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Compliance Engineering
What ?
A structured team analysis of the possible underlying causes of a known equipment failure. root cause analysis of a failure is needed
When ?
Why? - (outcomes)
A better set of action plans to eliminate those root causes (Step 4: Solution)
2 DATA 3 ROOT CAUSE 4 SOLUTION 5 CONFIRM RESULTS
No
1 THEME
6 STANDARDIZE
7 REFLECT
Yes
Compliance Engineering
Fault tree analysis is an effect and cause diagram that uses standard symbols developed in the defense industry and is used heavily in safety engineering. FTA is a structured approach for analyzing the root causes of a failure mode not yet fully understood.
Note: FTA is an alternative to Ishikawa (Fish Bone) Diagrams. Many feel that FTA is better suited to understanding layers and relationships of causes of equipment failures. However, if you still prefer fish bones after trying FTA, there is no reason not to use them. The goal always remains to use the most efficient method for solving problems.
Compliance Engineering
Failure: The indicator light is on yet even with sufficient amounts of smoke directly below the detector vents the alarm does not signal. Before we begin either a Fault Tree Analysis or Failure Modes and Effects Analysis, our first step should be to construct a Functional Block Diagram.
THEME
DATA
ROOT CAUSE
SOLUTION
CONFIRM RESULTS
No
Yes
STANDARDIZE
REFLECT
Compliance Engineering
Process
Detection of smoke
Outputs
Alarm signaling Signal/power to siren turns motor Motor causes siren to sound
Smoke is ionized and causes increase in voltage Signal sent from smoke detector triggers control box circuit Control Box sends signal/power to siren
Alarm signals
Compliance Engineering
Defective alarm
No power at alarm
Broken wire
Broken wire
1 THEME
2 DATA
3 ROOT CAUSE
CONFIRM RESULTS
No
STANDARDIZE
Compliance Engineering
Began by clearly identifying the failure as: The indicator light is on yet even with sufficient amounts of smoke directly below the detector vents the alarm does not signal. Began brainstorming and building a functional block diagram to fully understand how the smoke detector functions. Continued brainstorming on possible causes for the smoke detector failure resulting in the alarm not signaling. Probable causes were identified:
The team constructed the FTA around the three major categories in the functional block diagram, inputs, process, and outputs. The team continued to build the FTA and completed it by adding lower levels of detail under appropriate causes of failure. The team identified the types of failure where it did not have the expertise to analyze possible root causes. If deemed necessary, the team would seek help from suppliers or consultants to further analyze these area. The leading causes of failure and solutions were identified.
Compliance Engineering
Fault Tree
Symbols Review
Square
Describes the top and lower level failures Produces output (failure) if one or more inputs exist Produces output (failure) if and only if all inputs exist
Or Gate
And Gate
Circle
Potential root failure which cannot be broken down into lesser failures
Potential failure which is not analyzed for various reasons
Ultratech Internal Use Only Slide 8 May 8th, 2007
Diamond
Compliance Engineering
Determine which combination of contributors is needed to cause the top failure. (Ask: How many of the inputs are needed to cause the top failure? ) Link the contributors to the top failure with the correct gate. (And/Or)
Yes - repeat cycle making each contributor a top failure, assign gates, etc... No - we are finished - We may also end our fault tree when we reach all indeterminable, basics, or causes which require further research etc...
Ultratech Internal Use Only
Compliance Engineering
Failure
Failure
Compliance Engineering
Step 1 Identify Top Level Fault Step 3 Link contributors to top by logic gates Step 2 Brainstorm first level contributors Step 5 Link contributors to upper level by logic gates Step 4 Brainstorm second level contributors
(This page is taken from SVERDROP MANUAL - FTA and Risk Management by P.L. Clemens, 1992/1993, pg. 10 )
Compliance Engineering Ultratech Internal Use Only Slide 11 May 8th, 2007
Dos
Start at the Top Think Categories Brainstorm, then organize Facilitate proper brainstorming Know when to stop Have action plans for all circles Check that branches terminate with a circle or diamond Revisit the FBD or FTA when new data is found Use yellow stickies to capture the brainstormed causes Dont get bogged down Dont jump to solutions!
Ultratech Internal Use Only Slide 12 May 8th, 2007
Don'ts
Compliance Engineering