1、_SAE Technical Standards Board Rules provide that: “This report is published by SAE to advance the state of technical and engineering sciences. The use of this report is entirely voluntary, and its applicability and suitability for any particular use, including any patent infringement arising theref
2、rom, is the sole responsibility of the user.”SAE reviews each technical report at least every five years at which time it may be revised, reaffirmed, stabilized, or cancelled. SAE invites your written comments and suggestions.Copyright 2016 SAE InternationalAll rights reserved. No part of this publi
3、cation may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of SAE.TO PLACE A DOCUMENT ORDER: Tel: 877-606-7323 (inside USA and Canada)Tel: +1 724-776-4970 (out
4、side USA)Fax: 724-776-0790Email: CustomerServicesae.orgSAE WEB ADDRESS: http:/www.sae.orgSAE values your input. To provide feedback on thisTechnical Report, please visithttp:/standards.sae.org/ARP9136AEROSPACERECOMMENDED PRACTICEARP9136Issued 2016-11Technically equivalent writings published in all I
5、AQG sectorsAerospace Series - Root Cause Analysis and Problem Solving(9S Methodology)RATIONALEThe objective of root cause analysis and problem solving is to not only reduce the number of issues (i.e., undesirable conditions, defects, failures), but to minimize their impact on quality, delivery perfo
6、rmance, costs, and ultimately on the customer. Often big issues originate with small problems that were discovered too late or were discovered, but were never resolved due to a lack of understanding the actual issue(s), incorrect analysis of the root cause, and/or ineffective actionsbeing taken. Thi
7、s guidance document was created to provide a methodology for performing root cause analysis to resolve a significant or recurrent issue e.g., quality, On-time Delivery (OTD), process, documentation), as guidance within the aviation, space, and defense industry and/or when contractually invoked at an
8、y level of the supply chain.FOREWORDIn December 1998, the aviation, space, and defense industry established the International Aerospace Quality Group (IAQG) with the purpose of achieving significant improvements in quality and reductions in cost throughout the value stream. This organization, with r
9、epresentation from aviation, space, and defense companies in the Americas, Asia-Pacific, and Europe and sponsored by SAE International, Society of Japanese Aerospace Companies (SJAC), and AeroSpace and Defense Industries Association of Europe -Standardization (ASD-STAN), has agreed to take responsib
10、ility for the technical content of this document to promote best practices that would satisfy associated requirements of Aerospace Quality Management System (AQMS) standards (i.e., 9100, 9110, 9120).To assure customer satisfaction, aviation, space, and defense industry organizations must produce and
11、 continually improve safe, reliable products that meet or exceed customer and regulatory authority requirements. This includes having processes in place to detect and eradicate significant and recurrent issues. This document standardizes methodology to perform root cause analysis and problem solving
12、 to support these efforts. The establishment of a common methodology, for use by organizations at all levels of the supply-chain should result in improved action plans and a standardized way of exchanging information between organizations and external stakeholders (e.g., suppliers, partners, custome
13、rs, regulatory agencies).SAE INTERNATIONAL ARP9136 Page 2 of 48INTRODUCTIONThis document has been developed by the IAQG. In accordance with the continual improvement requirements defined in the 9100-series standards (see clause 8, “Measurement, Analysis, and Improvement”), it was deemed useful to pr
14、omote those industry recognized best practices for identifying the root causes of nonconformities or undesirable conditions (including potential issues and conditions) and implementing correction(s) and associated corrective/preventive actions. The process described in this document was created by c
15、omparing and mixing root cause analysis and problem solving methodologies e.g., 7 Steps, 8D, Root Cause Corrective Action (RCCA) used by main actors of aviation, space, and defense industry.Unless contractually specified, other root cause analysis processes with slightly different sequencing of acti
16、vities and/or different names of process steps may be acceptable, provided that these activities meet the intent of this document and deliver the same outcomes (i.e., immediate protection, temporary fix, durable solution, systemic improvement) and provides the same level of information.Throughout th
17、is document, the words “should” and “required” indicate strong recommendations to apply and correspond to actions that the authors of this document consider important in order to deliver robust root cause analysis. When strict application of this document is decided by an organization or is mandated
18、 by a customer, they shall be interpreted as an obligation to be complied with (i.e., interpreted as “shall” and “must”).SAE INTERNATIONAL ARP9136 Page 3 of 48TABLE OF CONTENTS1. SCOPE 41.1 General 41.2 Purpose. 42. APPLICABLE DOCUMENTS 43. TERMS AND DEFINITIONS . 44. GENERAL PROCESS 64.1 Basic Prin
19、ciples. 64.1.1 Cultural Change 74.1.2 Effective Communication 74.2 When to Apply a Structured Root Cause Analysis and Problem Solving Process. 84.3 Process Step Description 95. PROCESS STEPS 105.1 Step 0 - Start Immediate Containment Actions. 105.2 Step 1 - Build the Team 125.3 Step 2 - Define Probl
20、em 135.4 Step 3 - Complete and Optimize Containment Actions 155.5 Step 4 - Identify Root Cause(s). 175.6 Step 5 - Define and Select Permanent Corrective Actions. 195.7 Step 6 - Implement Permanent Corrective Action and Check Effectiveness 205.8 Step 7 - Standardize and Transfer the Knowledge Across
21、Business . 215.9 Step 8 - Recognize and Close the Team 226. INFORMATION AND DOCUMENTATION . 246.1 Information Data Definition and Documentation . 246.2 Forms 256.3 Control of Records 257. NOTES 257.1 Revision Indicator 25APPENDIX A ACRONYM LOG . 26APPENDIX B INFORMATION DATA DEFINITION. 27APPENDIX C
22、 FORM EXAMPLES . 40FIGURE 1 APPLYING A STRUCTURED ROOT CAUSE ANALYSIS AND PROBLEM SOLVING PROCESSDEPENDING ON THE IMPACT AND FREQUENCY OF A PROBLEM. 8FIGURE 2 ROOT CAUSE ANALYSIS GENERAL PROCESS MAPPING. 9FIGURE 3 TEAM COMPOSITION TEMPLATE (EXAMPLE). 13FIGURE 4 TYPICAL PROCESS STEP SEQUENCING. 24SAE
23、 INTERNATIONAL ARP9136 Page 4 of 481. SCOPE1.1 GeneralThe objective of any organization, as part of continual improvement, is to reduce the number of issues (i.e., undesirable conditions, defects, failures) and to minimize their impact on quality, delivery performance, and cost. This includes having
24、 processes in place to detect and eradicate significant and recurrent issues, which implies having well identified problems, a common understanding of their impact and associated root causes, and having defined and implemented adequate actions so that these problems, including similar issues will no
25、t happen again. 1.2 PurposePropose a methodology to improve the way escapes and issues are managed, including communication between all parties e.g., engineering, Materials Review Board (MRB), manufacturing, manufacturing engineering, supplier, customer to reduce their impact, contain them as far up
26、stream as possible, and prevent recurrence (i.e., ensure the right measures are taken at the right location and at the right time).2. APPLICABLE DOCUMENTSThe following documents should be considered for the application of this document. For dated references, only the edition cited applies. For undat
27、ed references, the latest edition of the referenced document, including any amendments applies.9100 Quality Management Systems - Requirements for Aviation, Space and Defense Organizations9110 Quality Management Systems - Aerospace - Requirements for Aviation Maintenance Organizations9120 Quality Man
28、agement Systems - Requirements for Aviation, Space, and Defense DistributorsISO 9000:2005 Quality management systems - Fundamentals and vocabulary3. TERMS AND DEFINITIONSDefinitions for general terms can be found in ISO 9000 and the IAQG Dictionary, which is located on the IAQG website. An acronym l
29、og for this document is presented in Appendix A. For the purpose of this document, the following terms and definitions apply.3.1 APPARENT CAUSE (also referred to as Obvious Cause, Direct Cause, or Immediate Cause)The event or action that immediately results in or precedes the nonconformity. NOTE: Th
30、is is generally NOT the root cause.3.2 CONTAINMENTAction to control and mitigate the impact of a problem and protect the organization and/or customer (i.e., stop the problem from getting worse), includes correction, immediate corrective action, immediate communication, and verification that problem
31、does not further degrade.3.3 CONTRIBUTING CAUSESCauses that by themselves would not cause the problem, but can increase the risk of the issue to occur. Analysis for these causes generally requires taking a closer look at the existing conditions and associated actions.SAE INTERNATIONAL ARP9136 Page 5
32、 of 483.4 CORRECTION (also referred to as Immediate Correction)Action taken to eliminate a detected nonconformity (adapted from ISO 9000:2005).NOTE 1: A correction can be made in conjunction with a corrective action.NOTE 2: For product nonconformity, correction might be understood as reworking the p
33、art, accepting the nonconformance through concession process, or scrapping the product. NOTE 3: For a system issue, it may include correcting the paper work or issuing a new purchase order. NOTE 4: For a delivery issue, it may include revising to air transportation instead of delivering product by t
34、ruck or ship, increasing production rate, etc.3.5 CORRECTIVE ACTIONAction taken to eliminate the cause of a detected nonconformity or other undesirable situation to prevent recurrence (adapted for ISO 9000:2005).NOTE 1: A correction can be made in conjunction with a corrective action.NOTE 2: Correct
35、ive action may address all types of causes (i.e., apparent, contributing, root causes).3.6 IMMEDIATE CORRECTIVE ACTIONAction taken to eliminate, prevent, or reduce the probability of any additional nonconformances related to the apparent cause from happening again in the short term.NOTE: These actio
36、ns may be temporary and should remain in place until the root cause(s) is identified and permanent RCCA is implemented and verified to be effective.3.7 NONCONFORMITYNon-fulfillment of a requirement (see ISO 9000). NOTE: It may be a nonconforming product, but may also be a late delivery, incorrect pa
37、perwork, incorrect process production or Quality Management System (QMS) related, etc.3.8 PREVENTIVE ACTIONAction to eliminate the cause of a potential nonconformity or other undesirable potential situation (see ISO 9000).NOTE: Preventive action is taken to prevent occurrence whereas corrective acti
38、on is taken to prevent recurrence.3.9 ROOT CAUSEThe original event(s), action(s), and/or condition(s) generating (directly or in cascade) an actual or potential undesirable condition, situation, nonconformity, or failure.NOTE: There is sometimes more than one root cause associated to a single noncon
39、formity or one root cause with multiple contributing causes.3.10 ROOT CAUSE ANALYSISThe process of identifying all the causes (root cause and contributing causes) that have or may have generated an undesirable condition, situation, nonconformity, or failure.SAE INTERNATIONAL ARP9136 Page 6 of 483.11
40、 ROOT CAUSE CORRECTIVE ACTION (RCCA) (also referred to as Permanent Corrective Action)Action implemented to address the root cause(s) and contributing cause(s) of the undesirable condition, situation, nonconformity, or failure; action taken to prevent recurrence.3.12 ROOT CAUSE CORRECTIVE ACTION (RC
41、CA) EFFECTIVENESS VERIFICATIONAction taken to verify that the planned corrective action(s) have prevented recurrence of the identified root cause or contributing causes, and have consequently eradicated the problem.NOTE: This may include auditing, monitoring of specific metrics, or any other reporti
42、ng methodologies. 3.13 ROOT CAUSE CORRECTIVE ACTION (RCCA) IMPLEMENTATION VERIFICATIONAction taken to verify that the planned actions were taken as scheduled. NOTE: This includes specific actions, milestones, completion dates, and responsibilities.4. GENERAL PROCESS4.1 Basic Principlesa. In many ins
43、tances, organizations and their suppliers do not provide adequate root cause analysis and problem solving results because:x No clear criterion exists for an acceptable corrective action plan; organizations are satisfied when they no longer receive defective parts.x The organization continues to acce
44、pt inadequate corrective action plans as priority is given to schedule versus quality.x Organizations (internal/external) do not have a root cause analysis mindset; people dont know or understand the process and/or have not been effectively trained.b. A robust root cause analysis and problem solving
45、 process should provide visibility of the following information:x How the issue is managed and communicated between all stakeholders (e.g., engineering, MRB, suppliers, customer). x How it is ensured that the actual root cause(s) has been identified.x How it is ensured that the right measures are ta
46、ken at the right location, at the right time, and by the right individuals.x How containment actions taken to protect the customer and production efforts are identified and managed.c. Problem solving approaches can be summarized as:x Reactive Mode - solving the abnormality that has occurred; gatheri
47、ng and analyzing data aims to provide customer protection and associated countermeasures.x Proactive Mode - analyzing failures and looking for product, process, or system improvements.x Preventive Mode - putting in place solutions before an undesirable condition, defect, or failure occurs.SAE INTERN
48、ATIONAL ARP9136 Page 7 of 484.1.1 Cultural ChangeCultural change is generally required to progress from a “reactive” mode to “proactive” and/or “preventive” modes.a. Examples of traditional behaviors:x Quick fix.x Not taking adequate time for analysis.x Going from one crisis to another.x Looking for
49、 the guilty party - “Who did that?” Blaming or transferring responsibility.x Generate laundry list of solutions to firefight the symptoms.x Narrow focus taken to address the immediate problem. x Focus on performance metrics/measures (e.g., sales, profits) with hope that processes will improve by themselves.b. Expected “systems thinking” behavior to get “systemic solutions”:x Understanding that many factor
