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Shaft Failure Root Cause Analysis Method

DrillSafe Perth 5th

September 2013

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Methodology

Step 1

Scenario Description

RealityChart describingscenario as a chronologicalsequence of conditions &facts

To identify high level causesto initiate root causeanalysis(Step 2)

Step 1 outcome =2 high level causes identified

To explore all possible relatedcauses in a systematic &structured way

Step 2 outcome =150 possible causes identified

To verify each cause through adedicated Mean ofCompliance: analysis,investigations, tests (flight,

bench, lab)

Step 3 outcome =root cause identified

Step 2

Root Cause Analysis

Step 3

Verification Plan

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Standards

Overall approach based on EUROCOPTER Guide

G070 077.A1 Eight Disciplines Problem-solving guide (8D)

Compliance with international standards

NPR 8621.1B NASA Procedural Requirements for Mishap and Close CallReporting, Investigation, and Recordkeeping 2006 NASA

Root Cause Analysis Overview 2003 NASA Seven Steps to Effective Problem-Solving and Strategies for Personal

Success Dean L. Gano (RealityCharting)

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STEP 1: Ditching scenario description 1/4

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STOP means that nofurther analysis is required

to describe scenario

Event =Combination ofConditions &

Facts

Condition

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STEP 1: Ditching scenario description 2/4

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STEP 1: Ditching scenario description 3/4

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STEP 1: Ditching scenario description 4/4

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Beginning of Crack Initiationroot cause analysis tree

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STEP 1: Ditching scenarioBack-Up

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STEP 2&3: Vertical shaft root cause analysisOverview 3 highest levels

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STEP 3: Verification Plan

Determination of influence level (without, moderate, significant) foreach branch of the tree

Internal examination of proves

External independent validation (Shainin)

Definition and implementation of preventive & corrective measures

according to the findings

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