Root cause analysis is a structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis helps determine what happened, how it happened, and why it happened.
The NASA Root Cause Analysis Tool (RCAT) is designed to facilitate the analysis of anomalies, close calls, and accidents and the identification of appropriate corrective actions to prevent recurrence. The RCAT software provides a quick, easy, accurate, and repeatable method to perform and document root cause analysis, identify corrective actions, perform trending, and generate data usable in precursor analysis and probabilistic risk assessment.
After extensive review, NASA found that none of the commercially available tools and methods would support a comprehensive root cause analysis of all the unique problems and environments NASA faces on the Earth, in the ocean, in the air, in space, and on moons and planetary bodies. Existing tools were designed for a specific domain (e.g., aviation), a specific type of activity, a specific type of human error (e.g., errors of omission) or had a limited set of cause codes. The NASA RCAT, a paper-based tool with companion software (now available free to government Agencies and contractors), was designed to address the shortcomings identified in existing tools.
The NASA RCAT was designed with the whole system in mind, so that all potential types of activities and all potential causes of accidents, whether they be initiated by hardware, software, humans, the environment, weather, natural phenomenon, or external events, could be incorporated into the timeline, fault tree, and event and causal factor tree.
The RCAT aids users by providing a step-by-step guide, intuitive logic diagramming capability, standard terminology, standard definitions and standard symbols.
The RCAT software provides the analyst with a quick and easy method to perform the following:
- Document case file properties,
- Identify and document the undesired outcome,
- Create and edit a detailed timeline,
- Create and edit a short timeline,
- Create and edit a fault tree,
- Create and edit an event and causal factor tree,
- Generate a report; and
- Trend case file properties, causes, contributing factors, and other information.
For information related to NASA's root cause analysis training and mishap investigation procedures you may also go to the Mishap Investigation Community of Practice.