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1、Root Cause AnalysisApollo Methodology根本原因分析_阿波罗法,Why RCA?.Prevailing most common industrial situation为何RCA？广泛适用,To implement a process and culture for improving and sustaining the maintenance performances of our assets.实施一种流程和文化，改善并维护我们的资产运营。,WHY RCA?为何应用RCA？,Am I responsible?.我有责任吗？Every member of
2、our production and manufacturing teams is responsible for reliability improvement.对于提高可靠性，所有生产制造团队成员匹夫有责。,Why RCA Contd.?RCA为何环环相扣？,RELIABILITY可靠性,TIMELY PROCUREMENT购买及时,CULTURE文化,SYSTEMS系统,RCA,LUBRICATION润滑剂,SKILL/TRAINING&MOTIVATION技巧/培训和激励,QUALITY OPERATION质量操作,QUALITY SPARE PARTS品质部件,PLANNED PRE
3、VENTIVE MAINTENANCE计划预防性维护,CBM,Important link in reliability chain可靠性链上的重要环节,TWO TYPE OF PROBLEMS两种问题,A PROBLEM RECOGNISED(DEFINED)IS A PROBLEM HALF SOLVED发现问题是解决问题的一半,Rule-Based Problems规则性问题Based on a convention or set of rules which dictate a single right answer.基于某种惯例或规则，且答案唯一。-If you run a red
4、light,the rule says you can be fined根据规则，运行红灯将被罚款。-Written procedures demand compliance.遵守已成文之规定。,Event-Based Problems突发性事件问题Based on the law of cause and effect where there are many possible solutions.基于因果关系法则，发现多种解决方案。-Why did the pump fail?泵为何停止工作？-How do I prevent accidents?怎样避免事故？,IN-EFFECTIVE
5、PROBLEM SOLVING无效解决方式,Ignore problem definition忽略问题定义-solution Oriented偏重解决方案-belief Problem is obvious认为问题显而易见,Fill out report forms填写汇报表-Problem is solved when we:Check the boxes;Fill in the blanks;categorize当我们做了标记，填完空格，分类之后，问题就解决了。,Tell stories叙述-Sequence of events事情进展-Focused on the actions注重行为
6、-Categorical thinking绝对性思维,ROOT CAUSE ANALYSIS根本原因分析,EFFECTIVE PROBLEM SOLVING DEFINED有效问题解决方式,Appreciative understanding有价值的理解-Diversity of thought is valuable多样性思维最具价值-Abandon right answer mind set改变一味追求正确答案的思维模式,Create a common reality-Use cause&effect chart使用因果关系表-Avoid categorical thinking避免绝对化
7、思维,Solution based on known cause&effect relationship在已知因果关系的基础上寻找解决方案,PROBLEM SOLVING问题的解决,A SIMPLE,EFFECTIVE METHODOLOGY一种简单有效的方法,A simple methodology一种简单方法,Used by anyone and everyone任何人均可使用,Applies to all event-based problems适用于所有突发性事件问题,Does not require forms or checklists无须表格或清单,Minimize story
8、telling叙述问题言简意赅,Creates a common reality建立一般事实,Encourages a questioning attitude鼓励提问,Uncover creative solutions发现创新的解决方案,ROOT CAUSE ANALYSIS根本原因分析,EFFECTIVE PROBLEM SOLVING有效问题解决方式,PROBLEM问题,CAUSE&EFFECT RELATIONSHIP因果关系,SOLUTIONS解决方案,ROOT CAUSE ANALYSIS(RCA)根本原因分析,THE FOUR STEP PROCESS四步走,Step 1.De
9、fine the Problem第一步：明确问题,Step 2.Create a Cause&Effect Chart第二步：创建因果关系表,Step 3.Identify Effective Solutions第三步：找到有效解决方案,Step 4.Implement the Best Solutions第四步：实施最佳方案,ROOT CAUSE ANALYSIS根本原因分析,FOUR CHARACTERISTICS OF THE CAUSE&EFFECT PRINCIPLE因果原则的四个特点,1st-Causes&Effects are the same thing因果同体,2nd-Cau
10、ses&Effects are part of an infinite continuum因果是无限连续统一体的一部分,3rd-Each effect has at least two causes in the form of actions and conditions，一果至少两因，分别以行为和条件形式存在。,4th-An effect exist only if its causes exist at the same point in time and space果只有在其多个因存在于时间和空间的同一点时才能产生。,ROOT CAUSE ANALYSIS根本原因分析,FIRST CH
11、ARACTERISTIC特点一,Injury受伤Effect果,Fall摔倒Cause Effect因果,Wet surface表面湿滑Cause Effect因果,Leaky valve管道漏水Cause Effect因果,Seal Failure密封不好Cause Effect因果,No Maintenance维护不到位Cause Effect因果,Causes&Effects Are The Same Thing因果同体,An Effect is the consequence of a cause果源于因,When we ask why of a cause it becomes an
12、 effect因又有因，则因亦为果,Perspective determines the starting point视角决定起点,ROOT CAUSE ANALYSIS根本原因分析,SECOND CHARACTERISTIC特点二,Causes&Effects Are An Infinite Continuum因果同为一个无限连续统一体的一部分,No matter where we start asking why,we are always in middle of a chain of causes无论我们从何处开始产生疑问，我们往往处于某个因的环节。,Causes are like p
13、ieces of jigsaw puzzle这些因就像智力拼图的碎片-they connect in several ways它们都有多个连接处-they are part of a bigger picture它们都是整体 的一部分-the more connections the better the picture连接越多拼图越完整-Individually they can be the beginning or the end单个碎片可能是头也可能是尾,The Phrase“Caused By”is the key to connecting the causes”由。引起“这一说法
14、是连接所有因的关键The first effect we choose to start with is the Primary Effect 我们选择的第一个结果叫做初级结果,Definition定义:The Primary Effect is the effect we want to prevent初级结果是指我们要避免的结果,ROOT CAUSE ANALYSIS 根本原因分析,THIRD CHARACTERISTIC特点三,Each Effect has at least two Causes in the form of Actions and Conditions一果至少两因，分
15、别以行为和条件形式存在,Cause因,Cause因,Effect果,Condition条件,Action行为,Caused,By,Everything that happens is the result of causes set in motion所有事件都是一系列因连续作用的结果,Each time we ask why,look for Actions&Conditions to identify causes每次产生疑问时，从行为和条件两方面去发现原因,ROOT CAUSE ANALYSIS根本原因分析,FOURTH CHARACTERISTIC特点四,Example:Actions
16、&Conditions例：行为和条件,Fire Triangle火的原理三角图,Heat热,Fuel燃料,Oxygen氧气,Ignition Source火源,Combustible Material 可燃材料,Open Fire明火,Condition条件,Action行为,Caused,By,Oxygen氧气,Condition条件,Match Strike划火柴,Condition条件,Actions are momentary causes that bring conditions together to cause an effect行为属瞬间因，它综合所有条件最终产生结果,Con
17、ditions are causes that exist over time条件是一直存在的因,An Effect exist onlyIf its causes exist atThe same point in timeAnd space,ROOT CAUSE ANALYSIS根本原因分析,OVERCOMING THE LIMITATIONS克服局限,When you dont know,admit it不知为不知 Go outside the group for specific knowledge专业知识寻求外援 Use a“?”it identify what you dont k
18、now不懂得地方标记“？”,Lack of Knowledge!缺乏知识,Identify all obvious causes,then work on the ones you can control找到所有显性的因，并处理可控 之因 If these do not provide effective solutions,look deeper into the other causes如仍无法找到有效解决方案，深入挖掘其他因,Lack of interest!缺乏兴趣,Establish priorities明确重点 Clearly define the problem before y
19、ou solve it解决问题之前明确问题所在,Lack of time!时间紧迫,ROOT CAUSE ANALYSIS根本原因分析,OVERCOMING THE LIMITATIONS克服局限,Establish a common reality with a C&E Chart.利用因果关系表建立一般事实 Look for actions and conditions at every“WHY?”针对每一个“为什么”，寻找行为和条件 Challenge everything质疑每一个环节 Go outside yourself and your group for answers寻求外援
20、,Favorite Solution Mindset!最中意之解决方案！,Use a Cause and Effect chart.利用因果关系表,Limitations of the Mind!思维局限,Continued.续,ROOT CAUSE ANALYSIS根本原因分析,PROBLEM DEFINITION定义问题,A PROBLEM RECOGNISED(DEFINED)IS A PROBLEM HALF SOLVED发现问题是解决问题的一半,ROOT CAUSE ANALYSIS根本原因分析,DEFINING THE PROBLEM定义问题,People can look at
21、the same event and see“the Problem”differently.对同一个问题的看法因人而异,ROOT CAUSE ANALYSIS根本原因分析,DEFINING THE PROBLEM,WHAT What is the problem?什么问题是什么？,WHEN When did it happen?何时何时发生的？,WHERE Where did it happen?何地发生在何地？,SIGNIFICANCE What is the significance?影响有何影响？,Write Down the following列出以下各项,The problem d
22、efinition does not contain定义问题不包括,WHO The focus in on Prevention not Blame谁重要的是解决问题，不是摊派责任,WHY Detracts from defining the problem为什么分散注意力-Example,“who knows why widgets breaks?例如：”谁知道这个东西为什么坏了？“,Write down the following:列出以下各项：What The Primary Effect The thing you want to prevent from occurring什么初级结
23、果需要避免发生的事情 When-Date?Time?Status?何时日期？时间？情形？Where-Physical location?Process Location?何地地点？进展到哪个步骤？Significance影响,1.Define the Problem定义问题,THE RCA PROCESS RCA流程,FIX THE CAUSES,NOT THE BLAME消除因，避免无谓谴责,Safety:安全：Injuries?Potential?受伤？潜在影响？Environment:环境：Regulations?Spills?Potential?规章？潜在问题？Production:生
24、产：MT?Rates?Delay?Hours?Quality?Peso?MT?误工？质量？Service:服务：Delay?Customer Satisfaction?延误？客户满意度？Maintenance:维护：Materials?Labor?Hours?Peso?材料？劳动力？任务单？Frequency:频率：Occurrence?Timeframe?发生频率？时限？,CAUSE and EFFECT ANALYSIS因果分析,ROOT CAUSE ANALYSIS根本原因分析,CAUSE and EFFECT CHART因果关系表,Cause因,Cause因,PrimaryEffect
25、初级结果,Evidence依据,Evidence依据,1 This is to where we begin to ask why?疑问产生之始,3 Look for causes in Actions&Conditions在行为和条件中寻找因,2 Think“Caused by”思考“由引起”,4 Support causes with Evidence or Use a“?”寻找因的依据或标记“？”,Condition条件,Action行为,Caused,By,The Cause&Effect Charting Concept因果关系表概念,ROOT CAUSE ANALYSIS根本原因分
26、析,LOOK FOR CAUSES IN ACTIONS AND CONDITIONS在行为和条件中寻找因,Actions and Conditions are both Causes行为和条件同为因,Each time you ask“Why?”look for Actions and Conditions寻找每一个疑问背后的行为和条件,An Action combines with Conditions to create an Effect行为与条件结合产生果,Typically there is one Action,and several Conditions一般来说，存在一个行为，
27、多个条件,ROOT CAUSE ANALYSIS根本原因分析,LOOK FOR CAUSES IN ACTIONS AND CONDITIONS在行为和条件中寻找因,We tend to see Actions and ignore Conditions我们往往只见行为，不见条件,The best solutions are often attached to Conditions最佳解决方案常常与条件密不可分,Actions usually involve people行为通常与人有关,Placing blame focuses on peoples Actions谴责的焦点常常是人的行为,
28、-Dont fall into this trap,it rarely prevents recurrence请勿陷入此误区，因为这样无法解决问题,Conditions are usually easier to control than Actions条件通常比行为更加容易控制,Actions can become Conditions and Conditions can become Actions.行为和条件可相互转化,ROOT CAUSE ANALYSIS根本原因分析,WHAT IS EVIDENCE?什么是依据？,Evidence:Data that supports a conc
29、lusion依据：推导出结论的数据,Evidence should be added to all cause blocks.所有因都应该具备依据,ROOT CAUSE ANALYSIS根本原因分析,Connecting rod breakage连接杆折断,connecting rod motion not synchronized连接杆移动不同步,Primary Effect初级结果,Machine Running机器运行,Axial Load connect rod轴向载荷连接杆,Movable frame Misalignment可移动框架连接错误,Excess force 承力过大,C
30、ross head shaft channel mis-aligned线路错误,Channel weak线路弱,Channel failed线路故障,Cyclic load high循环荷载过高,Observation:Axial load观察：轴向载荷,Alignment reading,Log sheet日志表,Observation:Log sheet 观察：日志表,Alignment reading,Inspection检查,Measurement测量,System design系统设计,System design?系统设计？,stop,ROOT CAUSE ANALYSIS根本原因分
31、析,“Not the root causes we seek for effective solutions”不是针对有效方案所寻找的根本原因“,SOLUTIONS CRITERIA解决方案的标准,Prevent recurrence防止问题再次发生,Within your control尽在掌控,Meets goals and objectives达到目标,ROOT CAUSE ANALYSIS根本原因分析,THE SOLUTIONS PROCESS解决流程,HOW TO FIND EFFECTIVE SOLUTIONS怎样找到有效解决方案,PRIMARY EFFECT初级结果,Caused
32、,By,Cause/Effect因/果,Cause/Effect因/果,Cause/Effect因/果,Caused,By,Cause/Effect因/果,Cause/Effect因/果,Caused,By,Caused,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,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 Solu
33、tion 4方案4,Caused,By,ROOT CAUSE ANALYSIS根本原因分析,THE SOLUTION PROCESS解决流程,-Start on the right side从正确的一面着手,Ask what can be done to change,control or prevent this one cause from acting想一想怎样改变，控制或防止这个因,1.Challenge each and every cause质疑每一个因,Focus on one cause at a time.Dont worry about solving the entire
34、 problem.一次处理一个因，不要顾虑整个问题。,-Be creative.Dont judge it as“right”or“wrong”at this stage.运用创造力。请勿盲目判断正确或错误,2.Offer possible solutions for each cause针对每一个因，找到可能的解决方案,-Solutions control specific causes.解决方案控制具体的因。,3.Evaluate possible solutions using criteria guidelines.运用标准原则评估每一个可能的解决方案,Nine Dots九点阵With
35、out lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines.You may cross lines.请用四条线将下列九个点连接起来，勿断笔或回笔，连线可以交叉。,Nine Dots九点阵Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines.You may cross lines.请用四条线将下列九个点
36、连接起来，勿断笔或回笔，连线可以交叉。,1 Line第一笔,Nine Dots九点阵Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines.You may cross lines.请用四条线将下列九个点连接起来，勿断笔或回笔，连线可以交叉。,2 Lines第二笔,Nine Dots九点阵Without lifting your pen or pencil or retracing any lines connect all nine dots
37、 with four straight lines.You may cross lines.请用四条线将下列九个点连接起来，勿断笔或回笔，连线可以交叉。,2 Lines,Nine Dots九点阵Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines.You may cross lines.请用四条线将下列九个点连接起来，勿断笔或回笔，连线可以交叉。,3 Lines第三笔,Nine Dots九点阵Without lifting your pen
38、 or pencil or retracing any lines connect all nine dots with four straight lines.You may cross lines.请用四条线将下列九个点连接起来，勿断笔或回笔，连线可以交叉。,4 Lines第四笔,The Lesson:教训：Think Outside the Box.跳出图外思考。Its counterintuitive,but there may be solutions there.虽然违反直觉，但找到解决方案并不是不可能的。,Beware!RCA SOLUTION KILLERS注意：RCA解决方案
39、的拦路虎,It will never work here.在这儿绝对行不通。Were too busy to do that.我们忙得不可开交，没时间。No one will buy it!没有人会买这玩意儿。We already tried that once.我们已经尝试过了。Thats not our policy here.这不符合我们的制度。It isnt in the budget.预算里没有这一项。Good thought,but impractical想法很好，但不实际。Top Management will never go for it.高层管理者不会理睬这个的。No on
40、e else is doing it that way.没有人这样做。Wrong!这是错的。Weve always done it that way我们一直是那样做的。Good idea,Ill get back to you.好想法，以后再说吧。Etc.,etc.,etc.等等。,“Doing the same thing over&over again and expecting a different result”永远重复同一件事，却幻想不同的结果“,Insanity,“If you do what you have always done you will get what you always got”机械重复只能带来相同的结果“,ROOT CAUSE ANALYSIS根本原因分析,“Keep questioning:It has created miracle!and brought human civilization from stone age to where we are”不断提出质疑：奇迹就是这样产生的，而人类文明也是这样由石器时代发展至今的“,
