RCA培训教材.

AsianAmericanGas1RootCauseAnalysis根源分析理论WangQuanNov15,2014AsianAmericanGas2根源分析基本原理问题显现出的症状“叶子”地上部分（明显）问题的根本原因“根部”地下部分（不明显）在根源分析里面的根源一词是指根本原因，而不是特指某一个原因AsianAmericanGas3Introduction介绍Principles原理CauseMapping–3stepsCM理论的3个步骤FacilitationandApplication便利性和适用性AsianAmericanGas4Today今天Challengeandaskquestions挑战和提问Practice实践Aftertheworkshop了解理论之后PracticetheRCAprocess将RCA理论用于实践ApplytheRCAonyourproblems用RCA理论处理你的问题LeadbyexampleinProblemsolvingsessions以身作则的处理问题Teachthistosomeoneelse将此理论教给别人YourRoles你的工作BeabletoanalyzeoneProblem要能分析问题AsianAmericanGas5Processmap流程图Amapofthespecificstepsofworkprocess工作进程中具体步骤的流程图Introduction介绍Theworkprocessdefineshowwewouldliketoconductthebusinesseveryday此图展示了每日工作的开展AsianAmericanGas6CauseMapsAmapofthecausesofaproblem问题起因的示意图Introduction介绍Thecausemapisavisualexplanationofwhywedidn’tgetthedesiredresultsfromtheworkprocess此图直观解释了为什么工作达不到预期效果1.Problem问题2.Analysis分析3.Solutions方案AsianAmericanGas7CycleofContinuousProcessImprovement工艺改进的连续循环示意图1.Problem问题2.Analysis分析3.Solutions方案Thecorrectiveactionsafteraninvestigationmakespecificchangestotheworkprocess经查究之后，某些整改措施会改变工作中的某些环节Whenaprocessdoesn’tproducethedesiredresultsoutfirstquestionshouldbe“WHY?”These“WHY?”questionsaretheanalysisoftheproblem一旦某个环节没能达到预期效果，首先要探究为什么，而这些发问就是在分析问题。AsianAmericanGas8Target:wewouldliketospendalloftimeexecutingworkprocesseswithouterrors.目标:我们无差错的完成所有工作Paradox矛盾点:wedon’twanttobecomegoodatinvestigatingproblemssothatwecaninvestigatemoreandmoreproblems我们不是因为想善于探究问题，从而去探究越来越多的问题.Wewanttobecomegoodatinvestigatingproblemssothatwecaninvestigatefewerandfewer.我们想善于探究问题，但能探究的问题越来越少TheFocusisonPREVENTION重点在于预防ProblemPrevention问题预防AsianAmericanGas9Step1Problem问题4simplequestions:what,when,whereandtheimpacttothegoals4个简单的发问：什么问题、何时发生、在何地、以及影响如何Step2Analysis分析Breaktheproblemdownintoitsparts.Itisdrivenbyevidencebasedcause-and-effectrelationshipsthatarecapturedvisually.将整个问题分解成一些单个的局部问题，根据因果关系的佐证将问题直观展现出来。Step3Solutions解决方案oncetheanalysisiscompleted,possiblesolutionsareidentifiedforspecificcauses.Thepossiblesolutionscanbelistedandfromthemweselectthebestsolutionsfortheactionplan.完成分析之后，确立出解决问题的所有可选方案。列出所有可选方案，并从中选出可以落实最可行的方案。CauseMapping–3stepsCM理论3步走AsianAmericanGas10No.ActionItem措施项目Cause原因Owner(s)(Names)负责人DateDue截止日期Status-Completed当前进展Notes备注Verification(Checkofeffectiveness)最终效果验证121.Problem问题2.Analysis分析3.Solutions方案Step1Problemoutline问题概要•What什么问题•When何时发生•Where在何地•Goals造成的影响Step2CauseMapStep3Solutions方案•Possiblesolutions所有可行方案•Bestsolutions最佳方案•ActionPlan措施落实计划AsianAmericanGas11Insteadofattemptingtochangetheculture,people,historyandtraditions,wesimplystartbyworkingoneproblem.Ifthatoneproblemgoeswell,iftheanalysisisthoroughandeasytounderstand,thenpeoplewillcopythatworks.要想改变企业的文化、人力、历史和传统，我们要做的不是直接尝试去改变，而是通过解决某一个难题开始。如果此问题得到有效解决，人们也能够简单透彻的理解其分析过程，接下来人们就会去效仿，从而潜移默化的做出了改变。OneProblemApproach通过一个难题Cultureischangedbystartingwithjustoneproblematonetime改变文化，仅仅可以先从解决一个难题开始AsianAmericanGas12PreventionProblemsolvingandreducingrisk预防措施解决问题并降低风险OverallgoalsPrioritizeeveryissueandincident整体目标确定问题和事件的轻重缓急PeopleCreativeresourcealreadyonthepayroll人力利用通过薪资开发现有资源PrinciplesConsistentapproach规章制度坚持贯彻实施BasicConcepts基本概念AsianAmericanGas13Someproblemsaresolvedbyfindingtherightanswerandsomeproblemsaresolvedbyfindingthebestsolutions.明确对错解决了一些问题，找到最佳处理方案解决了另一些问题。Prevention–reducingtherisk预防—降低风险Right-AnswerProblem对错问题Right对orWrong错Solved已解决orNotsolved未解决Yes是orNo否Safe安全orUnsafe危险SystemsProblem系统性问题Seatbelts安全带AirBags气囊CrumpleZones缓冲区Reliabilityistheprobabilitythata“system”willperformitsintendedfunctionforagivenperiodoftimeunderstatedconditions.Thisprinciplescouldbeusedinsafety,scheduling,business,project,operations,maintenanceandbusinessproblems可靠性指的是特定情况下，特定时段内，某个系统一直保持预期性能的可能性。Thecontinuousimprovementprocessmeanswecanneverarrive;wecanneverreachtheend.Thereisalwaysroomforimprovement.Thereisalwaysbeotherways.持续改进是一个我们无法最终实现的过程，更无法达到其终点。总会有改进的空间，也总会有改进的办法。Wecan’tmakecarssafe,butwecanmakerthemsafer.我们不能保证车辆绝对安全，但能保证它们相对安全。AsianAmericanGas14Allproblemswithinanorganizationimpacttheoverallgoalsinsomenegativeway.Ifthereisn’tanegativeimpactonthegoalsthenit’snotaproblem.在组织机构内部，所有问题都会对总目标产生消极影响，如若未产生消极影响也就不会被称作问题。Overallgoals–defineandprioritizeproblems总体目标—将问题定性并依次排序Peoplewilldisagreeabout“theproblem”,buttheywon’tdisagreeabouthowthegoalsareaffected.人们对“问题”的理解会有偏差，但人们对于实现目标的理解是统一的。Theimpactontheoverallgoalsfortheorganizationdictatesthenecessarylevelofdetailintheinvestigation.对机构内部的总目标产生的影响，也决定了探究过程中的所需的层次细节。Impacttothegoals对目标的影响Safety安全Production生产Maintenance维保Customer客服Risk风险=Consequence重要性XProbability几率Risk风险=Severity严重程度XLikelihood概率Risk风险=Impacttogoals影响XFrequency频率AsianAmericanGas15Step1.DefinetheProblem定义问题What何事Problem(s)问题When何时Date日期Time时间Different,unusual,unique特殊性Where何地Facility,site设施，地点Unit,area,equipment单位，面积，设备Taskbeingperformed执行的任务ImpacttotheGoals影响如何Safety安全方面Environmental环境方面CustomerService客服方面Regulatory管理方面Production/Schedule生产/日常方面Property/Equipment财产/设备方面Labor/Time人力/时间方面Thisincident此次事件成本损失$0Frequency频率AnnualizedCo