Root Cause Analysis As a Risk Mitigation Strategy As Practiced by United Space Alliance. Willian L. Vantine, United Space Alliance, 1150 Gemini, Houston, Texas 77058, USA, telephone +1(281) 212-6143, fax +1 (281) 212-6097, e-mail William.L.Vantine@USAHQ.UnitedSpaceAlliance.com; and Daniel M. Deans, ARES Corporation, 1331 Gemini, Suite 120, Houston, Texas 77058, USA, telephone +1 (281) 461-9797, fax +1 (281) 461-9898, e-mail ddeans@arescorporation.com
Risk management is an integral part of everyday operations at United Space Alliance (USA), the prime contractor for NASA’s Space Shuttle operations. With the tremendous responsibility that USA has to fly safely and achieve mission objectives, a diverse tool set is required to ensure that risks are effectively managed and controlled. Root cause analysis plays a major role in risk avoidance, in that classical and non-classical methodologies are employed to ensure that anomalies are proactively managed and recurrence avoided. Root causes are often difficult to uncover, and USA uses several different and innovative methodologies and processes to ensure that problems are adequately addressed and do not reoccur. This paper will address the Risk Management process within NASA’s largest space operations contractor, discuss how root cause analysis is employed within the risk control hierarchy, and provide innovative ideas for application within other organizations.
Background
NASA Johnson Space Center in Houston, Texas defines a root cause in its quality system documentation as the underlying reason for, or cause of, one or more nonconformances or deficiencies identified through investigations and studies, which, when corrected, will prevent or reduce the recurrence of the realized or potential nonconformance(s) deficiency(ies). Root cause analysis is a classical method for determining the underlying cause to an undesired situation, in a structured manner. Analysis of root causes to a nonconformance is a typical part of any failure or anomaly analysis activity, as avoidance of problem recurrence is always a goal. There are many ways to perform root cause analysis, but the process can be simplified to defining the problem, understanding the direct and contributing causes, and isolating the root cause or causes. Industry trends are shying away from deterministic causes and are trending towards probabilistic root causes and acceptance of uncertainty, especially where random events and natural/environmental inputs play a role in the nonconformance. Given that deterministic processes are giving way to probabilistic methodologies, the use of automated tools to speed the process and to quantify outcomes are becoming more accepted.
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