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ROOT CAUSE ANALYSIS OF PASSENGER SIDE DOOR SYSTEM

机译:乘客侧门系统的根本原因分析

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This paper presents a real-world application of Root Cause Analysis methods that were applied to analyze and resolve a side door problem that was occurring on a particular fleet of coach cars operated by Amtrak. The foundation of a Root Cause Analysis program is a disciplined engineering process designed to identify physical, human and latent roots of chronic or sporadic problems. This paper presents the engineering challenges encountered while conducting root cause analysis of a complex coach car side doors problem.rnThe coach car side doors system exhibited undesirable characteristics when in service. Mechanical staff received multiple reports that during station stops all of the open side doors would unexpectedly close even though the train speed was at zero. During this unexpected side door closing sequence all of the obstacle detection systems were disabled presenting a potential hazard to the traveling public.rnThe side doors Root Cause Analysis team found the Physical Root cause of failure to be located in the door system software code - a finding that was never suspected following years of trouble with the side doors. As a result of thisrnfinding, the door manufacturer corrected the software and issued revised software to be installed fleet-wide. The Human and Latent Root causes were addressed through the development of a standard operating procedure and training for conductors and crew on the proper operation of side doors. The Root Cause Analysis method proved to be a powerful and productive process for achieving a solution to a chronic passenger side door problem.
机译:本文介绍了根本原因分析方法在现实世界中的应用,这些方法用于分析和解决由Amtrak运营的特定长途客车车队发生的侧门问题。根本原因分析程序的基础是有条理的工程流程,旨在识别慢性或偶发性问题的物理,人类和潜在根源。本文提出了对复杂的客车侧门问题进行根本原因分析时遇到的工程挑战。客车侧门系统在使用中表现出不良特性。机械人员收到多个报告,说在车站停车期间,即使火车速度为零,所有打开的侧门也会意外关闭。在此意外的侧门关门过程中,所有障碍检测系统均被禁用,对行进的公众造成了潜在危害。rn侧门根源分析小组发现,故障的物理根源位于门系统软件代码中-发现经过多年的侧门麻烦之后,再也没有想到过。结果,门制造商更正了该软件,并发布了修订后的软件,以便在整个车队范围内安装。通过制定标准操作程序以及对指挥员和机组人员进行侧门的正确操作培训,解决了人为和潜在根源的原因。事实证明,“根本原因分析”方法是解决长期乘客侧门问题的强大而有效的过程。

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