RCA培训教材

we don’t want to become good at investigating problems so that we can investigate more and more problems 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. We want to become good at investigating problems so that we can investigate fewer and fewer. 我们想善于探究问题，但能探究的问题越来越少
Step 3 Solutions解决方案
once the analysis is completed, possible solutions are identified for specific causes. The possible solutions can be listed and from them we select the best solutions for the action plan.
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Introduction介绍 Principles原理 Cause Mapping – 3 steps CM 理论的3个步骤 Facilitation and Application便利性和适用性
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Your Roles你的工作
Be able to analyze one Problem 要能分析问题
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Introduction介绍
Process map流程图
A map of the specific steps of work process工作进程中具体步骤的流 程图
The work process defines how we would like to conduct the business everyday此图 展示了每日n Item措施项目
Cause原因
Notes备注
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One Problem Approach 通过一个难题
Instead of attempting to change the culture, people, history and
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。
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1. Problem问题
Step 1 Problem outline问题概要 • What 什么问题 • When 何时发生 • Where 在何地 • Goals 造成的影响
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Introduction介绍 Cause Maps A map of the causes of a problem问题起因的示意图
1. Problem问题
2. Analysis分析
3. Solutions方案
The cause map is a visual explanation of why we didn’t get the desired results from the work process此图直观解释了为什么工作达不到预期效果
The corrective 1. Problem问题 actions after an investigation make 2. Analysis分析 specific changes to the work process 3. Solutions方案 经查究之后，某些 整改措施会改变工 作中的某些环节
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。

Culture is changed by starting with just one problem at one time 改变文化，仅仅可以先从解决一个难题开始
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Cycle of Continuous Process Improvement 工艺改进的连续循环示意图
When a process doesn’t produce the desired results out first question should be “WHY?” These “WHY?” questions are the analysis of the problem 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。
Step 2 Analysis分析
Break the problem down into its parts. It is driven by evidence based cause-and-effect relationships that are captured visually. 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。
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Overall goals – define and prioritize problems 总体目标—将问题定性并依次排序
All problems within an organization impact the overall goals in some negative way. If there isn’t a negative impact on the goals then it’s not a problem. 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。 People will disagree about “the problem”, but they won’t disagree about how the goals are affected. 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。 The impact on the overall goals for the organization dictates the necessary level of detail in the investigation.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。
Today今天 Challenge and ask questions挑战和提问 Practice实践 After the workshop了解理论之后 Practice the RCA process将RCA理论用于实践 Apply the RCA on your problems用RCA理论处理你的问题 Lead by example in Problem solving sessions以身作则的处理问题 Teach this to someone else将此理论教给别人
The Focus is on PREVENTION重点在于预防
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Cause Mapping – 3 steps
Step 1 Problem问题
CM理论3步走
4 simple questions: what, when, where and the impact to the goals 4个简单的发问：什么问题、何时发生、在何地、以及影响如何
Crumple Air Seat Bags Zones belts 安全带 气囊 缓冲区
We can’t make cars safe, but we can maker them safer. 我们不能保证车辆绝对安全， 但能保证它们相对安全。
Reliability is the probability that a “system” will perform its intended function for a given period of time under stated conditions. This principles could be used in safety, scheduling, business, project, operations, maintenance and business problems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。 The continuous improvement process means we can never arrive; we can never reach the end. There is always room for improvement. There is always be other ways.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。
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Basic Concepts基本概念
预防措施 解决问题并降低风险

Prevention Problem solving and reducing risk
Overall goals Prioritize every issue and incident 整体目标 确定问题和事件的轻重缓急 People Creative resource already on the payroll 人力利用 通过薪资开发现有资源 Principles Consistent approach 规章制度 坚持贯彻实施
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Prevention – reducing the risk
预防—降低风险
Some problems are solved by finding the right answer and some problems are solved by finding the best solutions.