RCA根因分析_阿波羅_2014

1、ROOT CAUSE ANALYSISAPOLLO METHODOLOGY根本原因分析 阿波羅法 2Why RCA ?.Prevailing most common industrial situation為何RCA？廣泛適用3To implement a process and culture for improving and sustaining the maintenance performances of our assets.實施一種流程和文化，改善并維護(hù)我們的資產(chǎn)運營。WHY RCA ?為何應(yīng)用RCA？Am I responsible ?.我有責(zé)任嗎？Every member o

2、f our production and manufacturing teams is responsible for reliability improvement. 對于提高可靠性，所有生產(chǎn)制造團(tuán)隊成員匹夫有責(zé)。4Why RCA Contd. ? RCA為何環(huán)環(huán)相扣？為何環(huán)環(huán)相扣？RELIABILITY可靠性TIMELY PROCUREMENT購買及時購買及時CULTURE文化文化SYSTEMS系統(tǒng)系統(tǒng)RCALUBRICATION潤滑劑潤滑劑SKILL/TRAINING & MOTIVATION技巧技巧/培訓(xùn)和激勵培訓(xùn)和激勵QUALITY OPERATION質(zhì)量操作質(zhì)量操作QUALITY

3、SPARE PARTS品質(zhì)部件品質(zhì)部件PLANNED PREVENTIVE MAINTENANCE計劃預(yù)防性計劃預(yù)防性維護(hù)維護(hù)CBMImportant link in reliability chain可靠性鏈上的重要環(huán)節(jié) 5A PROBLEM RECOGNISED (DEFINED) IS A PROBLEM HALF SOLVED發(fā)現(xiàn)問題是解決問題的一半發(fā)現(xiàn)問題是解決問題的一半o Rule-Based Problems規(guī)則性問題規(guī)則性問題Based on a convention or set of rules which dictate a single right answer.基于某

4、種慣例或規(guī)則，且答案唯一。- If you run a red light, the rule says you can be fined根據(jù)規(guī)則，運行紅燈將被罰款。- Written procedures demand compliance.遵守已成文之規(guī)定。o Event-Based Problems突發(fā)性事件問題突發(fā)性事件問題Based on the law of cause and effect where there are many possible solutions.基于因果關(guān)系法則，發(fā)現(xiàn)多種解決方案。- Why did the pump fail?泵為何停止工作？- How

5、do I prevent accidents?怎樣避免事故？6IN-EFFECTIVE PROBLEM SOLVING無效解決方式o Ignore problem definition忽略問題定義-solution Oriented偏重解決方案-belief Problem is obvious認(rèn)為問題顯而易見o Fill out report forms填寫匯報表-Problem is solved when we : Check the boxes ; Fill in the blanks ; categorize當(dāng)我們做了標(biāo)記，填完空格，分類之后，問題就解決了。o Tell storie

6、s敘述-Sequence of events事情進(jìn)展-Focused on the actions注重行為-Categorical thinking絕對性思維7EFFECTIVE PROBLEM SOLVING DEFINED有效問題解決方式o Appreciative understanding有價值的理解-Diversity of thought is valuable多樣性思維最具價值-Abandon right answer mind set改變一味追求正確答案的思維模式o Create a common reality-Use cause & effect chart使用因果關(guān)系表-

7、 Avoid categorical thinking避免絕對化思維o Solution based on known cause & effect relationship在已知因果關(guān)系的基礎(chǔ)上尋找解決方案8A SIMPLE, EFFECTIVE METHODOLOGY一種簡單有效的方法o A simple methodology一種簡單方法o Used by anyone and everyone任何人均可使用o Applies to all event-based problems適用于所有突發(fā)性事件問題o Does not require forms or checklists無須表格

8、或清單o Minimize story telling敘述問題言簡意賅o Creates a common reality建立一般事實o Encourages a questioning attitude鼓勵提問o Uncover creative solutions發(fā)現(xiàn)創(chuàng)新的解決方案9EFFECTIVE PROBLEM SOLVING有效問題解決方式PROBLEM問題CAUSE & EFFECT RELATIONSHIP因果關(guān)系SOLUTIONS解決方案 10THE FOUR STEP PROCESS四步走Step 1. Define the Problem第一步：明確問題Step 2. C

9、reate a Cause & Effect Chart第二步：創(chuàng)建因果關(guān)系表Step 3. Identify Effective Solutions第三步：找到有效解決方案Step 4. Implement the Best Solutions第四步：實施最佳方案11FOUR CHARACTERISTICS OF THE CAUSE & EFFECT PRINCIPLE因果原則的四個特點1st-Causes & Effects are the same thing因果同體2nd-Causes & Effects are part of an infinite continuum因果是無限連續(xù)

10、統(tǒng)一體的一部分3rd-Each effect has at least two causes in the form of actions and conditions，一果至少兩因，分別以行為和條件形式存在。4th-An effect exist only if its causes exist at the same point in time and space果只有在其多個因存在于時間和空間的同一點時才能產(chǎn)生。 12FIRST CHARACTERISTIC特點一Injury受傷Effect果Fall摔倒Cause Effect因果Wet surface表面濕滑Cause Effect因

11、果Leaky valve管道漏水Cause Effect因果Seal Failure密封不好Cause Effect因果No Maintenance維護(hù)不到位Cause Effect因果Causes & Effects Are The Same Thing因果同體An Effect is the consequence of a cause果源于因When we ask why of a cause it becomes an effect因又有因，則因亦為果Perspective determines the starting point視角決定起點13SECOND CHARACTERIST

12、IC特點二Causes & Effects Are An Infinite Continuum因果同為一個無限連續(xù)統(tǒng)一體的一部分No matter where we start asking why, we are always in middle of a chain of causes無論我們從何處開始產(chǎn)生疑問， 我們往往處于某個因的環(huán)節(jié)。Causes are like pieces of jigsaw puzzle這些因就像智力拼圖的碎片- they connect in several ways它們都有多個連接處- they are part of a bigger picture它們

13、都是整體 的一部分- the more connections the better the picture連接越多拼圖越完整- Individually they can be the beginning or the end單個碎片可能是頭也可能是尾The Phrase “Caused By” is the key to connecting the causes”由。引起“這一說法是連接所有因的關(guān)鍵The first effect we choose to start with is the Primary Effect 我們選擇的第一個結(jié)果叫做初級結(jié)果Definition定義 :The

14、 Primary Effect is the effect we want to prevent初級結(jié)果是指我們要避免的結(jié)果14THIRD CHARACTERISTIC特點三Each Effect has at least two Causes in the form of Actions and Conditions一果至少兩因，分別以行為和條件形式存在 Cause因 Cause因 Effect果Condition條件Action行為Caused ByEverything that happens is the result of causes set in motion所有事件都是一系列因

15、連續(xù)作用的結(jié)果Each time we ask why, look for Actions & Conditions to identify causes每次產(chǎn)生疑問時，從行為和條件兩方面去發(fā)現(xiàn)原因15FOURTH CHARACTERISTIC特點四Example : Actions & Conditions例：行為和條件Fire Triangle火的原理三角圖Heat熱Fuel燃料Oxygen氧氣 Ignition Source火源 Combustible Material 可燃材料 Open Fire明火Condition條件Action行為Caused By Oxygen氧氣 Condi

16、tion條件Match Strike劃火柴Condition條件Actions are momentary causes that bring conditions together to cause an effect行為屬瞬間因，它綜合所有條件最終產(chǎn)生結(jié)果Conditions are causes that exist over time條件是一直存在的因16OVERCOMING THE LIMITATIONS克服局限o When you dont know, admit it不知為不知o Go outside the group for specific knowledge專業(yè)知識尋求外

17、援o Use a “?” it identify what you dont know不懂得地方標(biāo)記“？”Lack of Knowledge !缺乏知識缺乏知識o Identify all obvious causes, then work on the ones you can control找到所有顯性的因，并處理可控 之因o If these do not provide effective solutions, look deeper into the other causes如仍無法找到有效解決方案，深入挖掘其他因Lack of interest !缺乏興趣缺乏興趣o Establi

18、sh priorities明確重點o Clearly define the problem before you solve it解決問題之前明確問題所在Lack of time !時間緊迫時間緊迫17OVERCOMING THE LIMITATIONS克服局限o Establish a common reality with a C&E Chart.利用因果關(guān)系表建立一般事實o Look for actions and conditions at every “WHY?”針對每一個“為什么”，尋找行為和條件o Challenge everything質(zhì)疑每一個環(huán)節(jié)o Go outside y

19、ourself and your group for answers尋求外援Favorite Solution Mindset !最中意之解決方案！最中意之解決方案！o Use a Cause and Effect chart.利用因果關(guān)系表 Limitations of the Mind !思維局限思維局限Continued.續(xù)18PROBLEM DEFINITION定義問題A PROBLEM RECOGNISED (DEFINED) IS A PROBLEM HALF SOLVED發(fā)現(xiàn)問題是解決問題的一半發(fā)現(xiàn)問題是解決問題的一半19DEFINING THE PROBLEM定義問題2021D

20、EFINING THE PROBLEMWHAT What is the problem?什么問題是什么？WHEN When did it happen?何時何時發(fā)生的？WHERE Where did it happen?何地發(fā)生在何地？SIGNIFICANCE What is the significance?影響有何影響？Write Down the following列出以下各項The problem definition does not contain定義問題不包括WHO The focus in on Prevention not Blame誰重要的是解決問題，不是攤派責(zé)任WHY D

21、etracts from defining the problem為什么分散注意力 - Example, “who knows why widgets breaks?例如：”誰知道這個東西為什么壞了？“22Write down the following :列出以下各項：o What The Primary Effect The thing you want to prevent from occurring什么初級結(jié)果需要避免發(fā)生的事情o When- Date? Time? Status?何時日期？時間？情形？o Where- Physical location? Process Locat

22、ion?何地地點？進(jìn)展到哪個步驟？o Significance影響1. Define the Problem定義問題THE RCA PROCESS RCA流程流程FIX THE CAUSES, NOT THE BLAME消除因，避免無謂譴責(zé)Safety :安全： Injuries? Potential?受傷？ 潛在影響？Environment :環(huán)境：Regulations? Spills? Potential?規(guī)章？潛在問題？Production :生產(chǎn)： MT? Rates? Delay? Hours? Quality? Peso?MT ?誤工？質(zhì)量？Service:服務(wù)：Delay? C

23、ustomer Satisfaction?延誤？客戶滿意度？Maintenance :維護(hù)： Materials? Labor? Hours? Peso?材料？勞動力？任務(wù)單？Frequency :頻率： Occurrence? Timeframe?發(fā)生頻率？時限？23CAUSE and EFFECT ANALYSIS因果分析24 CAUSE and EFFECT CHART因果關(guān)系表 Cause因 Cause因 PrimaryEffect初級結(jié)果Evidence依據(jù)Evidence依據(jù)1 This is to where we begin to ask why?疑問產(chǎn)生之始3 Look fo

24、r causes in Actions & Conditions在行為和條件中尋找因2 Think “Caused by” 思考“由引起”4 Support causes with Evidence or Use a “?”尋找因的依據(jù)或標(biāo)記“？”Condition條件Action行為Caused ByThe Cause & Effect Charting Concept因果關(guān)系表概念25LOOK FOR CAUSES IN ACTIONS AND CONDITIONS在行為和條件中尋找因 Actions and Conditions are both Causes行為和條件同為因 Each

25、time you ask “Why?” look for Actions and Conditions尋找每一個疑問背后的行為和條件 An Action combines with Conditions to create an Effect行為與條件結(jié)合產(chǎn)生果 Typically there is one Action, and several Conditions一般來說，存在一個行為，多個條件26LOOK FOR CAUSES IN ACTIONS AND CONDITIONS在行為和條件中尋找因 We tend to see Actions and ignore Conditions我

26、們往往只見行為，不見條件 The best solutions are often attached to Conditions最佳解決方案常常與條件密不可分 Actions usually involve people行為通常與人有關(guān) Placing blame focuses on peoples Actions譴責(zé)的焦點常常是人的行為- Dont fall into this trap, it rarely prevents recurrence請勿陷請勿陷入此誤區(qū)，因為這樣無法解決問題入此誤區(qū)，因為這樣無法解決問題 Conditions are usually easier to co

27、ntrol than Actions條件通常比行為更加容易控制 Actions can become Conditions and Conditions can become Actions.行為和條件可相互轉(zhuǎn)化27WHAT IS EVIDENCE ?什么是依據(jù)？Evidence : Data that supports a conclusion依據(jù)：推導(dǎo)出結(jié)論的數(shù)據(jù)Evidence should be added to all cause blocks.所有因都應(yīng)該具備依據(jù) 28Connecting rod breakage連接桿折斷connecting rod motion not syn

28、chronized連接桿移動不同步Primary Effect初級結(jié)果Machine Running機(jī)器運行Axial Load connect rod軸向載荷連接桿Movable frame Misalignment可移動框架連接錯誤Excess force 承力過大Cross head shaft channel mis-aligned線路錯誤Channel weak線路弱Channel failed線路故障Cyclic load high循環(huán)荷載過高Observation: Axial load觀察：軸向載荷Alignment readingLog sheet日志表Observation

29、: Log sheet 觀察：日志表Alignment readingInspection檢查 Measurement測量System design系統(tǒng)設(shè)計System design ?系統(tǒng)設(shè)計？stop29“Not the root causes we seek for effective solutions”不是針對有效方案所尋找的根本原因不是針對有效方案所尋找的根本原因“30SOLUTIONS CRITERIA解決方案的標(biāo)準(zhǔn) Prevent recurrence防止問題再次發(fā)生 Within your control盡在掌控 Meets goals and objectives達(dá)到目標(biāo)3

30、1THE SOLUTIONS PROCESS解決流程HOW TO FIND EFFECTIVE SOLUTIONS怎樣找到有效解決方案PRIMARY EFFECT初級結(jié)果Caused ByCause/ Effect因/果Cause/ Effect因/果Cause/ Effect因/果Caused ByCause/ Effect因/果Cause/ Effect因/果Caused ByCaused By Solution 1方案1 Solution 2方案2 Solution 3方案3 Solution 1方案1 Solution 2方案2 Solution 1方案1 Solution 2方案2

31、Solution 1方案1 Solution 2方案2 Solution 3方案3 Solution 1方案1 Solution 2方案2 Solution 3方案3 Solution 4方案4Caused By32THE SOLUTION PROCESS解決流程- Start on the right side從正確的一面著手- Ask what can be done to change, control or prevent this one cause from acting想一想怎樣改變，控制或防止這個因1. Challenge each and every cause質(zhì)疑每一個因-

32、Focus on one cause at a time. Dont worry about solving the entire problem.一次處理一個因，不要顧慮整個問題。- Be creative. Dont judge it as “right” or “wrong” at this stage.運用創(chuàng)造力。請勿盲目判斷正確或錯誤2. Offer possible solutions for each cause針對每一個因，找到可能的解決方案- Solutions control specific causes.解決方案控制具體的因。3. Evaluate possible s

33、olutions using criteria guidelines.運用標(biāo)準(zhǔn)原則評估每一個可能的解決方案 33Nine Dots九點陣Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines. You may cross lines.請用四條線將下列九個點連接起來，勿斷筆或回筆，連線可以交叉。34Nine Dots九點陣Without lifting your pen or pencil or retracing any lines conn

34、ect all nine dots with four straight lines. You may cross lines.請用四條線將下列九個點連接起來，勿斷筆或回筆，連線可以交叉。1 Line第一筆35Nine Dots九點陣Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines. You may cross lines.請用四條線將下列九個點連接起來，勿斷筆或回筆，連線可以交叉。2 Lines第二筆36Nine Dots九點陣Wit

35、hout lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines. You may cross lines.請用四條線將下列九個點連接起來，勿斷筆或回筆，連線可以交叉。2 Lines37Nine Dots九點陣Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines. You may cross lines.請用四條線將下列九個點連