Root Cause Analysis- The Challenger Incident's Stats The first step in any root cause analysis approach

is to define the problem by asking four critical questions:

What is the problem? In investigating any incident, big or small, the process of specifying the problem is likely to elicit multiple responses. At this stage in the analysis, all potential problems are written down for later evaluation. In this example, we will begin by identifying the loss of all seven crewmembers and the loss of the space shuttle as the major problems.

When did it happen? In order to measure change, root cause analysis specifies as precise a time as possible for a given incident. Here, the Challenger broke apart two minutes into its tenth mission, at 11:39:12 AM EST on January 28, 1986.

Where did it happen? Root cause analysis also requires capturing as specific location as possible when defining the problem; in particular, emphasis is placed on specifying the location in which solutions can be enacted. Thus, while other Cause Maps related to space disasters technically describe one incident that occurs in two locations (with the space shuttle and at command center), the emphasis remains on the location that can be controlled: Command center. In this case, the space shuttle broke apart just after launch; the Challenger facility (STS 51-L) at Cape Canaveral is thus captured as the location for the incident.

How did it impact the goals? Root cause analysis involves being as specific to a given organizations goals as it is in defining the problem. All organizations have multiple goals in common. It is good business to ensure the safety of employees and the public, to remain within budget, to achieve the intended purpose of the organization, to avoid damaging equipment, and to do it all as efficiently as possible. Here, these elements are understood in terms of safety, vehicle, equipment, mission, and labor goals. Safety is clearly an important goal to NASAs spaceflight missions: a manned mission can never be considered a success unless all of the astronauts who are launched into space come back home. In this case, the safety goal was affected by the deaths of all seven astronauts aboard the Challenger. In addition, space flight is extremely expensive

business. The Challenger was built to complete multiple missions (indeed, it had already completed ten), and its construction involved a gigantic investment in time and money; losing the space shuttle meant losing billions of dollars of equipment as well as the possibility of reusing the shuttle in other missions. The total loss of the shuttle can therefore be considered to have impacted the vehicle goal. Since the shuttle disintegrated just after loss, the mission was a complete loss; this affected the mission goal. As a result of the disaster, the solid rocket booster joints had to be redesigned, impacting the equipment goal. Finally, investigation and testing in the wake of the disaster affected the labor goal.

Collecting Causes- The Next Step in Root Cause analysis for the Challenger The next step in root cause analysis breaks the incident down into a chain of cause and effect, with each cause documented on the cause map. That way we build a nice clean Cause Map for more efficient root cause analysis. In this case, the safety goal was affected because seven astronauts lost their lives. This is the first cause-and-effect relationship in the analysis.

The analysis continues by asking, Why?, moving to the right of the cause -effect relationship above. The astronauts deaths were due to the loss of Challenger, which was caused by an external tank explosion: the space shuttle broke apart because gasses in the external fuel tank mixed, exploded, and tore the space shuttle apart.

The external fuel tank exploded after a rocket booster came loose and ruptured the tank. Why? Because hot gasses and flames leaking out of the rocket boosters burned a hole into the external fuel tank and the piece that held the rocket boosters onto the shuttle. Why were hot gases leaking out of the rocket boosters? Because a seal around the O-ring (a piece of the rocket boosters) failed.

Why did the primary O-ring fail?

There are three reasons, the first of which was structural. There was a fundamental design flaw in the joint that engineers had grown accustomed to and had learned to live with. Although the boosters were not designed to work this way, it was not uncommon for the booster casing to balloon under the stress of ignition, causing the metal parts of the casing to bend away from each other, creating gaps through which hot gases could leak. In prior instances, the primary O-ring would shift out of its groove and form a seal. This process is called extrusion, and the hot gases escaping is called blow-by. The evidence of previous issues with o-ring erosion and blow-by can be captured directly on the Cause Map. The more time it takes for extrusion to occur, however, the greater the damage to the Orings. This brings us to the most immediate reason for the O-ring failure: the low temperatures at launch caused the O-rings to harden. On the morning of the launch, the cold weather lengthened the time of extrusion and hardened the O-ring, which could not form a seal in time. Finally, the primary O-ring blow-by (the escape of hot gas) occurred because the O-ring hardened and did not fully seal at the low temperatures, and because the decision was

made to launch in low temperatures, despite the fact that the vehicle was never certified to operate in temperatures that low. This decision was found to have been made because of ineffective launch commit criteria.

Root Cause Analysis Step 3: Select the Best Solutions (Reduce the Risk) Once the Cause Map is built to a sufficient level of detail with supporting evidence, the solutions component of root cause analysis can begin. The Cause Map is used to identify all possible solutions for given issue so that the best among them can be selected. Root Cause analysis thus makes it easier to identify many possible solutions from the detailed Cause Map; root cause analysis thus facilitates identifying more multiple workable solutions than can more oversimplified high-level analysis. In root cause analysis, solutions can be documented directly on the Cause Map, and are typically placed in a green box directly above the cause that the solution controls. At this stage, all solutions are considered and documented on the Cause Map.

After the analysis is complete, the best solutions are selected based on their impact on the organization's goals. Shown below are the action items implemented as a result of the Challenger disaster.

Every issue has its causes, and should be worked to a sufficient level of detail to prevent the incident or to reduce the risk of the incident occurring to an acceptable level. This is why solutions and work processes at a coffee shop are not as thorough or detailed as an airline or nuclear power facility. The risk or impact to the goals dictates how effective the solutions will be. Lower risk incidents will have relatively lower detail investigations while significantly high risk to an organizations goals requires a much more thorough analysis. Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.

Aftermath Every issue has its causes, and should be worked to a sufficient level of detail to prevent the incident or to reduce the risk of the incident occurring to an acceptable level. This is why solutions and work processes at a coffee shop are not as thorough or detailed as an airline or nuclear power facility. The risk or impact to the goals dictates how effective the solutions will be. Lower risk incidents will have relatively lower detail investigations while significantly high risk to an organizations goals requires a much more thorough analysis. As for the Teachers in Space Program, it was supplanted by the The Educator Astronaut Project. In August of 2007, Barbara Morgan, the backup teacher for the Challenger flight, became the first teacher in space on the orbiter Endeavour STS-118 mission.

Root Cause Analysis Improves Problem Solving Skills Grounded on the basics of the cause-effect principle, root cause analysis can be applied consistently to mundane as well as catastrophic or high-risk issues. The steps of root cause analysis are the same, but the level of detail will vary depending on the specific incident or issue under consideration. Focusing on the basics of the cause-

effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.