8d报告医学知识.pptVIP

* Discipline 4 – Identify Root Cause 识别根本原因 Root cause identification should include:根本原因识别应： Use tools from the Root Cause Analysis Tool Box (e.g. Fishbone Diagram, 5-Why Analysis, Pareto Analysis, etc). 使用“根源分析工具箱”中的工具(如鱼骨图，5Why分析（实例）， Pareto 分析，树图等) Test of each potential cause against the problem description and data. Each observable symptom should be explainable. 针对问题描述和数据，测试每个潜在原因。每一个可观测的症状都应是可解释的。 A detailed description of the actual failure mechanism to show that the failure has been fully understood.对实际失效机理有详细的描述，表明该故障已被完全弄懂。 The root cause is presented showing how it triggered the failure mechanism identified. 根本原因能表明它是如何触发了已确定的失效机理。 As much evidence as possible to show that the root cause is the real culprit behind the problem. 尽可能多的证据表明，根本原因是问题背后真正的罪魁祸首。 The root cause must be actionable. “Gravity” can’t be the root cause why something fell and broke. 根本原因必须是可控的。”重力“不能作为事物掉落或打破的根本原因。 * D4 –Root cause根本原因 Some Rootcause Analysis Tools:一些根本原因分析方法 Process map 过程图 Cause and Effect Analysis/ Fish bone diagram 因果分析/鱼骨图（头脑风暴） FTA (Fail Tree Analysis)故障树分析法（3*5W） 以往的经验（FMEA） 必要时的问题再现（问题验证） * D4 – Process map过程图 A process map is used to graphically identify which process is more likely the source of the problem.过程图是用图表判定哪个步骤更可能是问题的源头 Get the flow chart or draw the steps of the process and by brain storming get a consensus which processes are most likely the source.写出流程图或过程步骤，运用脑力风暴对最可能是源头的过程达成一致意见 * D4 – Cause and Effect/ Fish Bone 因果/鱼骨 Cause and Effect is team approach brain storming tool that uses a fish bone diagram to analyze all elements of the process and dig down to the main rootcauses by category such as Man, Machine, Method, Material, Handling, Design, Tools/ Mold, Etc,..因果是采用鱼骨图，分析过程中的所有元素，挖掘主要原因，例如人，机器，方法，原料，操作，设计，模具等的一种团队头脑风暴方法。 Look for identical or related elements that showed frequently in different areas. Those are most likely the main issues that needs to be have corrective actions. 寻找在不同区域频繁出现的相同或相关的元素。那些最有可能是需