AA3

Objective:
Apply the concepts of the root cause analysis to understand the reasons behind well-known
engineering failures and disasters

Required materials:
1. Case briefing (max half-page per case), choices for cases are listed below, please
add more if you could and comment on the cases presented:
a. Dona Paz tragedy
b. Fukushima Daiichi Nuclear Disaster
c. (Jollibee) Chickensad 2014
d. Aloha Airlines Flight 243
e. Bhopal gas tragedy

Instructions:
1. Select from any of the provided cases as the topic of the root cause analysis and
look up further information apart from what is provided in the case briefing
2. Provide a brief, one paragraph narrative of the case background
3. Conduct a root cause analysis guided by the 6Ms and the fishbone method. You may
also employ the 5 Whys to create deeper fishbones, although five levels are not
required.
4. Briefly elaborate on the identified root causes and how you identified them as such.
5. Provide brief but actionable recommendations to prevent similar incidents from
happening again.

Scoring guide:
1. Narrative case background - 5pts
The history and facts about the situation leading into, during and after the case were
all discussed with brief and narrative details.

2. Depth of RCA - 5pts

At least 3 levels of fishbone must be discussed, for each of the 6M’s.

3. Proper classification into 6Ms - 5pts

The causes indicated are classified properly into their respective M’s.

4. Identification of root causes - 5pts

Among the 6M’s and the causes identified, 2 root causes were determined and
discussed in detail. Each root cause must be presented with factual details found in the
investigation.

5. Recommendations - 5pts
Based on the two root causes, personal recommendations should be given. Keep the
recommendations brief and concise targeting the root of the problem with the most effective
and efficient solution in existence.