根本原因分析-阿波罗法

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,*,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 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 PREVENTIVE 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 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 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,-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 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.Define 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,1,st,-Causes&Effects are the same thing,因果同体,2,nd,-Causes&Effects are part of an infinite continuum,因果是无限连续统一体的一部分,3r,d,-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 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,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,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 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 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 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&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