Fault Tree Analysis
Fault Tree Analysis
Used in both reliability engineering and system safety engineering Developed in 1961 for US ICBM program Guide published in 1981 Used in almost every engineering discipline Not a model of all system or component failures
Applying Fault Tree Analysis
Postulate top event (fault) Branch down listing faults in the system that must occur for the top event to occur Consider sequential and parallel or combinations of faults Use Boolean algebra to quantify fault tree with event probabilities Determine probability of top event
Fault Tree Logic
Use logic gates to show how top event occurs Higher gates are the outputs from lower gates in the tree Top event is output of all the input faults or events that occur
Terms
Faults and failures
System and subsystem faults Primary and secondary failure Command fault
Fault Tree Symbols
Primary Event Symbols
Basic Event
Conditioning Event Undeveloped Event External Event
Gate Symbols
AND OR Exclusive OR
Priority AND
Inhibit
Intermediate Event Symbol Transfer Symbols
Transfer IN Transfer OUT
Fault Tree Symbols
Primary Event Symbols
Basic Event
Conditioning Event
Undeveloped Event External Event
Fault Tree Symbols
Gate Symbols
AND OR Exclusive OR Priority AND Inhibit
Fault Tree Symbols
Intermediate Event Symbol
Transfer Symbols
Transfer IN Transfer OUT
Union
A
No Current
A=B + C A=B Union C B OR C must occur for event A to occur
B
Switch A Open
C
Battery B 0 Volts
Intersection
D
Over-heated Wire
D=E * F D= E Intersection F E AND F must occur for D to occur
E
5mA Current in System
F
Power Applied t >1ms
Fault Tree Quantification
Fault tree analysis - is not a quantitative analysis but can be quantified How to
Draw fault tree and derive Boolean equations Generate probability estimates Assign estimates to events Combine probabilities to determine top event
Fault Tree Example
Outlet Valve
Relay K1
K2 Relay Timer
Pressure Switch S
Switch S1
Relay
Pressure Tank
Motor
Pump
Common Mistakes in Fault Trees
Inputs with small probabilities Passive components Does quantified tree make sense Dont fault tree everything Careful with Boolean expressions Independent Vs dependent failure modes Ensure top event is high priority
FMECA, Human Factors, and Software Safety
Non-Safety Tools
Failure Modes, Effects, and Criticality Analysis Human Factors Analysis
Software Safety Analysis
FMEA
Reliability engineering tool Originated in 1960s OSHA recognized Limitation - failure does not have to occur for a hazard to be present in system Used to investigate how a particular failure can come about
FMEA Process
Define system & analysis scope Construct block diagrams Assess each block for effect on system List ways that components can fail Assess failure effects for each failure mode Identify single point failures Determine corrective actions Document results on worksheet
System Breakdown
Subsystem 1
Assembly 1 a Assembly 1 b Assembly 1 c
Subassembly 1c.1 Subassembly 1c.2 Subassembly 1c.3
Component 1c.3.1 Component 1c.3.2 Component 1c.3.3
Subsystem 2
Subsystem 3
Total System
Part 1c.3.3.a Part 1c.3.3.b Part 1c.3.3.c
FMEA Worksheet
Component #, name, function Failure modes Mission phase Failure effects locally Failure propagation to the next level Single point failure Risk failure class Controls, recommendations
Failure Modes
Premature operation Failure to operate on time Intermittent operation Failure to cease operation on time Loss of output or failure during operation Degraded output or operational capability Unique failure conditions
Failure Modes, Effects, & Criticality Analysis
Virtually same as FMEA Identifies criticality of components Emphasizes probability of failure Criticality components
Failure effect probability Failure mode ratio Part failure rate Operating time
Human Factors Safety Analysis
Many different techniques Human element must be considered in engineering design The merging of three fields:
Human factors Ergonomics Human reliability
Performance & Human Error
Why do people make mistakes? Combination of causes - internal/external Performance shaping factors (factors that influence how people act)
External PSF Internal PSF Stressor PSF
Human Error
Out of tolerance action within human/machine system Mismatch of task and person Significant contributor to many accidents False assumptions
Human error is inevitable People are careless
More complex systems must be less dependent on how well people operate them
Human Error Categories
Omission - leaving out a task Commission
Selection error Error of sequence Time error Qualitative error
HF Safety Analysis The Process
Describe system goals and functions List & analyze related human operations Analyze human errors Screen errors & select Quantify errors & affect on system Recommend changes to reduce impact of human error
Software Safety
Newest member of system safety field Software controls millions of systems Treat software like any system component
Determine the hazards If software is involved in hazard - deal with it
Common tools
Software Hazard Analysis Software Fault Tree Analysis Software Failure Modes & Effects
Software Facts
Software is not a hazard Software doesnt fail Health monitoring of software only assures it performs as intended Every line of code cannot be reviewed Fault tolerant is not the same as safe Shutting down a computer may aggravate a an already dangerous situation
Software Safety Analysis (SSA) Flow Process
Software Requirements Development Top-level System Hazards Analysis Detailed Design Hazard Analysis Code Hazard Analysis Software Safety Testing Software User Interface Analysis Software Change Analysis
SSA
Required when software is used to:
Identify a hazard Control a hazard Verify a control is in place Provide safety-critical information or safety related system status Recovery from a hazardous condition
Safety Tool Categories
Software safety requirements analysis
Flowdown analysis Criticality analysis
Architectural design analysis Detailed design analysis
Soft tree analysis Petri-Net
Code analysis
Software Testing
Software testing
System safety testing Software changes IV &V organization
Other Techniques
MORT
Qualitative tool used in 1970s Merges safety mgt & safety engineering Analyses mgt policy in relation to RA and hazard analysis process Uses a predefined graphical tree Analyze from top event down Too large and doesnt tailor well to smaller problem
Energy Trace Barrier Analysis (ETBA)
Qualitative tool for hazard analysis Developed as part of MORT Traces energy flow into, through, & out of system Four typical energy sources Energy transfer points & barriers analyzed Advantages
ETBA Procedure
Examine system / identify energy sources
Trace each energy source through system
Identify vulnerable targets to energy
Identify all barriers in energy path
Determine if controls are adequate
Sneak Circuit Analysis
Standardized by Boeing in 1967 Formal analysis of all paths that a process could take Find sneak paths, timing, or procedures that could yield an undesired effect Review engineer drawings, translate, & identify patterns Disadvantages
Cause-Consequence Analysis
Uses symbolic logic trees Determine accident or failure scenario that challenges the system Develop a bottom-up analysis Failure probabilities calculated Consequences identified from top event Consequence may have variety of outcomes
Dispersion Modeling
Quantitative tool for environmental and system safety engineering Used in chemical process plants, can determine seriousness of chemical release Internationally recognized model CAMEO Features of the system Advantages
Test Safety
Not an analysis technique Assures safe environment during testing Must integrate system safety process into test process Three layers of test environment Safety analysis needed at each level Test readiness review
Comparing Techniques
Complex Vs simple Apply to different phases of system life cycle Quantitative Vs qualitative Expense Time and personnel requirements Some are more accepted in certain industries
Selecting A Technique
All techniques are good analyses Consider advantages and disadvantages Select technique most suited to the problem, industry, or desired outcome Ask yourself a few questions
Whats the purpose? What is the desired result? Does it fit your company and achieve goals? What are your resources and time available?
Data Sources and Training
Data Reliability
Start with company historical data
Analyses only as good as the data that is used Caution about misunderstanding data Quantifiable data is not always the best Always cite sources and assumptions
Data Limits
Most failure data is generic
Break large items into smaller parts
Data may not consider environmental changes
Use expert judgement to convert generic data into realistic values
Government Data Banks
Government Printing Office
Books from DoD, NASA, EPA, & OSHA
Government-Industry Data Exchange Program
Army, Navy, FAA, Dept of Labor, Dept of Energy, National institute of Standards and Technology
Databases of other countries
Industry Data Banks
Corporations Insurance companies Electronics Industries Associations Consumer Product Commission System Safety Society Material Safety Data Sheets
Creating Your Own Databank
Collect data on system
Design Assessments Hazard identification Compliance verification
Make the data easily accessible and consolidated in one place Computers and new software make collection easier
Data Bank
Systems Info
Hazardous materials MSDS System design info Safety critical systems Best design practices Testing history Failure history
System Safety Data
Safety analyses Accident histories Safety Standards Identified hazards Causes of hazards Proven hazard controls Hazard consequences Hazard tracking system
Safety Training
Twofold approach
Employee training Emergency response
Types of training
Initial training Refresher training New training for changes
Employee Training
Training needs assessment
Purpose of training
Assess current operations
Review hazard analysis data Develop and implement training Record training
Emergency Preparedness and Response Training
Train all personnel affected by possible emergency Training subjects
Evacuation procedures Shutdown of equipment Firefighting and first aid Crowd control and panic prevention
Conduct exercises
Certification for Hazardous Operations
Determine personnel that require training Certification program elements
Certification examination Physical examination Classroom and hands-on training Test of safe working practices Recertification schedule
Safety Awareness
Highlight safety in organization
Positive incentives Establish safety representatives in each area Conduct meetings to discuss safety program Safety reps should be trained in workplace safety inspections and program monitoring
Accident Reporting, Investigation, and Documentation
Reporting the Accident
Accident reporting without retribution
Posting of reportable accidents New-employee briefing Management involvement
Setting Up a Closed-Loop Reporting System
Pre-accident plan
Report within 24 hours
Pass data up the chain
Initiate board Capture perishable information
Investigate all accidents
Forming a Board
Company policy
Accident classification Standing list of board candidates
Selecting the Board members
Various backgrounds Voting members and advisors
Board responsibilities
Conducting the Investigation
Preparing for investigation
Gathering evidence and information
Analyzing the data
Discussion of analysis and conclusions
Recommendations
Investigation Report
Abstract of report Summary of F & R Procedure used Analysis results Conclusions Detailed F & R
Background
Sequence of events Analysis methodology
Minority reports
Appendixes
Accident Documentation
Investigation Report
Retained with supporting documents Corrective action implemented Available for future safety analysis
Retain the records Public release of information
Risk Assessment
What is Risk?
Severity of consequences of an accident times the probability of occurrence Risk perception may vary from actual risk Risk: realization of unwanted, negative consequences of an event (Rowe) Risk: summation of three elements
Event scenario Probability of occurrence Consequence
Risk Perception
Factors concerning perception of risk
Voluntary Vs nonvoluntary Chronic Vs catastrophic Dreaded Vs common Fatal Vs nonfatal Known Vs unknown risk Immediate or delayed danger Control over technology
Risk Assessment Methodology
Formal process of calculating risk and making a decision on how to react 1 Define objectives 5 Quantify scenarios
2 Define system
3 Develop scenarios
6 Consequences
7 Risk evaluation
4 Develop event trees
8 Risk management
Risk Assessment Methodology
Step 1 Step 2 Step 3 Step 4
Define Objectives
Define System
Develop Scenarios
Develop Event Trees
Step 5
Step 6
Step 7
Step 8
Quantify Scenarios
Consequences Determination
Risk Evaluation
Risk Management
Identifying Risk in a System
Risk identified through analysis techniques
Use several techniques
Construct fault tree
Use analysis tools to focus on which
component is the trigger
Risk Communication
Communicating with public
Acknowledge the community Do not imply irrationality or ignorance
Methods to promote communication
Community participation Approach group appropriately Consultation with community Involve community in negotiations Be open with information
Risk Evaluation
A Probabilistic Approach
Quantifying risk through probability of failure
Hard to quantify probability of some events Understand the data, the sources, & the limitations Follow rules of probability
Risk Analysis Model
Developing accident scenarios & initiating event Event Trees Consequences determination Uncertainty Risk evaluation - Risk profiles
Calculating Safety Costs
Tracking data costs
System downtime (lost productivity) Equipment damage and replacement Accident clean-up Personnel injuries and death
Expected value Cost-benefit analysis
