2019 Human Performance, Root Cause, & Trending (HPRCT) Conference
June 17-21, 2019
Cheyenne Mountain Resort
Colorado Springs, Colorado
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Thursday, June 20 • 9:10am - 10:00pm
Advanced Defense Systems - Investigative Methodology – Illustrated with "Ethiopian 737 MAX Crash" that occurred on March 10, 2019

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A thorough investigation is required in order to reach full understanding of failures in a complicated multidisciplinary defense system while still under development.

This presentation describes our best practices for obtaining full understanding and reaching broad insights to minimize similar failures across the organization.
the major steps of our failure analysis methodology are :

  1. Understanding the problem and the system
  2. Brain storming and constructing an initial failure tree of the possible causes
  3.  Gathering and analyzing the evidence
  4. Going through the physical, human and latent causes that led to the failure
  5. Explaining the chain of events leading to the failure
  6.  Insight output - corrective actions taken by the project and the higher levels in the organization.

The presentation will include a real life example of a failure analysis of a multidisciplinary system.



Chief Engineer RD&E Mechanical Department of the RD&E Division, Rafael Advanced Defense Systems LTD
Amit has worked 35 years as a Mechanical Engineer in various managerial positions.  These days, he is the Chief Engineer RD&E Mechanical Department of the RD&E Division.  Here,  he guides "failure analysis methodology".  He is also a chairman of failure investigations committ... Read More →

Thursday June 20, 2019 9:10am - 10:00pm MDT
Colorado Ballroom