Root Cause Investigation Best Practices Guide

A multi-discipline team composed of representatives from different organizations in national security space has developed the following industry best practices guidance document for conducting consistent and successful root cause investigations. The desired outcome of a successful root cause investigation process is the conclusive determination of root causes, contributing factors and undesirable conditions. This provides the necessary information to define corrective actions that can be implemented to prevent recurrence of the associated failure or anomaly. This guide also addresses the realities of complex system failures and technical and programmatic constraints in the event root causes are not determined. The analysis to determine root causes begins with a single engineer for most problems. For more complex problems, identify an anomaly investigation lead / team and develop a plan to collect and analyze data available before the failure, properly define the problem, establish a timeline of events, select the root cause analysis methods to use a long with any software tools to help the process. This guide focuses on specific early actions associated with the broader Root Cause Corrective Action (RCCA) process. The focus is the early root cause investigation steps of the RCCA process associated with space system anomalies during ground testing and on -orbit operations that significantly impact the RCA step of the RCCA process. Starting with a confirmed significant anomaly we discuss the collection and classification of data, what determines a good problem definition and what helps the anomaly investigation team select methods and software tools and also know w hen they have identified and confirmed the root cause or causes. Prepared in collaboration with the Boeing Co., Ball Aerospace & Technologies Corp., Lockheed Martin Corp., Northrop Grumman Corp., Orbital Sciences Corp., Raytheon Space and Airborne Systems and SSL. The original document contains color images.