Root Cause Analysis - Steps

1. Identify and clearly define the undesired outcome.

2. Gather data.
3. Create a timeline.
4. Place events & conditions on an event and causal factor tree.
5. Use a fault tree or other method/tool to identify all potential causes.
6. Decompose system failures down to a basic events or conditions (Further describe what
happened)
7. Identify specific failure modes (Immediate Causes)
8. Continue asking “WHY” to identify root causes.
9. Check your logic and your facts. Eliminate items that are not causes or contributing factors.
10. Generate solutions that address both proximate causes and root causes.
2004 MAPLD/Mishaps Seminar 2 Chandler
 Root Cause Analysis - Steps
3.Create a timeline (sequence diagram)
• Illustrate the sequence of events in chronological order
horizontally across the page.

• Depict relationships between conditions, events, and exceeded or

failed barriers/controls.

Condition

Exceeded- Undesired
Event Event Failed Barrier Event Outcome
Or Control

2004 MAPLD/Mishaps Seminar 3 Chandler

 Root Cause Analysis - Steps
Create a timeline (sequence diagram)
• If amelioration occurred (e.g., put out the fire, cared for the injured),
this should be included in the evaluation to ensure that it did not
contribute to the undesired outcome.

Example: In the case of a death, the investigation should ensure that

the death was the result of the mishap and not a delay in medical care
or inappropriate medical care at the scene.

Condition

Exceeded- Undesired
Exceeded-
Outcome
Event Event Failed Barrier Event Failed
Or Control Amelioration

2004 MAPLD/Mishaps Seminar 4 Chandler

 Root Cause Analysis - Steps

Example: simple timeline.

Lost High
Speed Data
Satellite Tech. Used Stream
Thrusters Oriented Satellite Failed to
Wrong Method (Mission
Powered Up Space Craft Deploy Antenna To Correct
Failure)

Poor
Line of
Sight

2004 MAPLD/Mishaps Seminar 5 Chandler

 Root Cause Analysis - Steps
4. Create an event and causal factor tree.
(A visual representation of the causes that led to the failure or mishap.)

• Place the undesired outcome at the top of the tree.

• Add all events, conditions, and exceeded/failed barriers that occurred

immediately before the undesired outcome and might have caused it.

Lost High Speed Data Stream From Satellite

(Mission Failure)

Satellite Thrusters Poor Satellite Failed Technician Used

Power Up Oriented Line of Sight To Deploy Wrong
Space Craft Antenna Method to Correct

2004 MAPLD/Mishaps Seminar 6 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree.
• Brainstorm to ensure that all possible causes are included, NOT just
those that you are sure are involved.

• Be sure to consider people, hardware, software, policy, procedures, and

the environment.
Lost High Speed Data Stream From Satellite
(Mission Failure)

Satellite Thrusters Oriented Poor Satellite Failed Technician Used Wrong

Power Up Space Craft Line of Sight To Deploy Antenna Method to Correct

Meteoroid Logic Control Power Supply Arming Relay Firing Relay Sabotage
Impacted Satellite Failed Failed Failed Failed

2004 MAPLD/Mishaps Seminar 7 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree continued...
• If you have solid data indicating that one of the possible causes is not
applicable, it can be eliminated from the tree.
Caution: Do not be too eager to eliminate early on. If there is a possibility that it
is a causal factor, leave it and eliminate it later when more information is
available.

Lost High Speed Data Stream From Satellite

(Mission Failure)

XSatellite
Power Up
Thrusters Oriented
Space Craft
Poor
Line of Sight
Satellite Failed
To Deploy Antenna
Technician Used Wrong
Method to Correct

Meteoroid Logic Control Power Supply Arming Relay Firing Relay Sabotage
Impacted Satellite Failed Failed Failed Failed

2004 MAPLD/Mishaps Seminar 8 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree continued…
• You may use a fault tree to determine all potential causes and to
decompose the failure down to the “basic event” (e.g., system component
level).
Lost High Speed Data Stream From Satellite
(Mission Failure)

Thrusters Oriented Poor Satellite Failed Technician Used Wrong

Space Craft Line of Sight To Deploy Antenna Method to Correct

Meteoroid Logic Control Power Supply Arming Relay Firing Relay Sabotage
Impacted Satellite Failed Failed Failed Failed

Battery Failed Converter Current Detection

Failed Circuit Failed

2004 MAPLD/Mishaps Seminar 9 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree continued…
• A fault tree can also be used to identify all possible types of human
failures.
Lost High Speed Data Stream From Satellite
(Mission Failure)

Thrusters Oriented Poor Satellite Failed Technician Used Wrong

Space Craft Line of Sight To Deploy Antenna Method to Correct

Didn’t Perceive Didn’t Understand Correct Interpretation Correct Decision But

System Feedback System Feedback Incorrect Decision Incorrect Action
Perception Error Interpretation Error Decision-Making Error Action-Execution Error

Knowledge-Based Rule-Based Skill-Based

Error Error Error

2004 MAPLD/Mishaps Seminar 10 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree continued…
• After you have identified all the possible causes, ask yourself “WHY” each
may have occurred.

• Be sure to keep your questions focused on the original issue. For example
“Why was the condition present?”; “Why did the event occur?”; “Why was
the barrier exceeded?” or “Why did the barrier fail?”

Undesired Outcome

Event #1 Condition Event #2 Failed or Exceeded

Barrier or Control

WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
Event #1 Event #1 Event #1 Condition Failed Failed Failed
Condition Condition Event #2 Event #2 Event #2
Occurred Occurred Occurred Existed or Exceeded Exceeded Exceeded
Existed or Existed or Occurred Occurred Occurred Barrier or Barrier or Barrier or
Changed Changed Changed Control Control Control

2004 MAPLD/Mishaps Seminar 11 Chandler

 Root Cause Analysis – Steps

Continue to ask “why” until you have reached:

1. Root cause(s) - including all organizational factors that exert control over the design,
fabrication, development, maintenance, operation, and disposal of the system.

2. A problem that is not correctable by NASA or NASA contractor.

3. Insufficient data to continue.

2004 MAPLD/Mishaps Seminar 12 Chandler

 Root Cause Analysis- Steps
The resultant tree of questions and answers should lead to a
comprehensive picture of POTENTIAL causes for the undesired
outcome

Undesired Outcome

Event #1 Condition Event #2 Failed or Exceeded

Barrier or Control

WHY WHY WHY WHY WHY WHY WHY WHY WHY

WHY WHY WHY
Event #1
Occurred
Event #1
Occurred
Event #1
Occurred
Condition
Existed or
Changed
Condition
Existed or
Changed
Condition
Existed or
Changed
Event #2
Occurred
Event #2
Occurred
Event #2
Occurred
Failed
Exceeded
Barrier or
Control
Failed
Exceeded
Barrier or
Control
XFailed
Exceeded
Barrier or
Control

WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY

WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY

2004 MAPLD/Mishaps Seminar 13 Chandler

 Root Cause Analysis- Steps
Check your logic with a detailed review of each potential cause.
• Verify it is a contributor or cause.
• If the action, deficiency, or decision in question were corrected, eliminated
or avoided, would the undesired outcome be prevented or avoided?
> If no, then eliminate it from the tree.

Undesired Outcome

Event #1 Condition Event #2 Failed or Exceeded

Barrier or Control

WHY

X
WHY WHY WHY WHY WHY WHY WHY WHY

X
WHY

X
WHY WHY

X
Condition Condition Condition Event #2 Event #2 Event #2 Failed Failed Failed
Event #1 Event #1 Event #1 Existed or Existed or Existed or Occurred Occurred Occurred Exceeded Exceeded Exceeded
Occurred Occurred Occurred Changed Changed Changed Barrier or Barrier or Barrier or
Control Control Control

XXWHY WHY WHY WHY WHY

XWHY WHY WHY WHY
XX
WHY WHY WHY WHY WHY WHY WHY

XX
WHY WHY WHY

XX WHY WHY WHY WHY WHY

XX WHY WHY WHY WHY
XX
WHY WHY WHY WHY WHY WHY WHY
XX X
WHY WHY WHY

2004 MAPLD/Mishaps Seminar 14 Chandler

 Root Cause Analysis - Steps
Create an event and causal factor tree continued…
• The remaining items on the tree are the causes (or probable causes).
necessary to produce the undesired outcome.
• Proximate causes are those immediately before the undesired outcome.
• Intermediate causes are those between the proximate and root causes.
• Root causes are organizational factors or systemic problems located at the
bottom of the tree.

Undesired Outcome

Event #2 Failed or Exceeded

PROXIMATE
Event #1 Condition
Barrier or Control CAUSES

WHY WHY WHY WHY

Event #1 WHY WHY WHY WHY
Event #1 Condition Condition
Occurred Event #2 Event #2 Failed/Exceeded Failed/Exceeded
Occurred Existed or Existed or
Occurred Occurred Barrier or Control Barrier or Control
Changed Changed
INTERMEDIATE
CAUSES
WHY WHY WHY WHY WHY
WHY WHY WHY WHY WHY WHY WHY

WHY
WHY WHY WHY WHY WHY WHY WHY WHY WHY ROOT CAUSES
2004 MAPLD/Mishaps Seminar 15 Chandler
 Root Cause Analysis- Steps
Some people choose to leave contributing factors on the tree to show
all factors that influenced the event.
Contributing factor: An event or condition that may have contributed to
the occurrence of an undesired outcome but, if eliminated or modified,
would not by itself have prevented the occurrence.
If this is done, illustrate them differently (e.g., dotted line boxes and arrows) so
that it is clear that they are not causes.

Undesired Outcome

Event #1 Condition Event #2 Failed or Exceeded

Barrier or Control

WHY WHY WHY WHY

Event #1 WHY WHY WHY WHY
Event #1 Condition Condition
Occurred Event #2 Event #2 Failed/Exceeded Failed/Exceeded
Occurred Existed or Existed or
Occurred Occurred Barrier or Control Barrier or Control
Changed Changed

Contributing
WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
WHY Factors
WHY WHY WHY
WHY WHY WHY WHY WHY WHY WHY

2004 MAPLD/Mishaps Seminar 16 Chandler

 Investigating Causes of Failures & Mishaps
Lost High Speed Data Stream From Satellite
(Mission Failure)

Thrusters Oriented Poor Satellite Failed Technician Used Wrong

Space Craft Line of Sight To Deploy Antenna Method to Correct

Power Supply
Failed

Battery Dead
Tells What Failed
Tells Types of Failures
Installed Beyond Shelf
Improperly Limit

Tells Why It Failed

Root Cause is Much Deeper
Keep Asking Why
2004 MAPLD/Mishaps Seminar 17 Chandler
 Investigating Causes of Failures & Mishaps
Lost High Speed Data Stream From Satellite
(Mission Failure)

Thrusters Oriented Poor Satellite Failed Technician Used Wrong

Space Craft Line of Sight To Deploy Antenna Method to Correct

MMOD Hit Correct Interpretation

Power Supply
Space Craft Failed Incorrect Decision
After Oriented Decision-Making Error
Battery Failed

New Task Insufficient

Anomaly Training
Installed Beyond Shelf
Improperly Limit Training Does
Not Exist
Procedure No Quality
Incorrect Inspection Insufficient
Not Updated Training Budget
Insufficient
Not Under Quality Staff Organization Under
Configuration Mgmt Estimates Importance of
Insufficient Anomaly Training
2004 MAPLD/Mishaps Seminar 18
Budget Chandler
 Root Cause Analysis- Steps
Generating Recommendations:
At a minimum corrective actions should be generated to eliminate proximate
causes and eliminate or mitigate the negative effects of root causes.

When multiple causes exist, there is limited budget, or it is difficult to

determine what should be corrected:

• Quantitative analysis can be used to determine the total contribution of

each cause to the undesirable outcome (see NASA Fault Tree
Handbook, Version 1.1, for more information).

• Fishbone diagrams (or other methods) can be used to arrange causes

in order of their importance.

• Those causes which contribute most to the undesirable outcome

should be eliminated or the negative effects should be mitigated to
minimize risk.

2004 MAPLD/Mishaps Seminar 19 Chandler