RootCauseFailureAnalysis_rev2

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3、ting, sales, operation or repair of John Deere, Timberjack or Hitachi branded products. No unauthorized disclosures may be made without the written permission of Deere & Company or one of its affiliated entities. Root Cause Failure AnalysisRoot Cause Failure Analysis Training AgendaTraining Agen

4、da What is Root Cause Analysis什么是根本原因分析 How to do Failure Analysis如何做故障分析 Examples of Failure Mode Analysis故障模式分析举例 Shafts轴 Hoses软管Root Cause AnalysisRoot Cause Analysis根本原因分析根本原因分析Objectives for this part of the training: 这个部分的培训目的Define Root Cause Analysis and know when to use it 定义根本原因分析，并知道何时使用它

5、Identify and explain the steps of the Root Cause Analysis Process, they are: 明确并解释根源分析流程的每一步，他们是：Define the event故障定义Collect data收集数据Analyze data分析数据Determine corrective action确定纠正措施Generate the finding report生成调查报告Follow up & assessment后续措施&评估RCA Defined RCA Defined RCARCA定义定义RCA is an effe

6、ctive process for finding the causes of an event, facilitating effective corrective actions, and preventing reoccurrence RCA是找到故障原因，推进有效地纠正措施，并且防止再次发生的有效途径The thrust of the root cause analysis is prevention 推行根源分析的目的是预防。 If you dont know what causes the problem, you cant fix it! 如果你不知道问题的原因，你就无法解如果你

7、不知道问题的原因，你就无法解决它！决它！When Should You Use RCA?When Should You Use RCA?Root cause analysis can be performed on anything but it might not be practical in all cases 任何问题都可以进行根本原因分析，但是不一定实用于所有情况。 It requires time and effort 需要付出时间和努力It is focused on what is the most important issues 它关注最重要的问题wSeverity严重程度

8、wSafety安全性wCost成本wCustomer satisfaction客户满意度Is it a reoccurring issue?是不是重复出现的问题Is it likely to reoccur?有没有可能再发生Exploring different views adds confidence to the process探索不同的见解增加流程的置信度Importance of Various OpinionsImportance of Various Opinions多种意见的重要性多种意见的重要性Having varied opinions brings different i

9、deas, needs and experiences不同的意见产生不同的观点、需要和经验Experience affects:经验影响：Areas investigated调查研究的范围Methods of data collection数据收集的方法How corrective action is identified如何验证纠正措施RCA Cause and Effect ChainRCA Cause and Effect ChainRCARCA因果关系链因果关系链Organization组织机构Root cause is identified by asking a series of

10、 “why” questions通过提问一系列的“为什么”的问题验证根源Asking why can be charted为什么能够制成图表Using cause chain diagrams allows you to handle large or complex problems that are difficult to process otherwise使用原因链图解让你能够处理巨大复杂的问题，否则很难处理EvEventent事件事件PhysicalPhysical RootRoot物理根源物理根源HumanHuman RootRoot认为根源认为根源HiddenHidden Roo

11、tRoot隐含根源隐含根源EventEvent ModeMode事件类型事件类型DirectDirect CauseCause直接原因直接原因Direct CauseDirect Cause直接原因直接原因ContributingContributing CauseCause作用原因作用原因WhyWhy? ?为为什么？什么？DirectDirect CauseCause直接原因直接原因WhyWhy? ?The EventThe Event事件事件An event is an inclusive term for any of the following: 一个事件包括以下所有的条目中的任何一个

12、：Product failure 产品失效Out of control process流程失控Audit finding审核发现Accident意外事件Customer complaint顾客抱怨Pleasant surprise, etc.惊喜等等EvEvententPhysicalPhysical RootRootHumanHuman RootRootHiddenHidden RootRootEventEvent ModeModePossible CausePossible CausePossible CausePossible CausePossiblePossible CauseCau

13、seEvent and Event ModesEvent and Event Modes事件和事件类型事件和事件类型Event is a brief description of the issue being analyzed事件是对已分析问题的简要描述Event modes are the answers to how the event has occurred in the past事件类型是对于以前事件如何发生的回答Your goal should be to define the event as simply, yet as completely as possible你的目标应

14、该是简要且尽可能完整地定义事件EvEventent事件事件PhysicalPhysical RootRoot物理根源物理根源HumanHuman RootRoot人为根源人为根源HiddenHidden RootRoot隐含的根源隐含的根源EventEvent ModeMode事件类型事件类型Possible CausePossible Cause可能的原因可能的原因Possible CausePossible Cause可能的原因可能的原因PossiblePossible CauseCause可能的原因可能的原因Event and Event ModesEvent and Event Mod

15、esPump FailurePump Failure泵故障泵故障 Bearing FailureBearing Failure轴承故障轴承故障 ContaminationContamination污染污染 Defining the EventDefining the Event定义事件定义事件A clearly defined problem is a key to problem resolution 清楚地定义问题是解决问题的关键It states what is wrong and the effect它描述什么是不对的，会带来什么影响It is measurable, how ofte

16、n and when did it occur?他具有可衡量性，多长时间发生一次，以前在什么时候发生过？Highlight the significance of effects?强调结果的重要性。Collect DataCollect Data收集数据收集数据Machine information:机器信息Model型号Serial number序列号Machine and component hours机器和零件工作小时数Operator/customer feedback操作者/客户的反馈Recent maintenance history最近维修保养记录Collect DataColl

17、ect Data收集数据收集数据Failure information:故障信息：Failed components part numbers损害零件的零件号Time of failure故障时间Picture of failed parts损坏零件的图片Application when failed出现故障时的使用状况Ambient condition when failed出现故障时的周围环境Preserve the Evidence!保护证据！保护证据！Sources of DataSources of Data数据来源数据来源Machine operator机器操作者Machine E

18、CU, TCU and monitor机械的行车电脑，牵引控制器和监视器Failed components损坏零件Machine Information Center (if available)机器信息中心（如有）Machine maintenance history log机器维修保养记录Oil analysis reports油样分析报告Possible CausesPossible Causes可能的原因可能的原因It is an educated guess not a fact这是有根据的猜测而不是事实Reasons that are supported by facts are

19、validated and considered possible causes有事实根据的原因是确认了的和考虑过的可能原因Reasons that cant be validated are then crossed out删除那些不能确认的原因For each validated cause, we again ask “why?”对每一个确认了的原因，我们要在问“为什么”EvEvententPhysicalPhysical RootRootHumanHuman RootRootHiddenHidden RootRootEventEvent ModeModePossible CausePo

20、ssible CausePossible CausePossible CausePossiblePossible CauseCauseTypes of CausesTypes of Causes原因类型原因类型Direct Cause直接原因Contributing Cause诱因Root Cause根本原因Possible CausesEvEvententPhysicalPhysical RootRootEventEvent ModeModeContributing CauseContributing CauseDirectDirect CauseCauseDirect CauseDirec

21、t Cause直接原因直接原因The cause that directly 直接导致结果resulted in an event导致事件发生The first cause in the chain在关系链中的首个原因EvEvententRoot CauseRoot CauseEventEvent ModeModeContributing CauseContributing CauseDirectDirect CauseCauseContributing CauseContributing CauseContributing CauseContributing CauseContributin

22、g CauseContributing Cause诱因诱因The cause that contributed to an event but, by itself, would not have caused the event是导致事件的原因，但其本身不能导致事件的发生The causes after the direct cause直接原因之后发生的原因The answer to asking why after the direct cause为什么会出现直接原因的问题的答案For a simple problem, there may not be any contributing

23、causes一个简单的问题，可能就没有任何诱因For a complex problem there could be dozens复杂的问题可能会有很多EvEvententRoot CauseRoot CauseEventEvent ModeModeContributing CauseContributing CauseDirectDirect CauseCauseContributing CauseContributing CauseContributing CauseContributing CauseRoot CauseRoot Cause根本原因根本原因The fundamental

24、 reason for an event 一个事件的基本原因It is the last cause in the chain是关系链图表中的最后一个原因EvEvententRoot CauseRoot CauseEventEvent ModeModeContributing CauseContributing CauseDirectDirect CauseCauseContributing CauseContributing CauseContributing CauseContributing CauseJust Keep Asking “Why?”Just Keep Asking “Wh

25、y?”一直提问一直提问“ “为什么为什么” ”Problem: Hydraulics were slow Problem: Hydraulics were slow 问题：液压系统延迟问题：液压系统延迟Why are the hydraulics vibrating and slowed? 为什么液压系统振动而且反映延迟Hydraulic system pressure is too low Hydraulic system pressure is too low 液压系统压力太低液压系统压力太低Why is the pressure low? 为什么压力低Hydraulic main pum

26、p failure Hydraulic main pump failure 液压主要泵故障液压主要泵故障Why did the pump fail? 为什么泵会出现故障Bearing failure Bearing failure 轴承故障轴承故障Why did the bearing fail? 为什么轴承会出现故障 Direct CauseDirect CauseContributingContributingContributingContributingRoot Cause?Why is there contamination in the system?系统中为何有污染Contrib

27、utingRoot CauseFaulty breather (ingression) 通气阀有故障（进入口）通气阀有故障（进入口）Contamination Contamination 污染污染Root CausesRoot Causes根本原因根本原因Physical roots:物理根源Tangible可触摸的Visible可见的Must endure validation必须经过确认Human roots:人为的根源Decision errors that triggers the physical root错误的决策引发物理原因Hidden Roots:隐含的根源Flaws in t

28、he organization system people use to make decisions人们用以决策的组织结构系统的缺陷EvEvententPhysicalPhysical RootRootHumanHuman RootRootHiddenHidden RootRootEventEvent ModeModePossible CausePossible CausePossible CausePossible CausePossiblePossible CauseCauseCause and EffectCause and Effect因果关系因果关系Received ticket

29、for safety violation收到违反安全的罚单Car exhaust too loud汽车排气设备声音太大Muffler knocked loose from tail pipe消声器敲击从排气管尾管Driver hit pot hole驱动器打击涡穴Pot holes in road路面的坑槽Winters damage roads冬季破坏路面Congress wont approve extra money for better roads国会不批准为改善道路拨额外资金Congress doesnt have extra money国会没有额外的资金Congress spent

30、 money on pork barrels国会将资金用于地方建设经费Too many lawyers in Congress国会中有太多的律师Solution? Drive car in Sweden where there are fewer lawyers解决办法？在瑞典律师少的地方开车Follow the DataFollow the Data遵循数据遵循数据Be completely honest十分诚实Eliminate preconceived notions排除先入为主的观念Explore every option研究每一个选择Cause Chain GuidelinesCau

31、se Chain Guidelines原因链指导方针原因链指导方针Start with defining the event从定义事件开始Write down each possible cause写下每种可能的原因Use the why method to sort运用为什么的方法排序筛选Take small steps迈出小步Dont jump to solutions不要跳到解决方案上Validate the chain验证关系链WHY?Hydraulic Pump FailureHydraulic Pump Failure液压泵故障液压泵故障Hydraulic Pump Failure

32、Hydraulic Pump FailureBearing failureBearing failure轴承故障轴承故障MishandlingMishandlingSeal failureSeal failure密封故障密封故障Improper installationImproper installationInsufficient lubricantInsufficient lubricantContaminated oilContaminated oilLubrication issue Lubrication issue Particles contaminationParticles

33、 contaminationMoisture contaminationMoisture contaminationWrong/degraded oilWrong/degraded oilOverheatOverheatIngestedIngestedInternally generatedInternally generatedResidentResidentShaft failureShaft failure轴故障轴故障Faulty breatherFaulty breatherFaulty sealFaulty sealFaulty capFaulty capFaulty cylinde

34、r sealFaulty cylinder seal液压油缸密封问题液压油缸密封问题Not monitoring machineNot monitoring machine没有监测机器没有监测机器 Not cleaning the systemNot cleaning the system没有清理系统没有清理系统No established procedures to No established procedures to monitor machine or clean the monitor machine or clean the systemsystem没有建立检测机器或清理系统的没

35、有建立检测机器或清理系统的规程规程Human rootHuman rootPhysical rootPhysical rootHidden rootHidden rootRoot CausesRoot Causes根本原因根本原因Determine Corrective ActionsDetermine Corrective Actions确定纠正措施确定纠正措施A set of planned actions implemented for the purpose of resolving the problem实施一套有计划的措施实现解决问题的目标Corrective actions ar

36、e the output of the process and should be monitored and evaluated纠正措施是流程输出，需要受到监管和评估Corrective ActionsCorrective Actions纠正措施纠正措施There are three types of corrective actions taken during the process:流程中有三种纠正措施：1. Immediate action is used to change the direct cause and effect 立即采取措施用于改变直接原因和结果 2. Inter

37、im action is used to minimize the possibility of an event recurring until the final preventive actions can be put in place 临时措施用于在最终预防措施前降低事件在发生的可能性。3. Preventive action is used to eliminate contributing and root causes 预防措施用于排除诱因和根本原因Generate ReportGenerate Report生成报告生成报告Generating a written report

38、 will:生成书面报告，将：Document RCA process记录下RCA流程Provide machine historical data提供机器的历史数据Keep management involved and aware of RCA success让管理层涉入了解RCA的成功Track corrective action and recommendation跟踪纠正措施和推荐Evaluate the organization RCA process评估RCA流程的组织机构Prepare the ReportPrepare the Report报告准备报告准备Machine in

39、formation机器信息Event definition or current situation事件定义或现状Summary of finding发现的概要Recommendation and/or corrective actions推荐方案和/或纠正措施Conclusion结论List of attachments (photos, lab results, emails, etc)附件清单（照片，实验结果，邮件等等）Follow Up & Assessment Follow Up & Assessment 后续跟踪和评估后续跟踪和评估Follow Up: A revi

40、ew done to insure all corrective actions were implemented as stated后续跟踪：完成审查，确保所有的纠正措施按照要求实施Assessment: An independent review to determine if the corrective actions have been effective in preventing recurrence评估：独立的审查，确定纠正措施对于预防再发生是否有效RCA Process Success FactorsRCA Process Success FactorsRCARCA流程成功的

41、因素流程成功的因素Management / Customers agree to implement corrective actions管理层/客户同意实施纠正措施Following the RCA process discipline and avoiding early conclusions遵守RCA流程的原则，避免提早给出结论All possible causes must be either verified or disapproved所有可能的原因要么经证实要么不被认可No one will be disciplined for an honest mistake没有会因为诚实

42、的错误而受罚A process to track implementation of team recommendations must be created必须建立团队建议实施的跟踪流程Failure Mode AnalysisFailure Mode Analysis故障类型分析故障类型分析Objective of this part of the training is to:这部分的培训目标是：Define and identify fatigue定义并验证pilaoIdentify types of fracture确定断裂类型Identify characteristics of

43、fracture 确定断裂的特性FatigueFatigue软化软化Most engineering materials contain imperfections大多数工程材料包含不合格折贴Imperfections can lead to cracks 不合格折贴会导致断裂Repeated loading weakens material循环负载是材料变弱Repeated bending of paper clip will lead to a fatigue failure反复弯曲回形针将会导致疲劳损毁Cyclic Loading and FatigueCyclic Loading an

44、d Fatigue循环载荷与疲劳循环载荷与疲劳132Fracture:Fracture:破裂破裂Fracture is a separation of a body into pieces due to forces greater than the strength of the material由于压力大于材料的强度，一个整体分离成碎片Fracture occurs in phases:破裂发生分为以下几个阶段：1. crack initiation裂纹开裂2. crack propagation裂纹扩展3. final fracture最终破裂Depending on the mater

45、ial, the fracture will have different characteristics根据材料不同，断裂特性也不同Two fracture modes = ductile and brittle两种破裂类型=形变断裂与脆性破裂Ductile Fracture Vs Brittle Fracture Ductile Fracture Vs Brittle Fracture 形变断裂与脆性破裂对比形变断裂与脆性破裂对比Most metal is ductile大部分材料是形变断裂When it fractures, there are small progression mar

46、ks ahead of the crack在发生形变破裂时，在破裂前只有很小的记号Brittle materials (ceramic and ice)脆性破裂（陶瓷和冰）When it fractures, the crack progresses rapidly在发生脆性破裂时，开裂很快Failure Mode Analysis: ShaftsFailure Mode Analysis: Shafts故障类型分析：轴故障类型分析：轴Objective of this part of the training is to:这部分培训的目的是：Identify types of loading确定负荷类型Identify the general categories of shaft failures确定轴故障的常规类别Identify types of loading确定负荷类型Visually inspect a failed shaft to determine the failure cause从外观上检查损坏的轴，确定故障原因Types of LoadTypes of LoadTorsion Torsion LoadLoad扭转负荷扭转负荷Bendi