Module-9 Fault Tree Analysis (FTA)

Fault Tree Analysis Learning Objectives

At the end of this section delegates will be able to: Understand the role of Fault Tree Analysis within the DMAIC Improvement Process Construct a Fault Tree from Top Event down to actionable Basic Events Identify appropriate actions to close a branch of the tree Recognise that Fault Tree can be used both as a prevention tool and a diagnostic tool

Fault Tree Analysis Agenda

1. Fault Tree Analysis Within DMAIC 2. Fault Tree Analysis Roadmap: Define Top Event Define scope of system Understand system Construct Fault Tree Analyse the Tree Closing Actions 3. Workshop 4. Summary

Six Sigma Transactional Improvement Process

Define
Select Project Define Project Objective Form the Team

Measure
Define Measures (ys)

Analyse
Develop Detailed Process Maps
START PROCESS STEPS DECISION STOP

Improve
Brainstorm Potential Improvement Strategies Select Improvement Strategy
Criteria Time Cost Service Etc A + + s B s + s C + D + s + +
10.2 10.0

Control
Control Critical xs
Upper Control Limit

Check Data Integrity

9.8

Lower Control Limit

9.6 1 5 10 15 20

Monitor ys

Map the Process Identify Customer Requirements

Determine Process Stability Determine Process Capability

LSL USL

Identify Critical Process Steps (xs) by looking for: Process Bottlenecks Rework / Repetition Non-value Added Steps Sources of Error / Mistake Map the Ideal Process Identify gaps between current and ideal Phase Review

Plan and Implement Pilot Verify Improvement

LSL USL

y
Validate Control Plan

15

20

25

30

35

15

20

25

30

35

Identify Priorities Update Project File

Set Targets for Measures

Implement Countermeasures

Identify further opportunities Close Project

Phase Review

Phase Review

Phase Review

Phase Review

Introduction to Fault Tree Analysis

Fault Tree Analysis (FTA) is a graphical tool for analysing possible causes of a failure. Can be used as a Prevention Tool - Prevent the failure mode from occurring. Or can be used as a Diagnostic Tool - Identify what caused the failure Focuses on a single failure mode (as opposed to FMEA that looks at all failures) In Six Sigma it can be used to help identify the Critical Inputs or Process Steps (xs) (Analyse), and develop improvements and controls for the Critical Inputs or Process Steps (xs) (Improve/Control)

Fault Tree Analysis Roadmap

Step 1: Define Top Event. Step 2: Define Scope of System Step 3: Understand System. Step 4: Construct Fault Tree Step 5: Analyse the Tree Step 6: Closing Action.

Step 1 Define Top Event

The Top Event is the major failure to be analysed in the fault tree. Within Six Sigma DMAIC this typically will be the issue(s) identified in the Measure Phase e.g. Delay in invoice payment, Incomplete order shipment etc. When identifying, consider main functions of processes, major customer effects, historical failures A separate fault tree should be generated for each Top Event that is a fundamental concern.

Step 2 Define Scope of System

What comprises the system (transactional process) to be analysed: Which parts/process steps will be considered ? Which parts/process steps will be outside the scope (responsibility of supplier or third party)? What level of detail ? (macro/micro process steps) System can consist of manual steps and / or automated steps (e.g. IT system).

Step 3 Understand the System

The relevant experts (IT, Process Operators etc.) explain the function of each part/process step to the team. Supported by: Process Maps Specification Documents Walking the process Customer Feedback data

Step 4 Construct Fault Tree

AND AND Gate

OR OR Gate
Bulb Blown

Dark Room

OR

No Power

Fuse Blown OR Loss of AND Power Power Cut Battery failure

Switch Failed To Close

Step 4 Construct Fault Tree

Basic Event
Specification

Top Event
OR

Intermediate Events
OR OR

Closing Action

AND

Supplier Quality

Process

Step 4 Construct Fault Tree

Top Event Intermediate Events

Main failure to be investigated Events leading to (causing) top event. Sequenced from high level to lower level (Macro process step to micro step). Lowest level events within scope of FTA. Actionable level of detail. Three types of basic events should be considered (although not all may be present).

Basic Events

Step 4 Construct Fault Tree

Basic Event Types

Specification Related Event relates to incorrect specification e.g. information not specified as required Event relates to supplier not meeting specification, e.g. incorrect information provided. Event relates to inadequate or incorrect processing, e.g. information entered incorrectly.

Supplier Quality Related

Process Related

FTA Example: Labelling Example

Top Event Intermediate Events
Wrong label fixed to product Wrong label printed

Basic Events Closing Actions

OR Incorrect part number entered

Incorrect labeling of product

OR

OR

Information on label incorrect

Error in database
Stock of Labels held on line AND Multiple Product Types on Production Line

No label Labels mixed up on line

FTA Example: Invoicing Example

Top Event
Missing/ Incorrect Information

Intermediate Events
Missing order number

Basic Events Closing Actions

OR Lack of authorisation

Delay in Invoice payment

OR

OR

Sent to wrong person/place

Pricing information incorrect

Not supplied by Sales

Bankruptcy

Step 4 Construct Fault Tree

Method 1
Brainstorm all possible events (causes) that might lead to Top Event. Transfer to Post-Its or cards. Sort into groups of events for related parts. Organise into a tree structure with Top Event on left side, branching to the Basic Events on the right.

Method 2
Starting from the top event and ask the question how could this happen ? Work on each branch in turn, repeating the question how could this happen?

In practice a combination of both methods can be used.

Step 5 Analyse Tree

Check: All known (historical) failures shown. Sequence of events from left to right. All branches have been developed to an actionable level. Optional step : Prioritize the basic events in terms of their probability of occurrence. (ref. FMEA Occurrence Rating).

Step 6 Closing Action

ALL Basic Events should have a closing action. Level / depth of action dependent upon the level of concern (occurrence). Three areas of focus: Specification Validation to ensure that the transactional process has been correctly specified Supplier Quality- to ensure that any process inputs are correct Process Control to ensure that the transactional process is operated correctly Action not closed (signed off) until completed.

Step 6 Closing Action

Typical closing actions include: Standard Operating Procedures, SOPs Operator Training Mistake Proofing Statistical Process Control, SPC Control Plan

Fault Tree Analysis Roadmap

Step 1: Define Top Event. Step 2: Define Scope of System Step 3: Understand System. Step 4: Construct Fault Tree Step 5: Analyse the Tree Step 6: Closing Action.

Six Sigma Transactional Improvement Process

Define
Select Project Define Project Objective Form the Team

Measure
Define Measures (ys)

Analyse
Develop Detailed Process Maps
START PROCESS STEPS DECISION STOP

Improve
Brainstorm Potential Improvement Strategies Select Improvement Strategy
Criteria Time Cost Service Etc A + + s B s + s C + D + s + +
10.2 10.0

Control
Control Critical xs
Upper Control Limit

Check Data Integrity

9.8

Lower Control Limit

9.6 1 5 10 15 20

Monitor ys

Map the Process Identify Customer Requirements

Determine Process Stability Determine Process Capability

LSL USL

Identify Critical Process Steps (xs) by looking for: Process Bottlenecks Rework / Repetition Non-value Added Steps Sources of Error / Mistake Map the Ideal Process Identify gaps between current and ideal Phase Review

Plan and Implement Pilot Verify Improvement

LSL USL

y
Validate Control Plan

15

20

25

30

35

15

20

25

30

35

Identify Priorities Update Project File

Set Targets for Measures

Implement Countermeasures

Identify further opportunities Close Project

Phase Review

Phase Review

Phase Review

Phase Review

Summary Fault Tree Analysis

Analyse - Fault Tree can be used to identify possible Critical Inputs or Process Steps (xs) that are causing the poor performance in Process Outputs (ys) Improve - Fault Tree can be used to help identify how the Critical Inputs or Process Steps (xs) might be changed / eliminated / controlled to improve the Process Output (y) Control - Fault Tree can be used to identify appropriate controls for the Critical Inputs or Process Steps (xs) Control - Fault Tree can be used as a diagnostic tool to identify corrective action when a failure occurs

Workshop Construct a Fault Tree Analysis

Develop a Fault Tree Analysis for the given Top Event and Transactional Process scope: 1. Understand the System (for a transactional process application, develop/review the process flow). 2. Brainstorm How could top event happen?. Put each idea onto a post-it as it is generated. 3. Organise the post-its into the tree structure, starting with the top event on the left, working towards the root causes (basic events) on the right. 4. Analyse the tree to check that the branches are logical and identify any missing causes. 5. Identify closing actions for the five most likely causes (use the FMEA Occurrence rating if required). 6. Prepare a short presentation on your team's findings. Workshop Time: