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Root Cause Failure Analysis Workshop & Simulation

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Day 1: Root Cause Failure Analysis

  • Introductory Concepts
    • Root cause failure analysis philosophy
    • The four-step problem solving approach
    • The importance of a priori failure cause identification
    • Mast Mounted Sight group exercise
  • Pareto analysis
    • Vilfredo Pareto and the 80/20 concept
    • Pareto analysis approaches and perspectives
    • Pareto analysis data sources
    • Using Pareto statistics to target root cause analysis efforts
  • Identifying potential root causes
    • Brainstorming
    • Mind-mapping
    • Ishikawa diagrams
    • The 5-Whys technique and the Why staircase
    • Fault tree analysis
  • Why analysis
    • The Why analysis approach
    • Staircase graphical format
    • Why analysis limitations
    • Why analysis example
    • Why analysis group exercise
  • Blending root cause analysis approaches
    • Pareto analysis
    • Fault tree analysis (FTA)
    • Event and causal factor analysis (ECFA)
    • Barrier analysis
    • Management oversight and risk tree analysis (MORT)
    • Change analysis
    • Critical incident technique (CIT)
    • The 5-Whys technique
    • Group exercise using different analyses (light bulb fails to illuminate)
  • Fault tree analysis introduction
    • Fault tree analysis history
    • Fault tree analysis applications
    • Fault tree analysis capabilities
    • Fault tree analysis construction introduction
    • Fault tree analysis example
    • Fault tree analysis group exercise (light bulb fails to illuminate)
  • Group discussion: Different analysis approach advantages and disadvantages
  • Case study homework assignment: The Uranium Water Treatment System Case Study (this major case study, running throughout the course, can be replaced by a case study specific to your industry).

 

Day 2: Fault Tree Analysis

  • Prior material review
  • Case study discussion
  • Fault tree analysis construction
    • Fault tree gate usage and interpretation
    • Relationships between logic operators and events
    • Fault tree gate usage and interpretation
    • Fault tree analysis example
    • Fault tree analysis group exercise
  • Inhibit gates
    • Using inhibit functions to model probability distributions
    • Inhibit gate examples
    • Inhibit gate group exercise
  • Fault tree analysis construction tips
    • Using a point to point approach
    • Navigating from the failure site
    • Using a sequential approach
    • State of the part events
    • State of the system events
  • Using fault trees to identify redundancy-defeating failure modes
    • Approaches for identifying redundancy defeaters
    • Existing but undetected failure events
    • Case study discussion: F-16 fly-by-wire design and DC-10 engine loss
  • Fault tree analysis quantification
    • Quantifying top undesired events
    • Failure rate sources
  • Case study homework assignment: Prepare preliminary fault tree analyses for the Uranium Water Treatment System case study.

 

Day 3: Events and Causal Factor Analysis, Barrier Analysis, and Change Analysis

  • Prior material review
  • Case study discussion
  • Events and causal factors analysis (ECFA)
    • Events and causal factors analysis definitions
    • Events, conditions, causes, and terminal events
    • Verifying causal chains and event sequences
    • Integrating investigation findings
    • Communication during and after the investigation
    • Events and causal factors analysis charts
    • Assessing the safety culture from employee, management emphasis, and management practice
    • The importance of quantification
  • Barrier analysis
    • Barrier concepts
    • Identifying and selecting optimum barriers
    • The hazard/barrier matrix
    • Hazard effect pathways
    • Failed countermeasures
    • Missing countermeasures
    • Sources of energy and tracing energy flows
    • Sources of change
    • Change-based characterizations
    • Assessing countermeasure effectiveness
    • Conducting the barrier analysis
  • Change analysis
    • The pervasive nature of change in complex endeavors
    • “What’s Different” analysis
    • Test and inspection data
    • Material certifications
    • Using flow charts for product performance and process evaluations
    • Interviewing techniques for field personnel
    • Customer/supplier interface issues
    • Engineering design and tolerance analysis
    • Other sources of change information
    • Words of caution: Change and correlation to the event
    • Case study discussion: CBU-87/B detonator change analysis
  • Case study homework assignment: Prepare ECFA, barrier analysis, and change analysis for the Uranium Water Treatment System case study.

 

Day 4: MORT Analysis, Critical Incident Technique, FMA&A, and Failed Hardware Analysis

  • Prior material review
  • Case study discussion
  • Management Oversight and Risk Tree (MORT) analysis
    • MORT history
    • General approach
    • MORT diagram conventions
    • MORT structure
    • Provisional and assumed risks
    • MORT as an investigational tool
    • Integrating MORT and Barrier Analysis
    • MORT analysis approach and procedures
  • Critical incident techniques
    • The Critical Incident Technique
    • CIT history
    • Definitions
    • The five CIT steps
    • Incident reviews
    • Fact finding
    • Issue identification
    • Decision making
    • Evaluation
    • Evaluating behaviors
    • Interviewing techniques
    • Effective versus ineffective behaviors
    • Gaining interviewee trust
    • Group exercise: Interviewing operators, engineers, and others
  • Using Failure Mode Assessment and Assignment (FMA&A) matrices
    • Constructing the FMA&A
    • Using the FMA&A to guide the root cause analysis
  • Failed Hardware Analysis
    • The value of failed hardware
    • Evaluating failed hardware conformance
    • Quality Assurance compliance assessment tools
    • Basic metallurgical and electronic component evaluations
    • Component failure analysis technologies, including optical microscopy, NDT methods, SEM, Composition Analysis, FTIR,
    • EDAX, X-ray, N-ray, SIMS, Auger and FEA
    • Crack appearance in different loading geometries, including axial, bending, torsion, direct shear, and contact loading
    • Commercial failure analysis laboratories
    • Evaluating leaks
    • Testing to confirm failure causes
  • Homework assignment: Prepare FMA&A, MORT, and CIT assessments for the Uranium Water Treatment System case study.

 

Day 5: DOE, Corrective Action, Reports, Procedures, Libraries, and Course Wrap-Up

  • Prior material review
  • Critical incident reports homework discussion
  • Design of Experiments
    • Basic experimental design concepts
    • Hypothesis testing
    • z-tests, t-tests, ANOVA
    • Taguchi experiments
    • Selecting test parameters
    • Defining test specimen configurations
    • Strategies for minimizing test risk
    • Case study discussion: The Navy ARS Guillotine
  • Corrective Action
    • Corrective action alternatives, including design modifications, process modifications, requirements relaxation, screening, and other corrective actions
    • Corrective action order of precedence
    • Corrective action implementation
    • Corrective action scope, including work in process, inventoried material, suppliers, and delivered equipment
    • Evaluating corrective action efficacy
    • Implementing corrective actions to address other hypothesized failure causes
    • Group exercise
  • A suggested failure analysis procedure
  • Creating a “Lessons Learned” document
  • Preventing future failures
  • Formal briefings by the class participants (organized into several teams)
  • Recap, Q/A, and evaluations
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