Root Cause Analysis

From: Pinizzotto,Russell (
Date: Fri Feb 07 2003 - 15:10:50 EST

  • Next message: Dale Ireland: "RE: Root Cause Analysis"

    Having been involved with failure analysis, I would agree with Markus that
    one piece is probably not THE root cause.  In cases like this one, there is
    usually a chain of events and causes that haven't been thought about very
    much that cascade into a catastrophe.  For example, the O-ring in the
    Challenger case is not THE root cause, it was a combination of weather,
    design, poor choice of materials and cutting some corners.  Remember, the
    joint was totally re-designed after that incident and not just to change the
    O-ring configuration.
    I expect that when the Columbia failure is finally understood, it will be a
    similar chain of events.  For example and totally hypothetically, a chain of
    events being foam coming off the ET, damaging one tile, which led to
    cracking of one carbon-carbon composite piece in the leading edge during
    re-entry which caused something else to disrupt the whole leading edge which
    led to failure of the entire wing assembly.
    A good example is the Turkish DC-10 crash of about two decades ago.  A
    technician moved the safety locking pin so the baggage door could be closed
    more easily.  That resulted in being able to close the latch handle when the
    actual latch was not positioned properly.  There was a design problem with
    the closing mechanism, but if the pin had been left alone, it would have
    been noticed.  Was the root cause the pin, the technician, the latch, of the
    unfortunate combination of all of the above?
    Best Regards,
    Russ Pinizzotto
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