Cause Mapping is a Root Cause Analysis method that captures basic

1 Problem
CHALLENGER Cause Map cause-and-effect relationships supported with evidence.

What Problem(s)
Date
Loss of Challenger, astronauts killed Cause Mapping
When January 28, 1986
Time 11:39:12 AM EST O-ring leaks in cold weather Problem Solving • Incident Investigation • Root Cause Analysis

Different, unusual, unique 100 year freeze (cold weather) Just after launch in unusually cold Florida weather, the space What's the
State, city shuttle Challenger experienced primary o-ring blow-by, causing an Step 1. 1 Problem Problem?
Where Cape Canaveral
Facility, site Challenger (STS 51-L) external tank to explode, destroying the shuttle and all aboard.
Task being performed First stage ascent (~46,000' altitude) Why did it
"Our objective has been not only to prevent any Step 2.2 Analysis happen?
Impact to the Goals recurrence of the failures related to this accident, but to
Safety Loss of 7 astronauts (entire crew) the extent possible to reduce other risks in future flights What will be
Vehicle Total loss of Challenger STS $1,000,000,000 . . . It is fully recognized that the risk associated with Step 3.3 Solutions done?
Mission Total loss of mission space flight cannot be totally eliminated."
Equipment Redesign of solid rocket booster joints - Presidential Commission on the Challenger Accident
Labor, Time Investigation, testing
$1,000,000,000
Frequency 1st loss of shuttle

2 Analysis
Basic Level Cause Map - Start with simple Why questions. Solution: Challenger Crew:
Effect Cause Standing, L to R: Ellison Onizuka,
Christa McAuliffe, Greg Jarvis,
Why? Why? Why? Why? Evidence: Judith Resnik
Seated, L to R: Mike Smith, Dick
Scobee, Ron McNair
Safety Goal Loss of 7 Loss of External tank Primary o-ring
Impact astronauts Challenger explosion blow-by

Possible Solutions:
Tests over full range
of operating
More Detailed Cause Map - Add detail as information becomes available. conditions, including
temperatures

Reduced o-ring
sealing at low
temperatures
Possible Solutions:
Redesign of solid Evidence:
Previous
issues with o-
ring erosion, Possible Solutions:
Safety Goal Loss of 7 Loss of External tank Jet blast into Primary o-ring
Propellant leak Establish Safety
Impacted astronauts Challenger explosion external tank blow-by
Advisory Panel,
AND develop launch
3 Solutions commit criteria
Decision to Launch commit
No. Action Item Cause For a free copy of our Root Cause Analysis Template in launch in low criteria
Microsoft Excel, used to create this page, visit our web site. temperature ineffective
Redesign of solid rocket
1 Primary o-ring blow-by
motor joint
2 Tests over full range of Reduced o-ring sealing at low
operating conditions, temperatures Investigate Problems. Prevent Problems.
including temperatures Houston, Texas 281-412-7766 ThinkReliability.com

3 Establish Safety Advisory Launch commit criteria Copyright ThinkReliability 2013

Panel, develop launch ineffective
commit criteria