Professional Documents
Culture Documents
Failure Reporting,
Analysis and
Corrective Action System
Dr. K. Radhakrishnan
Chairman
MESSAGE
ISRO Reliability Standards, addressing the various disciplines of Engineering, have been
in vogue for almost three decades now. These standards are followed across ISRO
centres as well as external work centers for design, fabrication, testing, analysis and
other processes involved in the realization of Launch Vehicles, Spacecraft, Space
Applications, Ground support systems and other launch infrastructure. The need for
standardization of processes towards achieving high reliability systems can never be
over emphasized, and ISRO Reliability Standards are just an attempt towards explicitly
stating this.
With the advent of newer techniques and with the evolution of technology itself, over the last 30 years, it
has become essential to revisit the existing ISRO Reliability Standards and revise and update the standards
wherever essential. Towards this, the Directorate of Systems Reliability and Quality (DSRQ) at ISRO
Headquarters has taken an initiative to re-invigorate the reach and visibility of ISRO Reliability standards
across all the Centres of ISRO. Specific Inter-centre teams were formed to revise each of these documents
and I would like to place on record their commendable efforts in bringing out these documents.
There is a pressing need for ensuring uniformity of practices, across various functions of design, fabrication,
testing, review mechanisms etc., across the centres and units of ISRO. Towards this goal, the mandatory
adoption of ISRO Reliability Standards will ensure standardization in quality processes and products. I am
certain that this will go a long way towards ensuring overall system level Quality and Reliability and in
achieving the goal of zero defects in the delivery of space systems of ISRO.
K Radhakrishnan
Chairman, ISRO
Directorate of Systems Reliability & Quality
ISRO Headquarters
Antariksh Bhavan
New BEL Road, Bangalore -560231
Ph :080 - 2341 5414
Fax :080 – 2341 2826
S Selvaraju Cell:09448397704
Senior Advisor, Systems Reliability and Quality Email: sselvaraju@isro.gov.in
PREFACE
ISRO Reliability standards are a result of the need for standardization of processes towards achieving high
reliability systems. The transfer of knowledge and techniques from the seniors to their successors is best
done with proper documentation and checklists translating the entire know-how into black and white.
This particular document ‘Failure Reporting, Analysis and Corrective Action System’, encompasses
the system of reporting, analyzing and correcting failures. The objectives of failure analysis, formation
of Failure Analysis Board (FAB) and its responsibilities and the role of quality professionals is clearly
documented. The concepts of Failure confirmation and procedure for Failure Analysis are also stressed
upon. The details of the aspects of failure notification, local records, impact analysis, initial inspection,
reporting format, trend analysis and close-out of actions are addressed at length. Specific attention is
drawn towards compliance of similar procedures at external work centers as well. Emphasis is also laid on
the development of a lessons learnt database and its dissemination across ISRO centers. Identification and
quarantine of rejected items is also elucidated.
It is deemed essential that these standards be strictly adhered to, in order to ensure uniformity of practices
across ISRO centers and achieve zero defects in the delivery of space systems.
I am grateful to Chairman ISRO, for being the source of inspiration in the release of these documents.
Thanks are also due to the centre Directors for their encouragement. I am also thankful to the Heads of
SR Entities/Groups of various ISRO centres for their relentless support and guidance. I am also indebted
to the members of the Integrated Product Assurance Board (IPAB) for the meticulous review of these
documents. I also owe gratitude to the task team members and other experts for putting efforts in the
realization of these documents. I am glad to carry forward this rich lineage of ISRO reliability standards,
championed by Shri R Aravamudan, a revered pioneer in the area of Quality & Reliability in ISRO.
S Selvaraju
Sr. Advisor (SRQ)
CONTENTS
1. SCOPE 9
2. DEFINITION 9
3. APPLICABLE DOCUMENTS 9
7. FAILURE RECORDS 15
7.1 Trend Analysis and Summary 15
7.2 Records Review 16
9. MISSION FAILURES 16
1. SCOPE
Failures though not desirable, teach important lessons.To prevent the recurrence of similar failures, it is all the more
essential to have a detailed analysis of the reasons/ root cause of failures and preventive / corrective actions required
to ensure the reliability of the system.
This specification document brings out a systematic approach for the failure reporting, analysis and implementation
of corrective action. These procedures are mandatory and are applicable for hardware and software developed for
all launch vehicles and satellite systems of ISRO.
2. DEFINITION
Failure
A failure is defined as a defect or malfunction which can prevent successful accomplishment of a mission. To be
precise, a part or a system encompassing hardware or software is considered to have failed under one of the
following three conditions:
Condition (a) and (b) above are unambiguous and are easily identified and they necessitate immediate removal of
the part or system from service for repair or replacement. The last condition, however, involves certain amount of
subjective assessment as to what is considered as satisfactory functioning. In such cases functional specification and
the operational tolerances of the system should be the basis for judging the malfunction observed.
Non Conformance
An item, be it a raw material or a finished product, will be identified as non-conforming when it does not conform
to the applicable drawing, specifications or other stipulated criteria during the course of procurement, fabrication,
assembly and testing. Technical judgment indicates that these deviations are not due to component failures. Such
deviations observed will not generally constitute a failure and will be routed to appropriate Non Conformance
Review Boards (NCRB) for assessment.
3. APPLICABLE DOCUMENTS
The relevant portions of the following specifications generally form part of this document.
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ISRO-PAS-201
(i) The prime objective of failure analysis is to analyze the failure signatures of failed unit, identify the rootcause
of the failure and then take corrective actions so as to improve the performance. A basic requirement of the
failure analysis is that, all failure modes and failure mechanisms of the failed unit are known and
understood.
(ii) An important outcome of failure analysis is improved design, process and testing procedure so as to prevent
the recurrence of similar failures in future.
(iii) One of the derived objectives of failure analysis is that, a well defined failure analysis effort aids the development
of unique experimental techniques to analyze failure symptoms of complex systems, and establishment of a
scientific approach to system realization.
(iv) Another objective is that, failure analyses provides a mechanism for experience retention through
documentation and also adds to the repository of lessons learnt.
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ISRO-PAS-201
Organized and timely failure reporting is essential in order to alert the project, and all concerned, that a failure has
occurred, which might impede the successful performance and delivery targets. A controlled reporting system is
mandatory for effective failure analysis.
The subsequent analysis and corrective action shall be incorporated for all similar applications in the whole
Project/ Mission.
5.1.1 Membership
The FAB shall be constituted by the Centre Director as a standing Failure Analysis Board for all the projects of the
Centre. Separate boards may be necessary for disciplines such as electronics, software, mechanical, chemical, etc.The
board shall have a Chairman preferably from the Systems Reliability (SR) agency of the Centre who is knowledgeable
in the area and can provide effective guidelines for carrying out failure analysis. The other members shall be from
design team, SR, project core team, and other specialists in the applicable area. The board shall have a convener/co-
convener preferably from Project/SR.
5.1.2 Responsibilities
In the analysis of the failure reported, the Board shall:
- Verify the failure
- Evaluate the effects of the failure on the performance requirements
- Review records of earlier analysis of similar failures, if any
- Consider alerts from other projects, vendor records, test reports, etc.
- Carry out a systematic investigation to determine the root cause of the failure and the failure mechanisms
- Get in-depth analysis made wherever necessary, by an appropriate failure analysis laboratory to identify
failure modes and reasons
- Evaluate secondary/propagated effects of the failure on other parts in terms of electrical/mechanical
stresses
- Determine the corrective and preventive actions to eliminate the root cause of the failure and to prevent
recurrence of similar failures
- Document the proceedings with all evidences including photographs and other relevant records
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ISRO-PAS-201
- If multiple failures of same type of components are observed, that batch is to be suspected. Additional tests
shall be done on that batch and based on the test results the batch shall be quarantined and controlled
- Categorise the failures as design related, process related, handling related, workmanship related or test
induced etc.
- Define the re-test guidelines on the refurbished hardware/software
shall be reported to FAB for analysis and shall not be simply kept aside without proper failure analysis. Failure of
ground equipments involved in the critical operation also shall be reported to FAB.
The failure report should be marked to Convener, Chairman and other members of the appropriate FAB, the SR
agency, System Development/ production agency, and the Project concerned.
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ISRO-PAS-201
- Operating environment
- Description of failure
- Circuit diagram/ drawing indicating the failed component & the operating conditions
- Effect of failure on system/subsystem performance
- Suspected cause
- Earlier failure history, if any
A notification format can be standardized by each centre, as found fit. Sample formats are given in annexures I & Ia.
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ISRO-PAS-201
5.4.2 Recommendations
FAB should bring out, based on studies/deliberations, the root cause of failure and circumstances for the same. Based
on detailed analysis and tests, FAB should recommend a set of corrective actions required for the removal of not
only the faulty or malfunctioning part but also other parts that may have been affected beyond their rated thresholds.
FAB should also recommend preventive actions to avoid recurrence of such failures in future. FAB should bring out
clearly, whether the failure is due to operational, workmanship or design related discrepancy.
It should be brought to the notice of Project as well as Project Configuration Management Board in case the
recommendations call for a change in configuration.
5.5 Close-out
5.5.1 Closure Report
The close-out should be presented to the FAB. The project, through the Project Engineer/ Manager concerned,
shall ensure that all actions on failures are closed appropriately. To prepare a Close-out, the following shall be
complied with:
- Corrective actions have been accomplished and verified
- Effectiveness of preventive actions (including review of relevant reliability analysis) has been established and
confirmed
- Close out documentation has been signed by appropriate authority and by the SR agency certifying the completion
of all close-out actions
Wherever interim corrective actions are necessary, these should be authorized by formal and standard procedures
to satisfy the immediate mission requirements. Further, in such cases the close-out should be completed prior to
subsequent missions of similar nature.
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ISRO-PAS-201
The Failure Closure Report should contain the following mandatory information:
• Report number and date of failure
• Project identification
• Identification of failed item
• Next higher assembly
• Identification of part drawing number, etc.
• Manufacturer
• Number of hours operated before failure
• Reporting agency
• Failure report reference and a summary
• FAB recommendations
• List of parts replaced/repaired, if any with identification
• Close-out status (whether action closed, waivers requested etc.)
A closure report format can be devised by each centre, as found fit. Sample formats are attached in
annexures III & IIIa.
7. FAILURE RECORDS
Convener of the FAB is responsible for maintaining all the failure records and corrective actions. In addition, minutes
of all FAB meetings shall be maintained to provide a continuous record of attendance and actions. Such records shall
be in a form showing the complete history of each failure including its identification, time, dates, locations, activities
in progress and environments prevailing at the time of occurrence of the failure as well as implications, actions taken
and traceability information.
A database of all failures/ corrective actions shall be maintained in an easily retrievable electronic form in each
centre. A repository of lessons learnt from the failures shall be maintained, updated periodically and intimated to the
concerned as alert notes. A lessons learnt document shall be brought out by SR team, after each mission along with
specific recommendations. Suitable higher level fora such as LV-FRR/SRC/Sub-system PSR shall review this document
and suggest mandatory actions further on.
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ISRO-PAS-201
SR agency should also send alerts on failures periodically to all the concerned design groups/projects highlighting
such failures for suitable corrective/preventive actions. These alerts as applicable, may also be shared with other
ISRO centres.
Procedures discussed in this document for failure reporting, failure analysis, closeout etc., are applicable to these
cases also. Failure records and trend analysis are also to be carried out as stipulated.
SR agency shall send alerts wherever required based on inputs of any lapses or use of non- standard practices to all
production agencies for corrective and preventive actions. The alerts as applicable, may also be shared with other
ISRO centres.
9. MISSION FAILURES
Analysis of mission failures (such as launch failures, in-orbit anomalies, major test failures etc.) is generally more
complex in nature and have a significant impact on ISRO programs.The nature/diversity of evidences vary vastly with
limited availability of data for analysis. It is therefore necessary to systematize special procedures for the analysis of
mission failures.
Specialist teams shall be constituted including National level experts from academia and industry to carry out
failure analysis at mission level. Such teams shall be constituted by Chairman, ISRO with clear definition of the scope
of work.
In-orbit anomaly or failures on-board the satellites shall also be analyzed by suitable expert teams and the root
cause established. The recommendations shall be communicated to SR and FABs involved in the mission and are to
be incorporated in all the missions thereafter.
The quality agencies involved, should establish a database tracking all the failures and close-out actions for both
launch vehicle and satellite missions.The dissemination of the failure analysis should be done to the lowest possible
level of the Project.
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ISRO-PAS-201
ANNEXURE-I:
FAILURE NOTIFICATION FORMAT
IN-HOUSE / VENDOR’S
( ISRO Center) / (Vendor under Contract)
ENGINEER
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ISRO-PAS-201
ANNEXURE-Ia:
FAB (AVN) FORM NO. 01: FAILURE REPORTING FORMAT
1. Reporting Agency :
8. Manufacturer/Fabricating agency:
ENGINEER
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ISRO-PAS-201
ANNEXURE-II:
FAILURE ANALYSIS SUMMARY FORMAT
IN-HOUSE / VENDOR’S
(ISRO Center) / (Vendor under Contract)
FAILED PART/ MATERIAL HISTORY AND REVIEW OF PREVIOUS FAILURE HISTORY, IF ANY
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ANNEXURE-IIa:
FAB (AVN) FORM NO. 02: FAILURE ANALYSIS FORMAT
(Package/Part)
7. Conclusion:
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ISRO-PAS-201
ANNEXURE-III:
CLOSURE REPORT FORMAT
IN-HOUSE / VENDOR’S
(ISRO Center) / (Vendor under Contract)
FAB RECOMMENDATIONS
PROJECT/SDA ENGINEER
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ISRO-PAS-201
ANNEXURE-IIIa:
FAB (AVN) FORM NO. 03: ANALYSIS AND CLOSURE REPORT FORMAT
9. Failure summary:
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