Project Management
Project Portfolio Management

 

NASA: Root Cause Analysis



The use of NASA Technology in Project Management

“NASA has been recognized as a world leader in mishap investigation.  Part of this recognition comes from NASA’s systematic and thorough evaluation of each NASA incident to determine cause and generate recommendations to prevent recurrence.  Although it has been NASA’s policy to conduct Root Cause Analysis (RCA) for more than a decade, NASA’s implementation of this requirement became consistent with the development of an Agency-wide standard RCA method and set of definitions in July 2003.

The standard method is the result of a joint effort between NASA’s engineering and safety communities to establish common terminology that facilitates improved communication and understanding of RCA.  NASA defines RCA as “a structured evaluation method that identifies the root causes of an undesired outcome and the actions adequate to prevent recurrence.”  NASA adopted this definition for RCA and definitions for root cause and related terms to ensure that when teams perform an analysis and state that they have reached a “root cause,” they have completed detailed evaluations, identified all relevant organizational factors, and exhausted all applicable data.  The standard set of definitions is applicable to both engineering and safety teams that use RCA to evaluate problems and mishaps.  The standard was initiated through a memo signed by both the NASA Chief Engineer and the NASA Chief, Safety and Mission Assurance.

In February 2004, the standard set of RCA definitions was incorporated into NPR

8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping.  Since that time, NASA has developed introductory web-based training and classroom instruction.

RCA is used by professionals in engineering, quality control, program management, and safety.  The RCA techniques are used in conjunction with other methods such as Barrier Analysis, Change Analysis, and Fault Tree Analysis to evaluate events and conditions that cause or contribute to an undesired outcome.

Today, one of NASA’s objectives is to expand the base of experts in RCA by providing both NASA civil service personnel and contractors with detailed guidance and instruction.  This guide is intended to facilitate the accomplishment of this objective by further documenting the methodology and terminology adopted by NASA.”

[ NASA Root Cause Analysis – Supplemental Training Material – Part I: NASA RCA, Foreword ]


You may copy, print, or distribute this document but only if you acknowledge NASA’s authorship.  This document is subject to continuous revision.  Consequently, we respectfully request that you reference the website from which you acquired it, rather than posting it in full on your own website.  Because this document was produced by the U.S. Government, no portion of it may be sold for profit.


Purpose of RCA

The purpose of RCA is to identify the causal and contributing factors that created an undesired outcome, so that the undesired outcome can be prevented in the future.  RCA is more than just a search for the obvious cause; it is a comprehensive analysis to identify root causes, both the basic and underlying organizational factors.  With an indepth look at causes and contributing factors, RCA enables the analyst to generate specific recommendations that can prevent a repeat of the undesired outcome, and prevent similar problems, close calls, and mishaps from occurring.  This is conducted through the creation and implementation of recommendations that specifically target the root causes of the undesired outcome.

How to access Nasa Software for Root Cause Analysis

    1. Go to https://software.nasa.gov/login
    2. Create your account
    3. Check the available catalog of software that is available for you (a few options to the open public and several other for Government employees)
    4. Follow instructions for getting access to the chosen software

After the steps are followed, the user will be granted an access to a website where one can download the available software.


In other posts, we will be discussing the RCA Method, the use of the software and others.
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