1、Root Cause AnalysisApollo Methodology根本原因根本原因分析分析_ _阿波罗法阿波罗法 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？Ever
2、y member of 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？为何环环相扣？RELIABILITY可靠性TIMELY PROCUREMENT购买及时购买及时CULTURE文化文化SYSTEMS系统系统RCALUBRICATION润滑剂润滑剂SKILL/TRAINING & MOTIVATION技巧技巧/培训和激励培训和激励QUALITY OPERATION质量操作质量操
3、作QUALITY SPARE PARTS品质部件品质部件PLANNED PREVENTIVE MAINTENANCE计划预防性计划预防性维护维护CBMImportant link in reliability chain可靠性链上的重要环节 A PROBLEM RECOGNISED (DEFINED) IS A PROBLEM HALF SOLVED发现问题是解决问题的一半发现问题是解决问题的一半o Rule-Based Problems规则性问题规则性问题Based on a convention or set of rules which dictate a single right an
4、swer.基于某种惯例或规则，且答案唯一。- If you run a red 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。o Event-Based Problems突发性事件问题突发性事件问题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
5、作？- How do I prevent accidents?怎样避免事故？IN-EFFECTIVE PROBLEM SOLVING无效解决方式o 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o 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。o Tell
6、 stories叙述-Sequence of events事情进展-Focused on the actions注重行为-Categorical thinking绝对性思维EFFECTIVE PROBLEM SOLVING DEFINED有效问题解决方式o 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o Create a common reality-Use cause & effect chart使用
7、因果关系表- Avoid categorical thinking避免绝对化思维o Solution based on known cause & effect relationship在已知因果关系的基础上寻找解决方案A SIMPLE, EFFECTIVE METHODOLOGY一种简单有效的方法o A simple methodology一种简单方法o Used by anyone and everyone任何人均可使用o Applies to all event-based problems适用于所有突发性事件问题o Does not require forms or checklist
8、s无须表格或清单o Minimize story telling叙述问题言简意赅o Creates a common reality建立一般事实o Encourages a questioning attitude鼓励提问o Uncover creative solutions发现创新的解决方案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 THE FOUR STEP PROCESS四步走Step 1. Define the Problem第一步：明确问题Step 2.
9、 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-Causes & Effects are part of an infinite continuum因果是无限连续
10、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。 FIRST CHARACTERISTIC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L
11、eaky 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 effect因又有因，则因亦为果Perspective determines the starting point视角决定起点SECOND CHARACTERISTIC特点
12、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 pieces 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
13、 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 Pri
14、mary Effect is the effect we want to prevent初级结果是指我们要避免的结果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，分别以行为和条件形式存在 Cause因 Cause因 Effect果Condition条件Action行为Caused ByEverything 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
15、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FOURTH CHARACTERISTIC特点四Example : Actions & 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Ma
16、tch 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Conditions are causes that exist over time条件是一直存在的因OVERCOMING THE LIMITATIONS克服局限o When you dont know, admit it不知为不知o Go outside the group for specific knowledge专业知识寻求外援o Use a “
17、?” it identify what you dont know不懂得地方标记“？”Lack of Knowledge !缺乏知识缺乏知识o 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o 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 !缺乏兴趣缺乏兴趣o Establish priorit
18、ies明确重点o Clearly define the problem before you solve it解决问题之前明确问题所在Lack of time !时间紧迫时间紧迫OVERCOMING THE LIMITATIONS克服局限o Establish a common reality with a C&E Chart.利用因果关系表建立一般事实o Look for actions and conditions at every “WHY?”针对每一个“为什么”，寻找行为和条件o Challenge everything质疑每一个环节o Go outside yourself and
19、your group for answers寻求外援Favorite Solution Mindset !最中意之解决方案！最中意之解决方案！o Use a Cause and Effect chart.利用因果关系表 Limitations of the Mind !思维局限思维局限Continued.续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发现问题是解决问题的一半DEFINING THE PROBLEM定义问题DEFINING THE PROBLEMW
20、HAT 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 definition 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 definin
21、g 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：o What The Primary Effect The thing you want to prevent from occurring什么初级结果需要避免发生的事情o When- Date? Time? Status?何时日期？时间？情形？o Where- Physical location? Process Location?何地地点？进展到哪个步骤？o Sig
22、nificance影响1. Define the Problem定义问题THE RCA PROCESS RCA流程流程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 :生产：MT? Rates? Delay? Hours? Quality? Peso?MT ?误工？质量？Service:服务：Delay? Customer Satisfaction?延误
23、？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 CAUSE and EFFECT CHART因果关系表 Cause因 Cause因 PrimaryEffect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 & Condi
24、tions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 ByThe Cause & Effect Charting Concept因果关系表概念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
25、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，多个条件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
26、 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- Dont fall into this trap, it rarely prevents recurrence请勿陷请勿陷入此误区，因为这样无法解决问题入此误区，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
27、 Actions can become Conditions and Conditions can become Actions.行为和条件可相互转化WHAT IS EVIDENCE ?什么是依据？Evidence : Data that supports a conclusion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 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
28、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Cross 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 readingLog sheet日志表Observation: Log sheet 观察：日志表Alignment reading
29、Inspection检查 Measurement测量System design系统设计System design ?系统设计？stop“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THE SOLUTIONS PROCESS解决流程HOW TO FIND EFF
30、ECTIVE SOLUTIONS怎样找到有效解决方案PRIMARY EFFECT初级结果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 Solution 1方案1 Solution 2方案2 Solution 3方案3
31、 Solution 1方案1 Solution 2方案2 Solution 3方案3 Solution 4方案4Caused ByTHE 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 ab
32、out solving the entire 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
33、每一个可能的解决方案 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。Nine Dots九点阵Without lifting your pen or pencil or retracing any lines connect all nine dots with four straight lines. You
34、 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。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 li
35、nes 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 LinesNine 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W
36、ithout 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。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 SO
37、LUTION KILLERS注意：RCA解决方案的拦路虎 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 ne
38、ver go for it.高层管理者不会理睬这个的。 No one 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“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“
