根本原因分析培训教材RCA.ppt

* Problem question Direct cause Cause that directly results in the problem Contributing cause Root cause By running it backwards, does it make sense? 1.问题疑问 2.直接原因 3.问题导火索 4.间接原因 5.根本原因 6.回过头看,是否有作用? Transition: We’ve been through the first two phases and are now on solution. Root cause analysis is all about implementing effective corrective actions. 过度:到此,我们已经完成了头两个阶段,现在进入解决方案阶段.根本原因分析就是实施有效纠正措施. * * Manual: Mod 4 – P 1 操作指南:步骤4-P1 What is corrective action? 纠正措施指什么? 纠正措施：为消除已发现的不合格或其他潜在不期望情况的原因，防止不合格的再发生所采取的措施。 预防措施：为消除潜在不合格或其他潜在不期望情况的原因，防止不合格的发生所采取的措施。 * Ask: Does everyone believe that if you correct only the root cause, every problem will be fixed forever. 问:是否每个人都相信,只要根本原因得到纠正,问题就可以得到永远解决. contributing causes need to be addressed also. 间接原因也要解决. * Manual: Mod 4 – P 1 操作指南:步骤4-P1 Short Term Corrective Action (addresses only the direct cause and effect). 短期性纠正措施(说明直接原因及其后果) Preventive corrective action ( addresses contributing and root causes). 长期（预防性）纠正措施(纠正间接原因和根本原因) To class: This is a new way of looking at the definitions! We have found one big reason why corrective actions have not worked. People just don’t understand the difference between these two actions. To fix the problem requires understanding the difference. 告诉班级学生:这是对定义这一概念的新看法!我们已经发现纠正措施不起作用的一个重要原因.那是因为人们还不明白两类措施的不同之处.要解决问题,就要先弄清楚它们之间的不同之处. * Very important page! Have class read text carefully. 本页很重要!让班级学生们仔细阅读. When people get Short Term Corrective Action confused with preventive action they will stop and not go any further. 当人们连短期性纠正措施和预防性纠正措施都分不清楚的时候,他们就无法进行后续工作. Make sure the participants fully understand just what Short Term Corrective Action is and how limited it is ( i.e. does very little to prevent recurrence). C/A’s that stop at Short Term Corrective Action a major problem seen in audit responses. History repeatedly shows that people do not understand the difference between Short Term Corrective Action and preventive. 确信参与者已经完全理解什么是短期性纠正措施及其局限性(几乎无法防止问题再次发生).历史一次次的说明,人们总是不理解短期性纠正措施和预防