问题分析的简略使用

阿波罗十三号上的问题

Reprinted from The New Rational Manager, by Charles H. Kepner and Benjamin B. Tregoe

Princeton Research Press, Princeton, NJ, 1991,  1997.

问题分析的最佳使用是最有效的使用。如果简短的、非正式的使用思路能够揭示出问题的原因,那么一味地坚持整个过程中的每一个步骤并没有什么特别的好处。事实上,人们使用问题分析的时间越长,他们就越善于挑选出适用于他们每天面临的各种问题的过程片段。当人们开始问一些问题,比如 "最近这个操作的时间有什么变化吗?"或者 "就在你注意到问题之前,这个过程处于什么阶段?"他们已经完成了对问题分析技术的学术欣赏和对其在日常问题解决中的实际作用的内部化之间的过渡。

绝大多数的问题分析都没有见过纸和笔。

This is especially true of the abbreviated application of the process. The seriousness of a problem does not necessarily determine the length or complexity of the analysis required to resolve it. Some extremely serious problems have been solved through abbreviated uses of the process. They were so data-poor that full use could not be undertaken. Fragments of the process had to be relied on and combined with educated speculation to arrive at a most likely cause.

阿波罗十三号正在前往月球的路上。

Fifty-four hours and fifty-two minutes into the mission—205,000 miles from earth—and all was well. Then John L. Swigert, Jr., duty commander at the time, reported: “Houston, we’ve got a problem here…. We’ve had a Main Buss B undervolt.” This was an insider’s way of saying that electrical voltage on the second of two power generating systems had fallen off and a warning light had appeared. A moment later the power came up again. Swigert reported: “The voltage is looking good. And we had a pretty large bang associated with the caution and warning there.” Three minutes later, as the dimensions of the problem became clearer, he reported: “Yeah, we got a Main Buss A undervolt too….It’s reading about 25½. Main B is reading zip right now.”

阿波罗十三号载着三个人以难以置信的速度向月球飞去,正在迅速失去动力,不久就可能变成一具尸体。太空中发生了一场灾难,没有人确定发生了什么。

美国国家航空航天局(NASA)的工程师将问题分析法用于工作。

在休斯顿的地面上,美国宇航局的工程师们立即将问题分析提问投入工作。他们开始从回答他们问题的信息和监测设备上显示的数据中建立一个偏差的规范。

采取了应急行动。

同时,他们开始了一些应急行动,以减少阿波罗十三号上的电力使用。在第一次报告的13分钟后,斯威格特报告说。"我们的O2低温二号罐的读数为零......在我看来,从舱门向外看,我们正在向太空排放某种东西......是某种气体。"

起初是一个电气问题--失去电压--变成了两个水箱中的第二个水箱突然失去氧气,而第一个水箱中的氧气则逐渐失去。由于氧气被用于发电以及直接用于生命支持系统,这种情况再严重不过了。

工程师找到原因并采取行动。

尽管当时没有人能够想象到是什么原因导致了罐体的爆裂,但 "二号低温氧气罐破裂 "可以解释电压的突然丧失和随后的压力损失。

Further actions were taken to conserve both oxygen and electricity. A number of “IS…COULD BE but IS NOT” questions were asked to get further data, and a series of system checks was undertaken to verify cause. In the end it was determined that the Number Two Tank had burst and vented all its oxygen, plus a large portion of the gas from the Number One Tank, through a damaged valve and out into space.

这三个人成功地返回了地球,但只是以最微小的差距。如果原因不明的时间更长,他们将没有足够的氧气来生存。

那么,根本原因是什么呢?

It was weeks before the root cause of this problem was established through on-the-ground testing and experimentation. Two weeks before the launch, a ground crew had piped liquid oxygen into the tanks in a countdown demonstration. After the test they had had difficulty getting the oxygen out of the Number Two Tank. They had activated a heater inside the tank to vaporize some of the liquid oxygen, thus providing pressure to force it out. They had kept the heater on for eight hours, longer than it had ever been used before. Although a protective switch was provided to turn off the heater before it became too hot, the switch was fused in the ON position because the ground crew had connected it to a 65-volt power supply instead of the 28-volt supply used in Apollo XIII. Later, in flight, the crew turned the heater on briefly to get an accurate quantity reading. The fused switch created an arc that overheated the oxygen in the tank, raised the internal pressure tremendously, and blew the dome and much of the connecting piping off into space.

美国宇航局休斯顿分局没有时间去完整地列出他们可能观察到的所有区别和变化。相反,他们问道:"什么创伤性变化会导致发电的突然、完全失败?"切断流向燃料电池的氧气会产生这种效果。当斯威格特报告说二号油箱的读数为零时,他们就知道哪些燃料电池不能工作了。

用已知的东西来测试原因。

他们测试了原因--二号油箱破裂,发现这可以解释说明书中描述的突然性和整体性。这也可以解释在第一次低电压指示时报告的爆炸声,飞行人员感觉到的阿波罗十三号的颤抖,以及 "有东西......流向太空 "的排放。这既说明了他们积累的IS数据,也说明了他们的监测活动中出现的IS NOT信息。更重要的是,它解释了系统内的一个突然的、完全的故障。

对于NASA休斯顿的工程师来说,这个原因是难以接受的。

They had unbounded faith in Apollo equipment, knowing that it was the best that could be devised. The idea of an oxygen tank bursting open in the depths of space was not credible. All this was justified from their experience. Without the bungling that had occurred on the ground two weeks before the launch, the tank would have gone to the moon and back just as it was designed and built to do. However, the Houston engineers stuck to the Problem Analysis process despite their incredulity, believing that the test for cause they had carried out had provided the correct answer. In fact, they proved this cause in record time. What saved the day was their knowledge of Apollo XIII’s systems and of what could produce the exact kind of sudden failure that had occurred.

对企业关键问题的分析方法。

In a case such as this, Problem Analysis is rendered difficult by two factors: secondary effects and panic. Sudden failure in a complex system usually causes other deviations that may obscure the original deviation. The shock of a sudden failure often precipitates panic, making a careful review and use of the facts even more difficult. A disciplined and systematic investigation is difficult in any case, but discipline becomes essential when a top-speed search for cause is undertaken and there is no possibility of amassing all the data that would be optimal in the investigation.

在美国宇航局的事件中,系统性方法的存在使一个团队能够作为一个整体一起工作,尽管他们与偏差相隔近25万英里。对于NASA休斯顿的工程师来说,这个原因是难以接受的。

 

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