4-Failure Mode Analysis

Failure Analysis of Engineering Systems
Instructor: Professor Steve Maher
Module 5: Scripture of the Module Some review of Module 3 8 Failure Mode Assessment and Assignment (FMA&A) 9 Pedigree Analysis 10 Change Analysis
Scripture of the Module

The plans of the diligent lead to profit as surely as haste leads to poverty.
- Proverbs 21:5
Failure Analysis of Engineering Systems ENGR 5323
Assignment
Read Chapter 8, 9, and 10 of Systems Failure Analysis Do Quizzes on Bb as they appear Quiz next week at beginning of class
Some Module 3 Leftovers
From Module 3 Quiz

We have 1000 parts that have run at an average of 800 hours each. 20 of them have failed. What is the failure rate? MTBF = total service hours/# failed = 800*1000/20 = 40000 hr/fail Failure rate = = 1/MTBF = 1/40000 = 0.000025 = 2.50E-5 = 2.5*10-5 fails/hr
From Module 3 Quiz

For the parts in Question 17, what is the Probability that a part will run to 1000 hours without failing? Ps = e-t = e-(2.5E-5)(1000) = 0.9753 (or 97.53% chance of running that long without failing. Some more info: PF = 1 Ps = .0247 = 2.47% chance of failing; i.e. ~25 parts will fail by 1000 hours of operation, or ~5 more between 800 and 1000 hours.
From Module 3 Quiz

Fig 7.1: Event B has a failure rate of 10-4. The part is operated for 100 hours. The probability of event C happening is .005. What is the probability that command event A will occur? OR gate, so PA = PB + PC PB*PC. PB = 1 e-t = 1 exp[-(10-4)(100)] = 0.00995 PA = .00995 + .005 (.00995)(.005) = .0149 = .015 or 1.5% chance of Event A happening.
From Module 3 Quiz

Fig 7.3: The system is operated for 100 hours. The failure rate for B is 2x10-5. The failure rate for C is 5x10-6. What is the probability that command event A will occur? AND gate, so PA = PB*PC. PB = 1 e-t = 1 exp[-(2x10-5)(100)] = ~0.002 PC = 1 e-t = 1 exp[-(5x10-6)(100)] = ~0.0005 PA = .002*.0005 = ~10x10-7 = ~1x10-6 or about 0.0001% chance of Event A happening.
Failure Mode Assessment and Assignment (FMA&A)
Berks Overall FA Process

Designate a team Determine Corrective Actions Gather all related information Implement Corrective Actions Review and define problem Assess Corrective Actions
Identify all potential failure causes

Evaluate for Preventive Actions List causes in FMA & A Incorporate FA Findings
Converge on root cause
10
What is FMA&A?
FMA&A = Failure Mode Assessment and Assignment It is a tool to help manage the evaluation of each of the hypothesized failure causes. It is generally a table textbook has 4 columns:
Event number Description of each hypothesized failure cause Likelihood assessment of each cause (updated as data becomes available) Actions necessary to evaluate the cause and status of the evaluation (sometimes separate columns).
See Table 8.1: FMA&A for light bulb example Spreadsheet (e.g. MS Excel) is an excellent tool for this; can use word-processing tool (e.g. MS Word)
11
Hypothesized Failure Causes

Each row of the table is a hypothesized failure cause Each of the causes is briefly described Can develop hypothesized causes with any method, then map them to a row/column List causes or inducing events only
In FTA terms, do not list command events Focus on basic failures, human errors, normal events, inhibiting conditions, and undeveloped events (using FTA terms)
Typically a repeat from previous activity of identifying potential causes (described in Modules 2-3)
Easier to work with table than with diagram(s) Saves time, less confusion
12
Event Number Column

Each of the hypothesized failure causes is numbered This is used for tracking and organizational purposes Can develop hypothesized causes with any method
Textbook uses FTA example Each team or individual can choose numbering system
List and assign numbers to causes or inducing events only

In FTA terms, do not list/assign command events Focus list/number on basic failures, human errors, normal events, inhibiting conditions, and undeveloped events (using FTA terms)
13
Assessment Column
Describes assessment for each of the hypothesized failure causes Default for each cause is Unknown As analysis proceeds, each cause will be updated using terms such as
Unlikely = evaluation showed no problem or no lead Likely = cause likely found but not conclusive, or Confirmed = we found it! (At least the objective evidence indicates it)
For FA (i.e. the failure has already occurred), Probabilities do not really matter that much
Can be used as a guide to prioritize evaluation Should NOT be used by itself to update status
14
Assignment Column
Defines action necessary to evaluate each of the hypothesized failure causes Review each hypothesized cause (i.e. row by row) and determine actions necessary to evaluate it
Evaluation needs to be objective (i.e. fact-based), not subjective (i.e. opinion-based) Focus on ruling the cause in or out Be careful!
of jumping to conclusions of ruling causes out too quickly and without evaluation
Best if ONE owner and a DUE DATE for the action(s) Status is updated as the actions are completed (in this column or an additional one)
15
Point of Emphasis
Do not touch any hardware or software from the failed system until you have defined an organized, systematic, and objective manner in which to proceed
16
Follow-On Activities (Team)

Meet regularly determined by priority, severity, and urgency
High profile: at least daily Low profile: at least weekly is recommended Use FMA&A to guide the meeting
Execute actions that are assigned and update status

Include findings in Assignment column Assessment and Assignment changes based on the data Clearly indicate items completed and ruled out (e.g. shading the row)
Distribute updates to team and stakeholders on a regular basis (e.g. after each team meeting)
17
Individual Approaches
Suggest you use FMA&A or a similar format
Some organizations use an FA Log or similar tool You want something to capture your thoughts, planned actions, and status updates
Update someone regularly determined by priority, severity, and urgency

Go no more than 2 weeks recommend weekly Use FMA&A or FA Log to guide the meeting
Execute planned actions and update status

Document findings as you go Adjust plans based on the data Clearly indicate items completed and ruled out
Have updates ready to distribute when needed

18
Performing the Evaluations

Pedigree analysis (Ch 9) Change analysis (Ch 10) Analytical equipment (Ch 11) Mechanical and electronic component failures (Ch 12) Leaks (Ch 13) Contamination (Ch 14) Design Analysis (Ch 15) Statistical Considerations (Ch 16) Design of Experiments (Ch 17)
19
Group Activity
* Discuss Scenario (pg. 72-73) * Document answers to questions in a file * Email file to me (one per team) *After emailing, take a 5-10 min break * Re-convene about ____
Which approach does your organization (or do you) follow? Do you think your failure analysis approach needs to change? If so, what can you do to initiate a change?
Pedigree Analysis
Berks Overall FA Process

Designate a team Determine Corrective Actions Gather all related information Implement Corrective Actions Review and define problem Assess Corrective Actions
Identify all potential failure causes

Evaluate for Preventive Actions List causes in FMA & A Incorporate FA Findings
Converge on root cause
24
Overall Process Flow for Diagnosing Root Cause of a Failure

Confirm the Failure Characterize the Failure
Isolate the Failure
Isolate the Defect Identify the Defect
Determine Root Cause

Failure Analysis of Engineering Systems ENGR 5323 25
What is a Pedigree? And How Do You Analyze it?

Product or System Pedigree = Essentially the history of the product
Describes design of product How it was built That it was built in accordance to specs, codes, etc.
Documents in a pedigree:
Records of how it was built Records of material used Conformance to drawing and material requirements
Will a suspect condition be revealed by an analysis of the pedigree?

26
Value of Reviewing the Pedigree

If it addresses the suspect area, examine the pedigree to see if there is something suspicious
Anomalies in test results Non-conformities found in inspections Missing items or documents
If it does not address the suspect area, maybe the pedigree should
Recommend for future builds Can be part of corrective action to prevent future failures
27
Examining the Pedigree

Purchase orders Nonconformance documentation Inspection records Test data Calibration data Drawings and specifications Drawing changes Work instructions Certificates of conformance
28
Surprisingly
Shipped systems do not always meet all of its requirements
Many pedigree reviews reveal that the product had/has a problem In some cases, pedigree directly related to the failure
Not necessary to check the ENTIRE pedigree

That may be a massive undertaking Only review areas that relate to the hypothetical causes
Pedigree can be suspect

Errors, omissions, or even fraud can happen Certificates of conformance are not a guarantee
29
Example: Tragedy in Hawaii

Tour Plane caught fire and crashed Oil leaking into engine caused the fire Oil filter gasket had melted Gasket was made of wrong material Maintenance, filter spec, and gasket spec were fine Gasket manufacturer noted different material Certificate of conformance was missing Gasket packing slip and certificate did not match Mismatch slipped through and nonconforming oil gasket was used, leading to the accident
30
Non-conformance Does Happen

Anomalous Certificates of Conformance are not uncommon
Typically not outright fraud Most are human error
Sometimes nonconforming material or system ships anyway Sometimes everything looks fine but something is suspicious
Follow-up independent verification may be needed Additional inspections, testing, etc. can be sought
31
Change Analysis
What is Change Analysis?

If a system WAS working, what changed? Need to determine if a change occurred and if the change induced the failure.
Options:
Nothing changed! Failure was happening, but not observed Failure occurs within normal statistical variation Change occurred, but unrelated to failure A change induced the failure
33
Things That Can Change

Design Manufacturing Process Test and Inspection Environment Lot Changes (Manufacturing variation) Aging Supplier Changes
34
Design Changes
Controlled design change Redlined design change Rejected material: use as is or repair Outsourced components and subassemblies
35
Process Changes
Work or Build Instructions
Many companies do not have instructions Imprecise work instructions Little rigor on changes Changes to equipment, tooling, settings not documented People not following the instructions
Investigate the documentation for changes Investigate for non-documented changes SPC can help and provide a starting point
36
Test and Inspection Changes

Investigate for issues in testing
Failures returned to manufacturing Reworked systems or components Results out of the ordinary Changes in the test process
Investigate inspection processes and results

Change of inspectors Change of instructions Items noted but system continued anyway
Changes in test or inspection equipment

37
Environmental Changes
Temperature and Humidity issues
Curing or dying of materials Non-environmentally controlled processes Investigate if failure correlates to temp/humidity
Storage
Investigate changes in environment or procedure Epoxies and raw material may be sensitive Moving locations can induce changes
Shipping
38
Lot and Supplier Changes

Manufacturing has normal variation
Sometimes failures correlate to supplier lots May be related to material distributions Investigate if failure correlates to supplier lots Need to understand suppliers processes
Aging Suppliers can change materials or designs

Purchased supplies may still meet specs Investigate for changes that affect system Can be difficult and sensitive to get information
39
Example from Textbook: CBU-87/B Cluster Bomb

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Failure Analysis of Engineering Systems

Instructor: Professor Steve Maher

Scripture of the Module

Failure Analysis of Engineering Systems ENGR 5323

Failure Analysis of Engineering Systems ENGR 5323

Some Module 3 Leftovers

From Module 3 Quiz

Failure Analysis of Engineering Systems ENGR 5323

From Module 3 Quiz

From Module 3 Quiz

Failure Analysis of Engineering Systems ENGR 5323

From Module 3 Quiz

Failure Mode Assessment and Assignment (FMA&A)

Berks Overall FA Process

Identify all potential failure causes

Converge on root cause

Failure Analysis of Engineering Systems ENGR 5323

Hypothesized Failure Causes

Event Number Column

List and assign numbers to causes or inducing events only

Failure Analysis of Engineering Systems ENGR 5323

Failure Analysis of Engineering Systems ENGR 5323

Follow-On Activities (Team)

Execute actions that are assigned and update status

Update someone regularly determined by priority, severity, and urgency

Execute planned actions and update status

Have updates ready to distribute when needed

Performing the Evaluations

Failure Analysis of Engineering Systems ENGR 5323

Failure Analysis of Engineering Systems ENGR 5323

Berks Overall FA Process

Identify all potential failure causes

Converge on root cause

Failure Analysis of Engineering Systems ENGR 5323

Overall Process Flow for Diagnosing Root Cause of a Failure

Isolate the Failure

Isolate the Defect Identify the Defect

Determine Root Cause

What is a Pedigree? And How Do You Analyze it?

Will a suspect condition be revealed by an analysis of the pedigree?

Value of Reviewing the Pedigree

Failure Analysis of Engineering Systems ENGR 5323

Examining the Pedigree

Failure Analysis of Engineering Systems ENGR 5323

Not necessary to check the ENTIRE pedigree

Pedigree can be suspect

Failure Analysis of Engineering Systems ENGR 5323

Example: Tragedy in Hawaii

Failure Analysis of Engineering Systems ENGR 5323

Non-conformance Does Happen

Failure Analysis of Engineering Systems ENGR 5323

What is Change Analysis?

Things That Can Change

Failure Analysis of Engineering Systems ENGR 5323

Failure Analysis of Engineering Systems ENGR 5323

Test and Inspection Changes

Investigate inspection processes and results

Changes in test or inspection equipment

Lot and Supplier Changes