Root Cause Analysis (RoCA) System

Prevision, Inc.

San Rafael, CA

The Root Cause Analysis (RoCA) System helps engineers analyze and track the root cause of process anomalies due to human factors, including incidents that cause personnel injuries, damage facilities, incur additional costs, or delay processing

• CA San Rafael, California small business has jointly developed with NASA a system to help engineers analyze and track the root causes of process anomalies due to human factors
• Prevision, Inc. implemented the Root Cause Analysis (RoCA) system under a Phase II Small Business Innovation Research (SBIR) contract with NASA at Kennedy Space Center
• Due to the technology that underlies RoCA, Prevision was purchased by Fair, Isaac, a U.S. company with offices worldwide that provides banking and financial services, personal lines insurance, retail, catalog and telecommunications industries
• The RoCA system tracks human factor issues at the organizational, team and individual level. Anomalies include incidents that injure personnel, damage facilities, incur additional costs, or delay processing. RoCA supports identification of both systemic and event-specific root causes

• The development of RoCA is motivated by the weaknesses of existing root-cause analysis techniques. Although statistical quality control methods (i.e., methods for assessing whether a process is in control) are quantitatively robust, widely used, and successful, only very simple qualitative methods (e.g., fishbone diagrams) are available for root-cause analysis (understanding why a process is not in control). The result is that industries frequently spend millions of dollars fixing the wrong process problems or developing suboptimal solutions
• The other major motivation for RoCA is the focus on the importance of human factors in industrial accidents. Research has shown that avoidable human errors are a significant source of process anomalies in many industrial processes (e.g., aircraft manufacturing and maintenance)

• The RoCA system is being used at KSC. The main application of RoCA is assisting the Shuttle Processing Human Factors Team in investigating, analyzing, trending, and reporting the contributing causes of Space Shuttle ground processing incidents. The Shuttle Processing team is a joint NASA/Space Flight Operations Contractor team
• The development effort is also supported by a KSC-wide Human Factors Integration Office. RoCA is being developed through rapid prototyping with significant design inputs from the eventual user community. Research in support of the RoCA software development has produced the technology of anomaly process diagrams (APDs). The APD is a new, theoretically well-founded methodology for root-cause analysis focused on the representation of causal, probabilistic relations between process variables
• Additional NASA/KSC applications of the root cause analysis methodologies are being pursued for identification of root causes of project schedule/budget risks and customer dissatisfaction

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