RootCauseAnalysis_FailuresMishaps

NASA Mishap  

An unplanned event that results in at least one of the following:

  • Injury to non-NASA personnel, caused by NASA operations.
  • Damage to public or private property (including foreign property), caused by NASA operations or NASA-funded development or research projects.
  • Occupational injury or occupational illness to NASA personnel.
  • NASA mission failure.
  • Destruction of, or damage to, NASA property.

Types of Mishaps

What can go wrong?

  • Equipment will fail
  • Software will contain errors
  • Humans will make mistakes
  • Humans will deviate from accepted  policy and practices

What is at stake?

  • Human life
  • One-of-a-kind hardware
  • Government equipment & facilities
  • Scientific knowledge
  • Public confidence

Investigating Causes of Failures & Mishaps

The purpose of NASA mishap investigation process is solely to determine cause and develop recommendations to prevent recurrence. However, often investigators:
  • Identify the part or individual that failed.
  • Identify the type of failure.
  • Identify the immediate cause of the failure.
  • And stop the investigation.

Example:

                                                     

This way, the underlying causes may continue to produce similar problems or mishaps in the same or related areas.

Investigating Causes of Failures & Mishaps

When performing an investigation, it is necessary to look at more than just the immediately visible cause, which is often the proximate cause.

There are underlying organizational causes that are more difficult to see, however, they may contribute significantly to the undesired outcome and, if not corrected, they will continue to create similar types of problems.  These are root causes.

Per NPR 8621.1: NASA Procedural Requirements for Mishap reporting, Investigating, and Recordkeeping: All NASA mishap and close call investigations must identify the proximate causes(s), root causes(s) and contributing factor(s).