Module-9

Fault Tree Analysis (FTA)

 Fault Tree Analysis Learning Objectives

At the end of this section delegates will be able to:

• Understand the role of Fault Tree Analysis within
the DMAIC Improvement Process
• Construct a Fault Tree from “Top Event” down to
actionable “Basic Events”
• Identify appropriate actions to “close” a branch of
the tree
• Recognise that Fault Tree can be used both as a
prevention tool and a diagnostic tool
 Fault Tree Analysis – Agenda

1. Fault Tree Analysis Within DMAIC

2. Fault Tree Analysis Roadmap:
• Define Top Event
• Define scope of system
• Understand system
• Construct Fault Tree
• Analyse the Tree
• Closing Actions
3. Workshop
4. Summary
 Six Sigma Transactional Improvement Process
Define Measure Analyse Improve Control

Select Project
Define Measures (y’s)
Develop Detailed
Brainstorm Potential
Control Critical x’s

Define Project Process Maps Improvement Strategies
10.2 Upper Control Limit
START
Select Improvement
Objective
PROCESS Strategy 10.0

Form the Team
Check Data Integrity STEPS

9.8 Lower Control Limit

DECISION Criteria A B C D 9.6

1 5 10 15 20
Time + s - +
STOP
Cost + - + s
Monitor y’s
Service - + - +

Identify Critical Etc s s - +
Process Steps (x’s)

Determine Process by looking for:

Map the Process Stability
Plan and Implement
– Process Bottlenecks y

Identify Customer
Determine Process
Pilot
Requirements Capability – Rework / Repetition
Verify Improvement
Validate Control
– Non-value Added Plan
Steps LSL USL
LSL USL
– Sources of Error /
Mistake

Map the Ideal 15 20 25 30 35
15 20 25 30 35 Process
Identify further

Identify Priorities
Implement opportunities
Set Targets for
Identify gaps

Countermeasures
Close Project

Update Project File between current and
Measures
ideal

Phase Review Phase Review Phase Review Phase Review Phase Review
 Introduction to Fault Tree Analysis

• Fault Tree Analysis (FTA) is a graphical tool for analysing

possible causes of a failure.
• Can be used as a Prevention Tool - Prevent the failure
mode from occurring.
• Or can be used as a Diagnostic Tool - Identify what caused
the failure
• Focuses on a single failure mode (as opposed to FMEA
that looks at all failures)
• In Six Sigma it can be used to help identify the Critical
Inputs or Process Steps (x’s) (Analyse), and develop
improvements and controls for the Critical Inputs or
Process Steps (x’s) (Improve/Control)
 Fault Tree Analysis Roadmap

Step 1:
Define Top Event.

Step 2:
Define Scope of System

Step 3:
Understand System.

Step 4:
Construct Fault Tree

Step 5:
Analyse the Tree

Step 6:
Closing Action.
 Step 1 – Define Top Event

• The ‘Top Event’ is the major failure to be analysed in

the fault tree.
• Within Six Sigma DMAIC this typically will be the
issue(s) identified in the Measure Phase e.g. Delay in
invoice payment, Incomplete order shipment etc.
• When identifying, consider main functions of
processes, major “customer” effects, historical
failures…
• A separate fault tree should be generated for each Top
Event that is a fundamental concern.
 Step 2 – Define Scope of System

What comprises the ‘system’ (transactional

process) to be analysed:
• Which parts/process steps will be considered ?
• Which parts/process steps will be outside the
scope (responsibility of supplier or third party)?
• What level of detail ?
(macro/micro process steps)
• ‘System’ can consist of manual steps and / or
automated steps (e.g. IT system).
 Step 3 – Understand the System

• The relevant experts (IT, Process “Operators” etc.)

explain the function of each part/process step to the
team.
• Supported by:
• Process Maps
• Specification Documents
• “Walking the process”
• Customer Feedback data
 Step 4 – Construct Fault Tree

AND OR

AND Gate OR Gate

Bulb Blown

Dark Fuse Blown

OR No Power OR
Room Power Cut
Loss of AND Battery failure
Power
Switch Failed
To Close
 Step 4 – Construct Fault Tree

Basic Closing
Top Event Intermediate Events Event Action
OR OR OR
Specification

Supplier
AND Quality

Process
 Step 4 – Construct Fault Tree

Top Event Main failure to be investigated

Events leading to (causing) top
Intermediate event. Sequenced from high level
Events to lower level (“Macro” process
step to “micro” step).
Lowest level events within scope of
FTA. Actionable level of detail.
Basic Events
Three types of basic events should
be considered (although not all
may be present).
 Step 4 – Construct Fault Tree

Basic Event Types

Event relates to incorrect
Specification
specification e.g. information
Related
not specified as required

Event relates to supplier not

Supplier Quality meeting specification, e.g.
Related incorrect information provided.

Event relates to inadequate or

Process Related incorrect processing, e.g.
information entered incorrectly.
 FTA Example: Labelling Example

Top Event Intermediate

Events Basic Events Closing
Actions
Wrong label Incorrect part
Incorrect Wrong label
fixed to number entered
labeling of OR OR printed OR
product product

Information on Error in
label incorrect database

Stock of Labels
No label held
on line
Labels mixed AND
up on line Multiple Product
Types on
Production Line
 FTA Example: Invoicing Example

Intermediate
Top Event Basic Events Closing
Events Actions
Missing/ Lack of
Delay in Missing order
Incorrect authorisation
Invoice OR OR number OR
Information
payment

Sent to wrong Not supplied

person/place by Sales
Pricing
information
incorrect
Bankruptcy
 Step 4 – Construct Fault Tree

Method 1
• Brainstorm all possible events (causes) that might lead to Top Event.
• Transfer to Post-Its or cards.
• Sort into groups of events for related parts.
• Organise into a tree structure with Top Event on left side, branching
to the Basic Events on the right.
Method 2
• Starting from the top event and ask the question “how could this
happen ?”
• Work on each branch in turn, repeating the question “how could
this happen?”
In practice a combination of both methods can be used.
 Step 5 – Analyse Tree

Check:
• All known (historical) failures shown.
• Sequence of events from left to right.
• All branches have been developed to an
actionable level.
• Optional step :
• Prioritize the basic events in terms of their
probability of occurrence. (ref. FMEA
Occurrence Rating).
 Step 6 – Closing Action

• ALL Basic Events should have a closing action.

• ‘Level / depth’ of action dependent upon the level of concern
(occurrence).
• Three areas of focus:
• Specification Validation– to ensure that the transactional
process has been correctly specified
• Supplier Quality- to ensure that any process inputs are
correct
• Process Control – to ensure that the transactional process
is operated correctly
• Action not closed (signed off) until completed.
 Step 6 – Closing Action

Typical closing actions include:

• Standard Operating Procedures, SOP’s
• Operator Training
• Mistake Proofing
• Statistical Process Control, SPC
• Control Plan
 Fault Tree Analysis Roadmap

Step 1:
Define Top Event.

Step 2:
Define Scope of System

Step 3:
Understand System.

Step 4:
Construct Fault Tree

Step 5:
Analyse the Tree

Step 6:
Closing Action.
 Six Sigma Transactional Improvement Process
Define Measure Analyse Improve Control

Select Project
Define Measures (y’s)
Develop Detailed
Brainstorm Potential
Control Critical x’s

Define Project Process Maps Improvement Strategies
10.2 Upper Control Limit
START
Select Improvement
Objective
PROCESS Strategy 10.0

Form the Team
Check Data Integrity STEPS

9.8 Lower Control Limit

DECISION Criteria A B C D 9.6

1 5 10 15 20
Time + s - +
STOP
Cost + - + s
Monitor y’s
Service - + - +

Identify Critical Etc s s - +
Process Steps (x’s)

Determine Process by looking for:

Map the Process Stability
Plan and Implement
– Process Bottlenecks y

Identify Customer
Determine Process
Pilot
Requirements Capability – Rework / Repetition
Verify Improvement
Validate Control
– Non-value Added Plan
Steps LSL USL
LSL USL
– Sources of Error /
Mistake

Map the Ideal 15 20 25 30 35
15 20 25 30 35 Process
Identify further

Identify Priorities
Implement opportunities
Set Targets for
Identify gaps

Countermeasures
Close Project

Update Project File between current and
Measures
ideal

Phase Review Phase Review Phase Review Phase Review Phase Review
 Summary Fault Tree Analysis
• Analyse - Fault Tree can be used to identify possible Critical
Inputs or Process Steps (x’s) that are causing the poor
performance in Process Outputs (y’s)

• Improve - Fault Tree can be used to help identify how the Critical
Inputs or Process Steps (x’s) might be changed / eliminated /
controlled to improve the Process Output (y)

• Control - Fault Tree can be used to identify appropriate controls

for the Critical Inputs or Process Steps (x’s)

• Control - Fault Tree can be used as a diagnostic tool to identify

corrective action when a failure occurs
 Workshop – Construct a Fault Tree Analysis
Develop a Fault Tree Analysis for the given “Top Event” and
Transactional Process scope:
1. Understand the “System” (for a transactional process application,
develop/review the process flow).
2. Brainstorm “How could top event happen?”. Put each idea onto a
post-it as it is generated.
3. Organise the post-its into the tree structure, starting with the top
event on the left, working towards the root causes (basic events) on
the right.
4. Analyse the tree to check that the branches are logical and identify
any missing causes.
5. Identify closing actions for the five most likely causes (use the
FMEA Occurrence rating if required).
6. Prepare a short presentation on your team's findings.

Workshop Time: