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1、 2002 Pratt&Whitney CanadaAll rights reserved 1问题根源纠正行动(RCCA)Training for Pilots and ACE Implementation Managers 2002 Pratt&Whitney CanadaAll rights reserved 2l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l执行ImplementationEight-step proces

2、s including tools 八个步骤l特征CharacteristicsDefine the problem 定义问题Analyze the problem 分析问题Identify the root cause 确定根本原因Apply mistake proofing 运用错误预防Overview概述 2002 Pratt&Whitney CanadaAll rights reserved 3lObjectives 目标page 4lIntroduction 简介page 5lRCCA Steps 步骤page 18lConclusion 结论page 36Table of cont

3、ents目录 2002 Pratt&Whitney CanadaAll rights reserved 4Objectives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

4、题。Understand the 8 steps that form the RCCA process 了解组成RCCA 的8个步骤Know when to use it 掌握何时运用RCCA。2002 Pratt&Whitney CanadaAll rights reserved 5Introduction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 oppor

5、tunitiesStandard WorkRoot CauseAnalysisMap processCollect dataSelect best opportunitiesQCPC&MFASurvey customersObjectives320%65%510%415%220%130%ProcessGFEDCBAHighMediumLowWhy?Why?Why?2002 Pratt&Whitney CanadaAll rights reserved 6What is it used for 使用目的?Correct a problem methodically系统地纠正问题:By deter

6、mining 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?Introduction 2002 Pratt&Whitney CanadaAll rights reserved 7When do we use 何时使用RCCA?lWe have a recurring problem 问题重复出

7、现.Or或lWe are not sure of the causes 不能确定原因or 或lThe problem is not constant(it comes and goes)or 问题不持续（时有时无）lWe 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 2002 Pratt&Whitney CanadaAll rights reserved 8UTC UTC 目前的思想状态目前的思想状态UTC Current MindsetUTC Current M

8、indsetWe 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 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

9、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 future 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”！2002 Pratt&Whitney CanadaAll rights reserv

10、ed 9UTC UTC 渴望的思想状态渴望的思想状态UTC Desired UTC Desired MindsetMindsetThe New Spirit of Management管理新精神l“We must be actively involved to find root causes”“必须积极参与寻找问题根源”l“We must fix defects 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”l“85%of all quality problems are a resu

11、lt 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!l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环境 2002 Pratt&Whitney CanadaAll rights reserved 10Philosophy理念Root Cause Corrective Action is the rapid and persistent pursuit of

12、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 2002 Pratt&Whitney CanadaA

13、ll rights reserved 11PhilosophyEach problem must be pursued and resolved rapidlySolving problems 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 inc

14、idents)The“true”problem must be understood from the data before action is taken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 2002 Pratt&Whitney CanadaAll rights reserved 12Philosophy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

15、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 2002 Pratt&Whitney CanadaAll rights reserved 13PhilosophyProblem 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 w

16、orkFinalinspectionSignificant reworkDelay of deliveryAdditional inspectionCustomerWarranty costAdmin.costReputationLoss of market share 2002 Pratt&Whitney CanadaAll rights reserved 14Each problem is a golden nugget每个问题都是一块金砖Capacitor 电容器:$0.05Circuit Board电路板:$34 Elevator 电梯:$350,000Philosophy 2002

17、Pratt&Whitney CanadaAll rights reserved 15Each 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 included包括时间和材料)Total cost for OTIS 总花费:$13,6 MPhilosophy 2002 Pratt&Whitney Cana

18、daAll rights reserved 16Each 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 included包括时间和材料)Philosophy 2002 Pratt&Whitney CanadaAll rights reserved 17“低品质费用低品质费用”模型模型“Cost of Poor Quality

19、”Cost of Poor Quality”ModelModelExtra InspectionWarrantyEscapesScrapReworkEngineering ChangesLong Cycle TimesExtra SetupsExpediting CostsLost SalesLate Delivery ChargesLost Customer LoyaltyExcess InventoryNon-Visible5-8%of SalesVisible2-3%of SalesRepairRecurringService BulletinsRecurringEngineering

20、NoticesNon-Contractual WarrantySupplier QualityLost CredibilityHidden?2002 Pratt&Whitney CanadaAll rights reserved 18PhilosophyGroup Discussion小组讨论lQuestion 1:How many times does the same problem have to occur before action is taken?lQuestion 2:Should an action be dependent on the cost of the part?l

21、Question 3:Why is it important to treat each problem like a golden nugget?lQuestion 4:Is best-in-class or simply beating your competitors quality levels good enough?l问题 1:采取行动之前相同的问题出现了多少次?l问题 2:采取行动与零件的成本有关吗？l问题 3:为什么将每个问题当作一块金砖来处理很重要？l问题 4:是做到最佳状态还是略略超过竞争对手 就可以了？2002 Pratt&Whitney CanadaAll rights

22、 reserved 198 Steps of Equal Importance同等重要的8个步骤RCCA的步骤 Steps in the RCCA ProcessSteps in the RCCA Process 2002 Pratt&Whitney CanadaAll rights reserved 20RCCA 的表格 P&WC#5532 2002 Pratt&Whitney CanadaAll rights reserved 21Visit the site 现场调查Collect the relevant information 收集相关信息Describe the situation

23、 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1.1.Steps of RCCASteps of RCCA RCCA RCCA的步骤的步骤Describe and understand the situation描述和了解情况 2002 Pratt&Whitney CanadaAll rights reserved 22RCCA步骤Statement requirements陈述要求陈述Statement必须描述结果Must describe the effe

24、ct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 2002 Pratt&Whitney CanadaAll rights reserved 23Not specificScope creepNot measurableDont know if we are improvingNot emphasizing the non-conformanceFocused on wrong problemLimit search t

25、o some causesNot describing the effectLack of purposeLack of urgencyAmbiguousRoom for assumptionsImpact of a Bad StatementImpact of a Bad Statement陈述不清楚的影响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 2002 Pratt&Whitney CanadaAll rights reserved 242.2.Assess the need for

26、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 persons 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Steps of RCCAIdentify required resources确定所需资源 2002 Pratt&Whitney CanadaAll rights reserved 25Practical Tip实践经验点

27、滴Form 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 requiredProblem 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 boundariesThe solution will require buy-in from multiple organizations该问题跨度范围很大问题解决需要

28、多个组织机构参与!2002 Pratt&Whitney CanadaAll rights reserved 263.3.Look for the 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

29、要仅止于人为的错误.挑战业务实践Steps of RCCAIdentify,select and prioritize probable root causes确定问题可能的根源原因并进行选择和排序 2002 Pratt&Whitney CanadaAll rights reserved 273.3.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Steps of RCCAIdentify

30、,select and prioritize probable root causes确定问题可能的根源原因并进行选择和排序 2002 Pratt&Whitney CanadaAll rights reserved 28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Cause&Effect Diagram因果

31、图 2002 Pratt&Whitney CanadaAll rights reserved 29Cause&Effect Diagram因果图问题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 2002 Pratt&Whitne

32、y CanadaAll rights reserved 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4.4.Validate probable root causes验证可能的根源原因Steps of RCCA To make sure the causes are credible:Double-check the sourceHow much does the cause contribute to the problem?Tools:Machine capability(check)Statistical Proce

33、ss ControlPictogramValidation ListSurvey 2002 Pratt&Whitney CanadaAll rights reserved 31Look for the best possible correction action寻找最可能的纠正行动Prioritize 优先处理5.5.Steps of RCCAIdentify,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解决方案#3Decision Matrix 决策矩阵Effectiveness

34、 of C/A 效力Benefits/Cost Ratio 利益/成本比率Delay of implementation 执行延迟Criteria标准 2002 Pratt&Whitney CanadaAll rights reserved 32This is definitelythe best solution!6.6.To choose the appropriate corrective action选择适当的纠正行动Prototype 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

35、错误测试Tools工具:Statistical Process Control统计过程 控制Steps of RCCAValidate the potential solutions验证潜在的解决方案 2002 Pratt&Whitney CanadaAll rights reserved 336.6.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!Steps of RCCAValidate the potent

36、ial 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 the process?Yes!If we correct/improve the root cause we have identified,will that ensure that the iden

37、tified 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 347.7.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 s

38、olution 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Measures 衡量Steps of RCCAImplement an action plan and monitor the effectiveness of the selected solution执行行动计划并监控所选方案的效力 2002 Pratt&Whitney CanadaAll rights reserved 358.8.Ap

39、ply the solution to all similar activities/processes将解决方案应用于所有相似的活动/过程Update procedures and systems更新程序和系统Other processes that may experience the same problem must be considered 必须考虑其他经历相同问题的程序Standardize across all applicable plants,departments and/or divisions所有应用的工厂，部门和/或单位进行标准化Tools工具:Timetable时

40、间表Standard methods标准方法Steps of RCCAStandardize similar processes规范化相似的过程 2002 Pratt&Whitney CanadaAll rights reserved 36Conclusion结论8 Steps of Equal Importance 8个步骤同等重要 Resist the temptation to skip a step抵抗跳过任何一个步骤的诱惑!2002 Pratt&Whitney CanadaAll rights reserved 37ConclusionWhen do we use 什么时候使用RCC

41、A?lWe have a recurring problem 问题重复出现.Or或lWe are not sure of the causes 不能确定原因or 或lThe problem is not constant(it comes and goes)or 问题不持续（时有时无）lWe 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！2002 Pratt&Whitney CanadaAll rights reserved 38JeffersonLincolnExercise练习The Bird Story