001 Pratt & Whitney Canada - Tous droits rservs, 32,This is definitely the best solution!,6.,To choose the

34、 appropriate corrective action 選擇適當(dāng)?shù)募m正行動(dòng) Prototype 原形 Test 測(cè)試 Is the solution mistake-proofed是否防錯(cuò)的解決方法? Try-storm 嘗試風(fēng)暴 Nasty test 錯(cuò)誤測(cè)試 Tools工具: Statistical Process Control統(tǒng)計(jì)過(guò)程 控制,Steps of RCCA,Validate the potential solutions 驗(yàn)證潛在的解決方案, 2001 Pratt & Whitney Canada - Tous droits rservs, 33,6.,根源是否可以控

35、制? 是! 能否再問(wèn)一次 “為什么?” 獲取另一個(gè)可控根源？ 否! 確定的根源是否為過(guò)程失敗的基本原因？ 是! 如果我們糾正/改進(jìn)我們確定的根本原因，能否保證確定的問(wèn)題 不再發(fā)生？ 是! 是否檢查過(guò)我們確定的根源適合于多個(gè)零件/過(guò)程？ 是!,Steps of RCCA,Validate the potential solutions 確認(rèn)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 id

36、entified 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!, 2001 Pratt & Whitney Canada - Tous droits rservs, 34,7.,Develop an action plan 制定行動(dòng)計(jì)劃 Target dates 目標(biāo)日期 Implementation steps 執(zhí)行步驟 Actionees / resources 責(zé)任人/資源 When and how the solution effectiveness wi