5WHY分析

5-WHY PROBLEM SOLVING PROCESS
PRACTICAL PROBLEM SOLVING 实际问题解决
Introduction 介绍 In the Delphi organization, a common problem solving process is used to analyze and solve quality problems. 在德尔福组织里，一个共同的问题解决过程是用于分析和解决质量问题。 There are four major parts of the process: 这有过程中四个主要部分 ? ? ? ? ? Grasp the Situation 掌握情况 Cause Investigation 调查情况 Problem Correction 问题纠正 Prevention through Errorproofing 预防错误
Grasp the Situation 掌握情况 During the first part of the process, you: 在过程的第一部分，你要： ? Identify the Problem 识别问题 ? Clarify the Problem 阐明问题 ? Locate the Point of Cause (PoC) 查找发生事故的地点
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Cause Investigation 原因调查 In the second part of the process, you: 在过程的第二步你要： ? Conduct a “5-Why” investigation to identify the root cause进行“5-WHY”调查以识别问题根源。 for the specific problem 特殊问题 for why the problem was not detected 为什么问题没有被发现。 for why the “system” allowed the problem to occur 为什么系统允许问题发生
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Problem Correction 问题纠正 In the third part of the process, you: 在过程的第三部分，你要： ? Take specific action to correct the problem. At a minimum, short-term temporary measures are required to protect the customer. 采取特殊措施改正问题，至少，要求用短期暂时的方法去保护顾客。
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Prevention Thru Errorproofing 预防错误 In the fourth part of the process, you: 在过程的第四部分，你要： ? Take specific action to make sure the problem cannot recur, typically through errorproofing ? Capture Lessons Learne 采取特殊措施以保证问题不在发生，代表性的错误论据 取得课程学习。
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5-WHY PROBLEM SOLVING PROCESS
PRACTICAL PROBLEM SOLVING MODEL 实际问题解决模型 5 Why Funnel 5个为什么漏斗 个为什么漏斗
G S R I A T S U P A T T I H O E N C A U S E I N V E S T I G A T I O N
PROBLEM IDENTIFIED 问题识别 (Large, Vague, Complicated) （大的，含糊的，复杂的） Problem Clarified 阐明问题 过程里问题发生在哪？ ↓ 查找问题范围 Area of Cause Located Where in the process Point of Cause 发生事故 is problem occurring? 了解问题 的地点 (PoC) “Go See” the problem Why? 1 为什么？ 基本原因 /结果调查 Cause 原因 Basic Cause/Effect Investigation Why? 2 Cause 5WHY？ 问题根源的调查 Why? 3 Cause 5 Why? Why? 4 Investigation of Root Cause Cause Why? 5 Why did we Why did it
have the problem? get to the customer?
Why did our “system” fail?
↓ Root Cause 问题根源 ↓ Corrective Action 纠正措施 ↓ Lessons Learned 课程学习
为什么我们会有 这种问题？
为什么对顾客有影 响？
为什么我们的 系统失效？
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5-WHY PROBLEM SOLVING PROCESS
BASIC STEPS OF PRACTICAL PROBLEM SOLVING 时间问题解决的基本步骤 Part I – Grasp the Situation 第一部分---掌握情况。 ? Step 1: Identify the Problem 第一步：识别问题 第一步： In the first step of the process, you become aware of a problem that may be large, vague, or complicated. You have some information, but do not have detailed facts. Ask: 在过程的第一步，你可以意识到问题可能是大的、含糊的或是复杂的，你有一些信息，但是没有详细事实。问： What do I know? 我了解什么？ ? Step 2: Clarify the Problem 第二步：阐明问题。 第二步：阐明问题。 The next step in the process is to clarify the problem. To gain a more clear understanding, ask: 过程的下一步是阐明问题，为了得到一个更清楚的认识，问： What is actually happening? 实际发生了什么？ What should be happening? 什么应发生？ ? Step 3: Break Down the Problem 第三步：分解问题 第三步： At this point, break the problem down into smaller, individual elements, if necessary. 在这一点，如有必要，把问题分解成更小的单个元素。 What else do I know about the problem? 我还要对问题了解什么？ Are there other sub-problems? 那里还有其它问题吗？ ? Step 4: Locate the Point of Cause (PoC) 第四步；查找事故发生的地点。 第四步；查找事故发生的地点。 Now, the focus is on locating the actual point of cause of the problem. You need to track back to see the point of cause first-hand. Ask: 现在，中心是查找问题的根源的实际地点，你需要追踪直接的事故点。问： Where do I need to go? 我们需要去哪里？ What do I need to see? 我们需要了解什么？ Who might have information about the problem? 谁可能会有有关此问题的信息？ ? Step 5: Grasp the Tendency of the Problem 第五步；掌握问题倾向 第五步； To grasp the tendency of the problem, ask: 为了掌握问题倾向，问： Who? 谁？ Which? 那一个？ When? 什么时候？ How often?（ 单位时间发生的频率）多少？ How much? 多少？ It is important to ask these questions before asking “Why?” 在问“WHY”之前问这些问题是很重要的。
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5-WHY PROBLEM SOLVING PROCESS
Part II: Cause Investigation 第Ц部分：原因调查。 部分：原因调查。 ? Step 6: Identify and confirm the direct cause of the abnormal occurrence. 第六步：识别和确认反常事件的直接原因。 第六步：识别和确认反常事件的直接原因。 If the cause is visible, verify it. If the cause is not visible, consider potential causes and check the most likely causes. Confirm the direct cause based on fact. Ask: 如果原因明显，验证它。如果原因不明显，考虑潜在的原因和检查类似事故，以事实为基础确认直接原因。问： Why is the problem occurring? 问题为什么发生？ Can I see the direct cause of the problem? 我能看到问题的直接原因吗？ If not, what do I suspect as potential causes? 如果不能，我猜想潜在原因是什么？ How can I check the most likely potential causes? 我怎么检查类似的潜在的原因？ How can I confirm the direct cause?我怎么确认直接原因？ ? Step 7: Use 5-Why investigation to build a chain of cause/effect relationships that lead to the root cause. Ask: 第七步：利用5Why调查以建立一通向问题根源的原因 结果的关系链。问： 调查以建立一通向问题根源的原因/结果的关系链 第七步：利用 调查以建立一通向问题根源的原因 结果的关系链。 Will addressing the direct cause prevent recurrence?查明直接原因预防再发生了吗？ If not, can I see the next level of cause? 如果没有，我能看到下次再发生的机率吗？ If not, what do I suspect as the next level of cause? 如果没有，对于下次再发生的机率我觉察到什么？ How can I check and confirm the next level of cause?我怎样检查和确认下次再发生的机率？ Will addressing this level of cause prevent recurrence? 查明事故级别预防再发生了吗？ If not, continue asking “Why?” until you find the root cause.如果没有，继续问为什么直到你找到了问题根 源。 Stop at the cause that must be addressed to prevent recurrence. Ask: 停止这些，预防事故再发生。问： Have I found the root cause of the problem?我找到问题的原因根源了吗？ Can I prevent recurrence by addressing this cause?我根据找到的原因，预防再发生吗？ Is this cause linked to the problem by a chain of cause/effect relationships that are based on fact?根据基 于事实的原因/结果关系链，这个原因与问题有联系吗？ Does the chain pass the “therefore” test?这个链能通过“因此”测试吗？ If I ask “Why?” again, will I be into another problem?如果我再次问“为什么”，我会深入到另一个问题之 中吗？ Be sure you have used 5-Why Investigation to answer these questions:确信你会用5-Why调查回答这些问题： Why did we have the problem?为什么我们会有这种问题？ Why did the problem get to the customer?为什么问题会对顾客有影响？ Why did our “system” allow it to occur?为什么我们的系统“允许”它发生？
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5-WHY PROBLEM SOLVING PROCESS
5 WHY CAUSE INVESTIGATION 5Why原因调查 原因调查
Abnormal Occurrence反常事件 Why? (cause/effect relationship)原因 结果关系 原因/结果关系 原因
C
C
C
C Why?
Direct Cause直接原因 (cause/effect relationship)原因 结果关系 原因/结果关系 原因
C
C
C
C Cause原因 Why? (cause/effect relationship)
C
C
C Why?
Cause
(cause/effect relationship)
C
C
C Why?
Cause
C
C
C
Root Cause 问题根源
Therefore Test 因果测试
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5-WHY PROBLEM SOLVING PROCESS
Step 8: Take Specific Action to Address the Problem 第八步：采取特殊措施解决问题 Use temporary measures to eliminate the abnormal occurrence until the root cause can be addressed. Ask: 使用临时方法消除反常事件直到问题根源被找出。 Does it contain the problem until a permanent solution can be implemented? Implement corrective actions to address the root cause to prevent recurrence. Ask: 在执行一项持久解决方案之前，它可以解决问题吗？ 实施纠正措施以标明问题根源防止再发生。问： Does it prevent the problem?它能预防问题发生吗？ Follow-up and check results. Ask:跟踪和检查结果，问： Is the solution working?此解决方案运行了吗？ How do I know?我怎么知道？
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5-WHY PROBLEM SOLVING PROCESS
PRACTICAL PROBLEM SOLVING CHECKLIST 实际的问题解决检查表 To be sure you have followed the problem solving model, use this checklist as you complete the problem solving process. 确信你遵循了问题解决模型，当你完成问题解决过程时使用这项检查表：
Grasp the situation掌握情况 掌握情况 ___ Pick-up the problem. 提取问题 ___ Clarify the problem. 阐明问题 ___ Break down the problem. 分解问题 ___ Locate the Point of Cause (PoC).查找发生事故的地点 ___ Grasp the tendency of the problem.掌握问题倾向
Cause Investigation原因调查 原因调查 ___ Identify/confirm the direct cause.识别/确认直接原因 ___ Ask 5 Why's to identify the root cause.提问5Why去识别问题根源 ___ Ask 5 Why's for “Why the problem was not detected and reached the customer?” 提问5Why中的为什么问题没有被顾客发现和传达。 ___ Ask 5 Why's for “Why did the system allow the problem to occur?” 提问5Why中为什么系统允许问题发生？
Problem Correction问题纠正 问题纠正 ___ Implement corrective action; at a minimum, implement temporary measures 实施纠正措施；至少实施临时方法。
Prevention预防 预防 ___ Errorproof the root cause.错误论证问题根源 ___ Capture Lessons Learned.取得课程学习
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5-WHY PROBLEM SOLVING PROCESS
ACTIVITY:活动 活动 FLEX INDUSTRIES CASE STUDY 弯曲工业事例研究
Directions: 说明 Use the Delphi Problem Solving Process to evaluate the Flex Industries Case Study below and on the following pages. Review the 5-Why Investigation results on Page 11. 使用德尔福问题解决过程，评价页底及下页的弯曲行业事例研究。评审第11页的5-Why调查结果。 Use the worksheets on Pages 13 and 14 to record your work.使用第13、14页的工作表记录你的工作。 Use only the information provided.仅用于假设信息 Do not try to re-engineer the rivets or solve the technical problems in the case study. The purpose of this activity is to use the Problem Solving model to organize the given data. 在这个事例研究中，不要试图模仿设计铆钉或解决技术问题。这项行动的目的是使用问题解决模型去组织特定 数据。
FLEX INDUSTRIES CASE STUDY 弯曲工业事例研究
Background 背景 Jake Ryan is the Quality Manager at Flex Industries. Flex is a component supplier that manufactures metal stampings and light assembly products. The company has a reputation for supplying high quality parts on a consistent basis. Seldom has there been a customer complaint. Flex has Quality representatives called Customer Support Engineers (CSE’s) at every customer assembly plant. The CSE’s report any problems to Jake for investigation and follow-up. JackeRyan是弯曲行业的质量经理，弯曲是生产金属冲压件和照明装配产品的供应商的组成部分。此公司在提供高 质量产品上享有声誉。很少有客户抱怨，Flex的每个顾客装配厂都有称为顾客支持工程师（CSE）的质量代表，顾 客支持工程师给Jacke报道大量问题，以调查和跟踪。 At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the Winding River Assembly Plant. Janet informed him that the customer had found five defective stabilizing brackets on second shift last night. She checked the remaining inventory and there were no defects in the remaining 326 pieces. The manufacturing sticker on the back of the brackets indicated that they were made by the second shift operator. Normally, the stabilizing bracket is fastened to the regulator motor with three rivets. The five defective brackets had only two rivets in them. The lower set of rivets on all five brackets was missing a rivet. This was the first time that the problem occurred. 早上7：00Jake接到了JanetWandingRiver装配厂的ＣＳＥ，Janet的电话，告诉他昨天晚上在第二轮班，顾客发现 五个有缺陷的固定支架，她检查了剩余的存货且剩余的３２６个产品没有缺陷。支架背部的生产标签显示，它们是 第二轮班操作工制造的。通常固定支架用三个铆钉固定在发动机调整器上。这五个支架上较底位置的铆钉缺少了一 个，这个问题是第一次发生。
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5-WHY PROBLEM SOLVING PROCESS
GOOD
BAD
Jake set-up containment procedures at the plant warehouse to sort for discrepant materials. As of this morning, two more defective brackets had been found in the remaining 2019 pieces of inventory at Flex. Jake对仓库施行围堵政策程序，以挑选差异原料。就在今天早上，在Flex剩余2019个存货中发现了不至两个缺陷支 架。
Cause Investigation原因调查 原因调查 Jake went out to the floor to talk with the team leader of the two rivet lines (East and West) and the area quality assurance auditor. He informed Sam (the team leader) of the quality problem and asked him to identify the line which runs the stabilizing bracket assembly. Sam directed Jake to the East line which runs Winding River assembly brackets only. Jake去基层与东西两个铆钉生产线的领导组和区域质量保证审核员谈话。他告诉Sam（本组领导）这个质量问题。 并且要求他 验证是哪个线进行固定支架装配的。Sam直接告诉Jake仅东线进行WindingRiver支架装配。 At the East Line, he spoke with Judy (the QA Auditor for the area) and asked to see the quality log sheets. Jake and th Judy reviewed the Nov. 11 log sheet and could not find anything out of the ordinary. He asked her to set-up in-house containment procedures to sort for any discrepant material in the finished goods area. 在东线，他与Judy（此区域QA审核员）讲话并且要求去看质量日志表。Jake和Judy评审了11月11号的日志表，并 没有发现任何异于平常的事情。他要求她去建立内部围堵政策程序在成品区挑选任何差异原料。 Next, Jake tried to locate the second shift operator whose clock number was on the defective parts. Since that operator was gone, Jake spoke with the current machine operator (Ben). He asked Ben about any recent difficulties with the rivet machine. Ben said that he hadn’t noticed anything out of the ordinary. Ben also mentioned, however, that there had never been any quality bulletins posted in the two years that this particular part has been running. 接着，Jake试着查找工作时间在出现缺陷零件的第二轮班操作工，操作工走之后，Jake与当前操作员Ban谈话，他 问Ben近来在铆钉加工有 什么困难。Ban说他没有发现任何异与平常的事。然而，Ben也提起在用精确零件运行的 两年内，那里没有任何的质量报告。 Jake decided to stay in the area to watch the machine run for a while. After about 15 minutes, he watched Ben dump rivets into the feeder bowl to prepare for the next run.
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5-WHY PROBLEM SOLVING PROCESS
Shortly after restarting rivet operations, Ben walked over to another riveter and came back with a steel rod. Ben poked around the rivet chute and then continued working. Jake approached Ben and asked him about the steel rod. Ben replied that from time to time the chute gets jammed and he has to clear it out. This happens two or three times during a shift. He didn’t mention this in his earlier conversation with Jake because the problem has existed ever since he started working with this machine. The previous operator showed him how to clear the chute. All the rivet machines are like this. Jake决定暂时呆在这监视机器运转。大约15分钟后，他观察到Ben把铆钉倒入进料钵，准备下此运转。很快重新开 始铆钉操作。Ben走到另一个打铆机并且带了一个钢棒回来，Ben捅了捅铆钉斜槽，然后继续工作。Jake靠近Ben 问他关于钢棒的事。Ben回答说有时这个斜槽被堵塞，并且他必须清除它，一个轮班出现两三次。在同Jake的早期 谈话中，他没有提及这件事，因为从他开始在这台机器工作以来，这个问题一直存在。先前的操作工教给他怎样清 除斜槽。所有的铆钉机器都是这样。 Jake called the Machine Repair Department and asked that someone look at the rivet track. A slight gap in the track was found and removed, and Ben continued to work. Jake叫来机器修理部且要求看这个铆钉通道，通道中一个微小的缺口被发现，除去后，Ben 继续工作。 Two hours later, Jake got a call from Ben saying that the track was still jamming. As far as Jake could see, only rivets were in the bowl. Next, Jake looked into the rivet supplier containers. There was some foreign material in the blue container, but none in the red container. The label on the blue container showed that it was from Ajax Rivet, Inc., and the label on the red container indicated that it was from Frank’s Fasteners. Obviously, the foreign material was entering the rivet feeder bowl and jamming the track. 两个小时以后，Jake接到Ben 的电话说通道仍然堵塞。至到Jake看到仅铆钉在钵内。接着，Jake看到铆钉厂商的箱 子，蓝色箱子里有一些杂质材料，但是 红色箱子没有。蓝色箱子的标签显示它来自Ajax Rivet 公司并且红色箱子的 标签显示它来自Frank’s Fasteners，明显的，杂质材料进入铆钉进料器，并且阻塞了通道。 Jake called Maintenance and requested that the bowl be cleaned. He also added the cleaning operation to the preventive maintenance schedule on the equipment. He then called both Ajax Rivet, Inc. and Frank’s Fasteners. He asked about the cleaning procedures on the returnable containers. Frank’s did a full container purge and clean. Ajax just re-introduced the containers back into their system. When Jake asked why Ajax did not clean their containers, he was told that Ajax was not aware that such a policy was needed. Jake命令维修并要求清扫钵，他也把清扫工作加到预防性维护时间表上。然后他打电话给Ajax Rivet I公司和Franks Fasteners，他要求在 可退回的箱子上有清洁程序。Frank公司做了一次全面的清除和清扫。Ajax正 好重申退回这些箱子。 当JAKE问Ajax为什么不清扫他们的箱子时， 他被告之Ajax没有意识到诸如这个方针是必要的。 Upon further investigation, Jake learned that Frank’s Fasteners supplies other major automotive companies. Since these companies require that all returnable containers be cleaned, Frank’s instituted the purge as part of its practice for all customers. Ajax Rivet, however, depends primarily on Flex as its major customer. No such policy has ever been required of them. 在更深的调查上，JAKE认识到Frank’s Fasteners供应其它的重大汽车公司， 自从这些公司要求清扫所有的可退回的 箱子之后。Frank’s开始将清除作为为顾客实践的一部分，诸如这样的方针以前从来没有被要求过。（以下为方框中 的译文）：JAKE号召材料控制部门起草一项适用于他们所有厂商的包装箱维护政策，他也要求修正机器以能判断铆 钉的存在。 Jake called the Material Control Department and requested that a container maintenance policy be drafted which would apply to all their suppliers. He also asked that a machine modification be developed to sense for the presence of rivets. Hopefully, this would error-roof the process. KEY PLAYERS Jake Janet Sam Judy Ben Quality Manager CSE, Winding River Plant Team Leader, East Line QA Auditor, East Line Machine Operator
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5-WHY PROBLEM SOLVING PROCESS 5-Why Cause Investigation
Reference No. _参考号______________ (Spill, PR/R…) Date: ____________________
5WHY原因调查 原因调查 纠正措施
Corrective Actions
Date
Define Problem
Missing rivets on brackets shipped to customer WHY?
明确问题
Use this path for the specific nonconformance being investigated
Automated rivet machine did not place rivet in position WHY?
用这种方法调查 特殊的反常
问题根源 自动化铆钉机器在一定部 位没有安装铆钉
Root Causes
缺少 铆钉 的支 架运 送给 顾客
Feedline had obstruction 利用这种方法调 查为什么问题没 WHY? Use this path 有被发现 to investigate why the problem was not detected No requirement on control plan to sample brackets continuously; only at set-up WHY?
Not identified on PFMEA as possible failure mode except at set-up
生产线被堵塞
Foreign material found in dunnage obstructing feedline WHY?
杂质材料阻 塞生产线
校订包装规范以反映没有杂质 材料的要求 供方对日常用品没 有维护过程
样品支架控制计划仅是 创建而没有持续要求， 除了建立没有验 证PFMEA可能的 失效模式
Supplier had no maintenance program for dunnage WHY?
A - Revise packing specification for dunnage to reflect no foreign material requirement
B
Supplier not aware of requirement about foreign material
A
B & C - Revise scope of PFMEA to include entire process from dock to dock
Use this path to investigate the systemic root cause
用这种文法调查 系统故障根源
供方没有注意到有 关杂质的要求
B&C-校订PFMEA范围包括从 一方到另一方运送整个过程
Potential failure mode not identified on PFMEA WHY?
潜在失效模式在 PFMEA没有验证
B - Update PFMEA and Control Plan to reflect continuous sampling plan for brackets
Failure modes associated with incoming dunnage not addressed WHY?
与引入日常用品相关的失效 模式没有标明
B – Modify machine to sense for presence of rivets
更新PFMEA和控制计划以反映持续 支架抽样检验方法 PFMEA范围仅限 于制造过程 修正机器以判断铆钉存在
Scope of PFMEA limited to manufacturing process only
C
Lessons Learned:课程学习 1. Make supplier part of APQP activities.做APQP活动的供应商部分 2. Make PFMEA’s comprehensive of entire system
做整个系统的PFMEA的全部
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5-WHY PROBLEM SOLVING PROCESS Delphi 5-Why Template to be used for all 5-Why Investigations
Reference No. __________ (Spill, PR/R…) Date: ____________________
Define Problem
Use this path for the specific nonconformance being investigated
WHY?
5-Why Analysis
Corrective Actions
Date
Root Causes
A
WHY?
Use this path to investigate why the problem was not detected
WHY?
WHY?
B
WHY? WHY?
A
Use this path to investigate the systemic root cause
WHY? WHY?
WHY?
WHY?
B
WHY?
C
WHY?
Lessons Learned:
WHY?
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5-WHY PROBLEM SOLVING PROCESS
FLEX INDUSTRIES WORKSHEET
FLEX工业工作表
GRASP THE SITUATION掌握情况 掌握情况 Activity (Step)措施（步骤） Identify the problem识别问题 识别问题 What did they know?他们知道什么 他们知道什么 What did they do?他们做什么 他们做什么
PROBLEM IDENTIFIED (Large, Vague, Complicated) Problem Clarified Area of Cause Located Point of Cause (PoC) Why? 1 Cause Why? 2 Cause Why? 3 Cause Why? 4 Cause
Clarify the problem阐明问题 阐明问题
Break down the problem分解问题 分解问题
Locate point of cause查找事故地点 查找事故地点 (geographic location)地理位置 地理位置
Why? 5
↓
Grasp tendency of the problem (What questions are you asking?)掌握问题倾向（你问的是什么 掌握问题倾向（ 掌握问题倾向 问题） 问题）
Root Cause ↓ Corrective Action ↓ Lessons Learned
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5-WHY PROBLEM SOLVING PROCESS
CAUSE INVESTIGATION问题调查 问题调查 Activity (Step)措施 Identify/confirm the direct cause识别/确认直接原因 Ask 5 Why’s to identify the specific root cause提问5WHY以识别特殊问题根源 associated with the problem联系问题
PROBLEM IDENTIFIED (Large, Vague, Complicated) Problem Clarified Area of Cause Located Point of Cause
What did they know?他们知道什么 他们知道什么
What did they do?他们做什么 他们做什么
Ask 5 Why’s for why the problem was not detected and reached the Customer
提问5WHY中的为什么问题没有被顾客发现和传达
(PoC) Why? 1 Cause Why? 2 Cause Why? 3 Cause Why? 4 Cause Why? 5
Ask 5 Why’s for why the “System” allowed it to happen
提问5WHY中为什么系统允许它发生
Implement temporary measures to protect the Customer
执行临时方法以保护顾客
Implement corrective actions to prevent the problem from recurring实施纠正措施以预防问题再发生 Follow-up and check results
跟踪和检查结果
↓ Root Cause ↓ Corrective Action ↓ Lessons Learned
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