The definition of root cause is one of multiple factors events, conditions, or organizational factors that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated or modified, would. A thorough root cause analysis built as a cause map can capture all of the causes in a simple, intuitive format that fits on one page. Click download or read online button to get apollo root cause analysis book now. The rca tools are utilized and retainedattached as objective evidence to support root cause validation. Nasas understanding of risk in apollo and shuttle ntrs. Wikipedia a structured evaluation method that identifies the root cause of an undesired outcome and the actions adequate to prevent recurrence. Apollo root cause analysis methodology the apollo root cause analysis methodology is a 4stage process that provides a new way of thinking and goes far beyond the traditional root cause analysis problem solving processes. Root cause analysis helps determine what happened, how it happened, and why it happened. The sketches above are taken from the nasa book apollo expeditions to the moon, nasa sp350. It is generally agreed that the purpose of root cause analysis is to find effective solutions that prevent recurrence of the defined problem. The purpose of this book is to share what the author has learned about effective problem solving by exposing the ineffectiveness of conventional wisdom and presenting a principlebased alternative called apollo root cause analysis that is robust, yet familiar and easy to understand. It ensures standardization and consistency in your problemsolving process and easily communicates the results. Jumping to a probable cause is a major pitfall in root cause analysis rca.
The nasa sti program office is operated by langley. Fault tree analysis is a topdown approach to the identification of process hazards. The apollo root cause analysis methodology is a 4stage process that provides a new way of thinking and goes far beyond the traditional root cause analysis problem solving. The fact that apollo root cause analysis is the leading root cause analysis methodology in the world should lend some credence to its value. The key, and the goal of root cause analysis, is to produce possible solutions at multiple points in the chain of causes and effects so that the level of risk is reduced to an acceptable level. Root cause analysis methodology follows three steps. Challenger explosion thinkreliability, case studies. Root cause analysis rca is a systematic process for identifying root causes of problems or events and an approach for responding to them. The rcat software provides a quick, easy, accurate, and repeatable method to perform and document root cause analysis. The rcat software provides a quick, easy, accurate, and repeatable method to perform and document root cause analysis, identify corrective actions, perform trending, and generate data usable in precursor. Arca is a principlebased problem solving method designed to help you master strategies which, combined with your copy of realitycharting software, will enable you to construct a powerful understanding of any problem. Apollo fire thinkreliability, root cause analysis case studies. Only when the failure reoccurs is the original root cause questioned.
The apollo root cause analysis methodology facilitates the creation of a common reality, using input from all stakeholders to produce an evidencebased understanding of the problem and ensures your solutions address proven causes to prevent recurrence. It is touted as one of the best methods for systematically identifying and graphically displaying the many ways something can go wrong. The apollo experience lessons learned for constellation lunar. The top diagram shows the details of oxygen tank number 2 and the heater and thermostat unit. Also, the landing crew was to gather a third set of selenological samples from the lunar surface. He was vindicated by postmission analysis, and implemented a rule that. Out of well over 200 classes i have taken in a 30 year aviation career, your class may be the best one i have ever attended. The fact that most major comapnies in the world use this methodology shuold also provide some measure of value. The apollo root cause analysis facilitator training course was great. The actual root cause may lead to a redesign which becomes too painful to correct.
A scientific package of five experiments was to be emplaced on the lunar surface. Apollo was the seventh crewed mission in the apollo space program and the third meant to. It happened because many people made the mistake of fa iling to. Apollo fire thinkreliability, root cause analysis case. Reprinted from the new rational manager, by charles h. Download the pdf it was supposed to be nasas first manned apollo mission to earth orbit, but it was over. Tool failure modes and effects analysis fmea is similar to fault tree analysis in that it is primarily used in the design of engineered systems rather than root cause analysis. Mars orbiter thinkreliability, root cause analysis case. Root cause analysis root cause analysis rca a methodology for problem solving aimed at identifying the proximate root cause for an issue. Use this guide to walk through a root cause analysis rca to investigate events in your facility e. Learn the differences between the two methodologies so you can decide between using fish bone vs. To view a intermediate cause map of this issue, click on download pdf above. After reworking the nature of the rework is unspecified in failure analysis report the. Once more information is released about the specifics of the issues that delayed the launch, more detail can easily be added to the cause map to capture all the causes for the delay.
The number of planned shuttle flights was greatly reduced. It is widely used in it operations, telecommunications, industrial process control, accident analysis e. It is used so we can correct or eliminate the cause, and prevent the problem from recurring. The apollo root cause analysis methodology is a 4stage process that provides a new way of thinking and goes far beyond the traditional root cause analysis problemsolving processes.
Perform a cause failure analysis to determine the cause s of the problem. Nasa also uses an approach they call a causal factor tree, which is a visual picture of the root cause analysis and their potential countermeasures or, in their words, corrective actions. To properly evaluate root cause analysis methods and tools, we need a standard to which they can be compared. Introduction to the apollo root cause analysis methodology. The selected landing site was in the hilly uplands of the fra mauro lunar region. An abbreviated use of problem analysis kepnertregoe. Probabilistic risk analysis pra found a roughly 1 in 100 chance of a shuttle failure. Discover new communications tools that are revolutionizing the way people all around the world think, communicate, and make decisions together. The fire aboard apollo 1 serves as an example of how the root cause analysis process can be applied to a specific incident. The oxygen tank of the apollo service module sm is constructed of. Nasa archives your expert root cause analysis resource. Managing nasa in the apollo era nasa history division.
In that forum, oconnor shared and explained common root causes from the apollo i, challenger and columbia accidents. Root cause analysis department of enterprise services. The apollo root cause analysis methodology, created by dean gano, is a simple, but powerful, 4 step problem solving method that. Rooney and heuvel give an overview of methods for using rootcause analysis to identify what, how, and why an undesired outcome occurs and preventing future recurrence. Create a reality chart effective problem solving video. Nasa jpl technical report server root cause analysis.
Root cause analysis rca is a popular and oftenused technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can. Guidance for performing root cause analysis rca with pips. One glaring outcome from the nasa approach to root cause analysis is a bias toward pointing to organizational issues. Publication in 1960 of the first procedures manual.
Princeton research press, princeton, nj, 1991, 1997 the best use of problem analysis is the use that works best. This book will change the way readers understand the world without changing. It is truly a new way of thinking that will ensure effective solutions to almost any kind of problem. Gano across multiple fileformats including epub, doc, and pdf. Apollo mission is widely regarded as a successful failure because despite the catastrophic explosion of one of the oxygen tanks, the crew members were able to return to earth successfully. Facilities accredited by the joint commission or in states with regulations governing completion of rcas should refer to those requirements to be sure all necessary steps are followed. There is no particular virtue attached to slavish adherence to every step in the entire process if a brief, informal use of the ideas can reveal the cause. Apollo root cause analysis is about effective problem solving.
The solutions, delivered by arms reliability, provided the structure and framework that helped me hone, and perfect my critical thinking and problemsolving skills, taking my effectiveness to the. Uploaded by booksalecataloger4 on september 26, 2011. The appropriate root cause analysis tool will be used. The analysis of the trajectory from liftoff to spacecraftsivb separation was.
It facilitates the creation of a common reality, using input from all stakeholders to produce an evidencebased understanding of the problem and ensures your. Rca is based on the basic idea that effective management requires more than merely putting out fires for problems that develop, but finding a way to prevent them. This document is an official release of the apollo program office. At the time of apollo, lovell was the nasa astronaut with the most time in. The apollo root cause analysis methodology and realitycharting software help resolve some of our most complex and longest running aerospace production and engineering problems. It makes problemsolving easy and gives those who have been trained, the skills to solve. As our root cause analysis of the mars climate orbiter incident has shown, even sophisticated organizations can make simple mistakes. The investigation is closed before all potential causes are investigated. Accordingly, we believe an effective problemsolving process should meet the following six. In science and engineering, root cause analysis rca is a method of problem solving used for identifying the root causes of faults or problems. Analysis is a combination of analysis presented in apollo documents and analyses by the author. Failure mode, effects, and criticality analysis is a reliability procedure which. Root cause analysis rca is a method that is used to address a problem or nonconformance, in order to get to the root cause of the problem. This bibliography contains references to documents in the nasa scientific and technical information sti database.
Check out our root cause analysis of the fire aboard apollo 1 or the 1986 challenger explosion. Gano 1 in his book apollo root cause analysis argues that each individual is unique, with our own perceptions, beliefs and values, and that this leads each of us to arrive at quite different conclusions even when presented with the same facts. To prevent this, nasa opted for an inwardopening hatch design for apollo 1, which trapped the astronauts inside the vessel when it caught fire on a launch pad test, killing the entire crew, including grissom click here to see our root cause analysis of the fire aboard apollo 1. A new way of thinking apollo root cause analysis is about effective problem solving.
The apollo mission, planned as a lunar landing in the fra mauro area, was aborted. Using ingenuity reminiscent of apollo, the crew on the international space. Apollo root cause analysis download ebook pdf, epub. The nasa root cause analysis tool rcat is designed to facilitate the analysis of anomalies, close calls, and accidents and the identification of appropriate corrective actions to prevent recurrence. The lower picture shows the apollo service module and the location of the oxygen tanks relative to the other systems. Space shuttle columbia thinkreliability, case studies. A new way of thinking free ebook apollo root cause analysis. The following slides are not contractual in nature and are. Apollo root cause analysis arms reliability apollo rca. The solutions, delivered by arms reliability, provided the structure and framework that helped me hone, and perfect my critical thinking and problemsolving skills, taking my effectiveness to the next level. Fishbone diagrams, also known as ishikawa or cause andeffect diagrams, are often used in six sigma projects, but the apollo root cause analysis method designed by dean gano is also useful.
1285 66 746 537 1041 1551 561 1072 1248 461 1164 887 162 568 406 1182 806 1538 1267 869 796 1288 1324 1369 1199 1174 438 451 211 1078 76 1193 1453 413 521 217 1337 621 569 1221