REG NASA-LLIS-0757--2000 Lessons Learned The Team Approach to Fault-Tree Analysis.pdf

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1、Best Practices Entry: Best Practice Info:a71 Committee Approval Date: 2000-04-04a71 Center Point of Contact: MSFCa71 Submitted by: Wilson HarkinsSubject: The Team Approach to Fault-Tree Analysis Practice: Use a multi-disciplinary approach to investigations using fault-tree analysis for complex syste

2、ms to derive maximum benefit from fault-tree methodology. Adhere to proven principles in the scheduling, generation, and recording of fault-tree analysis results.Programs that Certify Usage: This practice has been used on the Space Shuttle Solid Rocket Motor (SRM), Space Shuttle Main Engine (SSME),

3、and Space Shuttle External Tank (ET).Center to Contact for Information: MSFCImplementation Method: This Lesson Learned is based on Reliability Practice Number PD-AP-1312, from NASA Technical Memorandum 4322A, Reliability Preferred Practices for Design and Test.The use of the team approach to fault-t

4、ree analysis permits a rapid, intensive, and thorough investigation of space hardware and software anomalies. This approach is specifically applicable when the solution of engineering problems is urgent and when they must be resolved expeditiously to prevent further delays in program schedules. The

5、systematic, focused, highly participative methodology permits quick and accurate identification, recording, and solution of problems. The resulting benefits of the use of this methodology are reduction of analysis time, and precision in identifying and correcting deficiencies. The ultimate result is

6、 improved overall system reliability and safety.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Implementation Method:Determination that a Team Approach to Fault-Tree Analysis is Required:In situations where program hardware or software anomalies are

7、 uncovered which could potentially reduce the possibility of mission success or cause harm to personnel, and where the pressure of schedules requires a rapid and accurate solution of problems, the team approach to fault-tree analysis should be strongly considered. Fault-trees are necessary when the

8、system in question is complex and has many potential contributors to the problem so that the solution defies simple intuition, engineering judgement, or easy elimination of the events that contributed to the problem. The team approach to fault-tree analysis brings all disciplines to bear simultaneou

9、sly in an interactive but controlled environment.A fault-tree is defined as, “a graphic depiction or model of the rationally conceivable sequences of events within a complex system that could lead ultimately to the observed failure or potential failure.“ It is a systematic approach to fault preventi

10、on achieved by postulating potential high level faults, and identifying the primary and secondary causes, down to the lowest piece-part, that could induce the high level fault. A typical arrangement of a fault-tree showing the potential types of “gates“ containing Boolean logic is shown on Figure 1.

11、 In situations of high urgency and cost or schedule sensitivity, it is often desirable to apply a team approach to development and use of the fault-tree methodology.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-refer to D descriptionD Fault-Tree Te

12、am Methodology:The keys to a successful team approach to a fault-tree analysis are: (1) selection of the right people to participate in the analysis; (2) interactive meetings of these people in a creative but focused environment; (3) thorough documentation of objectives, fault-tree structure, and ac

13、tion items; (4) parallel (but not redundant) participation by all team members; and (5) careful attention to general ground rules for effective team dynamics. All of the preceding must be backed up by a data base containing the hardware/software configuration, operational time lines, potential failu

14、re causes, and exonerating or indicting data. Logic flow networks are built based on the systems design, then laboratory test results, hardware/software test results, and modeling based on deterministic and/or probabilistic statistical analyses. These logic flow networks also feed into the informati

15、on data base that is used by the fault-tree team.An integral part of successful fault-tree methodology is the selection of an orderly structure on which to base the fault-tree and the team participation. The Work Breakdown Structure (WBS) is an ideal starting point for the team as well as for the de

16、sign. Each event or activity in the WBS is subdivided Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-into its main contributing events or activities, then the tree is subdivided again until the smallest activity that cannot be further subdivided is

17、reached. These final events or activities are the “leaves“ on the fault-tree.Team Composition:Given the nature of the failure or anomaly being investigated, people should be assembled who have both an intimate disciplinary knowledge and a knowledge of the overall system. Elements heads and subteam l

18、eaders should be established for major investigative elements of the work breakdown structure. Important administrative functions to support the team are: (1) the maintenance of a current address, phone, and fax listing of all persons involved; (2) recording daily team meeting minutes; (3) preparati

19、on of agenda for the next day, (prepared at the end of the current day); (4) recording of all action items including the name of the person responsible, suspense dates, and the specific action required; and (5) the maintenance of a master schedule of major planned events, based in part on the suspen

20、se dates.Team Dynamics and Work Strategy:The entire team should meet together in one location in a meeting to expose all known data related to the anomaly or failure, then the team should meet at least once per day thereafter. Action items should be assigned and as much work as possible should be do

21、ne in parallel without undue redundancy. Series activities of the team should be avoided. Team interaction is important because the fault-tree is built in a dynamic, contributory fashion.During the fault-tree team activities, the team leader and scribe should keep files of action items, agendas, tec

22、hnical data related to development of the fault-tree, correspondence, administrative reports, the master fault-tree diagram, and the teams schedule. Top management and other related organizations should be kept informed as to the progress of the team. Hand written notes to the key players from the t

23、eam leader “en route,“ at key milestones and critical junctures, and on successful completion of the investigation are particularly helpful. Rambling discourses should be avoided. Meetings and discussions must be diplomatically kept on track. The leader should be as democratic as possible in team me

24、etings. No one should be affronted, but in case of an impasse, the team leader must make the decision. Refreshments should be provided occasionally, especially on Saturday or Sunday and after hours. This will boost morale and provide an atmosphere conducive to free discussion.Other General Technique

25、s and Methods:The purpose of the team approach is to provide multidisciplinary perspectives that will uncover details and to resolve cause/effect relationships which may not be apparent in more narrowly focused detailed engineering analytical and design methods. Therefore, each element of the fault-

26、tree must be doggedly and systematically analyzed, persistently subdivided into its smallest elements, and Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-pursued to the lowest level.The history of these types of investigations has indicated that a m

27、ethodical, vigorous assessment is needed to develop and to utilize a fault-tree of sufficient depth. This vigorous assessment will eliminate illogical assumption, identify or eliminate synergistic effects, help to avoid partial fixes and reduce intuitive or random approaches that cannot be substanti

28、ated. The team should resist the temptation to preconceive a conclusion or take on a “pet theory“ to the exclusion of a systematic, orderly, and vigorous treatment of all elements in the decision tree. The team should avoid any tendency to slow down the analysis process or to assume that a conclusio

29、n has been reached when a likely cause candidate has been identified, because this potential candidate could mask the true cause or divert the teams attention from a more fruitful path.Probability and statistics are important disciplines to use in the fault-tree analysis process. The team should hav

30、e an appreciation of the fact that if it is necessary to stack too many possible events together to eventually postulate the occurrence of the failure, then it is improbable that it occurred in that manner. The references list several computer-aided fault-tree analysis software packages that will ai

31、d in performing the statistical analysis and informing the decision tree graphics required to document a fault-tree analysis.Technical Rationale:The team approach to fault-tree analysis described in this practice was used very successfully in a number of in-depth investigations of problems that occu

32、rred in propulsion elements of the Space Shuttle, and related facilities and equipment. The procedure was first used in full measure in the investigation of a fire in the casting pit of the Space Shuttle Solid Rocket Motor (SRM) in 1984. It was also used in identifying causes of problems in the SRM

33、propellant mix facility.Several problems and potential problems with the Space Shuttle Main Engine (SSME) were successfully investigated using the team approach to fault-tree analysis. These investigations involved the bearings for the alternate turbopump, and a synchronous vibration problem. Hydrog

34、en leaks in the Space Shuttle Columbia were investigated and successfully resolved in an in-depth and intensive three-month team approach to fault-tree analysis.References1. Dhillon, Balbir S: “Fault-Tree Analyses,“ (Chapter 20 of “Mechanical Engineers Handbook“) John Wiley (2) expenditure of the va

35、luable time and efforts of engineering personnel with less than optimum performance; and (3) failure to pinpoint problem causes and corrective actions with precision. Overall results could be slippage of the schedule, increased costs, unidentified hazards to the crew and other personnel, and nonperf

36、ormance of the mission.Related Practices: N/AAdditional Info: Approval Info: a71 Approval Date: 2000-04-04a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-