Professional Documents
Culture Documents
IMECE2011
November 11-17, 2011, Denver, Colorado, USA
IMECE2011-65159
APPLYING ADVANCED FMEA METHODS TO VEHICLE FIRE CAUSE DETERMINATIONS
Pat J. Mattes
Quality Tools Consultant
9732 Lafayette Center Road
Yoder, Indiana 46464
patmatt247@gmail.com
ABSTRACT
BACKGROUND
Most modern motor vehicle and equipment manufacturers and
their suppliers use a Quality Management System such as QS9000 promulgated by the Automotive Industry Action Group
(AIAG) or ISO/TS 16949:2002, developed by the
International Automotive Taskforce (IATF), as part of their
product design processes. These systems provide a common
1.
2.
3.
4.
5.
6.
7.
Figure 1
Primary failure
1. Does not provide heat (valid)
Range failure
2. Insufficiently provides heat (valid)
3. Excessively provides heat (valid)
Time failure
4. Provides heat too slowly (valid)
5. Provides heat too quickly (perhaps
invalid)
Stability failure
6. Unevenly provides heat (valid)
7. Erratically provides heat (valid)
Adjacent
Systems
Cause
Categories
Changes
over time
Figure 3
Environment
Figure 2
There are several other main factors that make motor vehicle
investigations so challenging. First is the large number and
variety of ignitable materials contained in a motor vehicle. In
2004, it was estimated the typical passenger car contained 258
pounds of plastic materials [14, 15]. Additionally, most fluids
typically found in motor vehicles are ignitable by hot surfaces
[1, 16, 17]. The second factor is the large number of potential
ignition sources contained within a vehicle [1, 18]. These
factors are important because the large amount of ignitable
materials often results in a large amount of damage that
eliminates the evidence, and allows the fire to propagate at a
rapid pace making the area or point of origin difficult to
determine [9, 20]. Since the specific cause of a failure is
directly related to the function of that system, an analyst must
first understand the design and function of all the various
automotive systems before their failure modes and their
corresponding causes can be well understood [21].
1.
2.
3.
4.
5.
6.
7.
Effect
Failure
Cause
Figure 4
Next, the analyst has to consider that each failure had a cause.
Think of a cause as the immediate reason for the failure.
Remember that failures can have more than one cause, so all
potential causes have to be listed and then each one will be
further evaluated later to determine its corresponding causes.
By doing this, the methodology considers every cause that
In NFPA 921 terminology, every
may have happened.
hypothesis is being developed and evaluated, i.e. tested. The
cause or alternate potential causes are listed in the third
column of the form in appendix A.
The next step in the methodology is to determine the cause of
the cause (2nd order cause), and then the cause of the cause of
the cause (3rd order cause), and so on until the point where the
most probable root cause is found or to the point where the
analysis no longer makes sense and has to stop. The most
Harness loose
Cause
Failure
Effect
Failure
Cause
Harness loose
Effect
Figure 5
Failure
Cause
Harness loose
Effect
Figure 6
Figure 7
1.
2.
3.
Engine was excessively low on motor oil (SAE 15W40). Only two quarts remained from a sump capacity
of 24 quarts.
engine block itself, and the engine oil cooler. These are the
first order causes. The turbocharger in turn has three major
potential leak points which are its second order causes. The
engine block can only leak if it is cracked. This is its second
order cause, and the oil cooler has two potential leak points,
the base plate and the seams for the cooling fins. The
turbocharger was inspected and no problems were found, so
this causal sequence stops. No cracks were found on the
block, so this sequence stops as well. The engine oil cooler
was removed and found to have a cracked base plate. Further
investigation into the manufacturing process revealed a recent
design change to the thickness of the base plate material. This
is a third order cause. This crack allowed motor oil to be
sprayed on either the turbocharger housing or on the exhaust
manifold. Since either of these surfaces is sufficiently hot to
allow for a hot surface ignition of the motor oil, this is a
probable root cause for the fire and we have arrived at a final
hypothesis in compliance with NFPA 921 and 1033.
CONCLUSION
The third observable effect was that the engine was low on
motor oil. The failure mode here that causes a fire is if hot
motor oils sprays on the hot surfaces of the turbocharger
turbine housing or the exhaust manifold which are located in
close proximity to each other. The engine components in this
area that can leak hot motor oil are the turbocharger, the
ACKNOWLEDGEMENTS
We would like to acknowledge Stahl Engineering & Failure
Analysis, LLC for all the support, as well as all the reviewers
for their helpful comments.
[12.]
Senders, J. W. "FMEA and RCA: the Mantras of
Modern Risk Management." Qual. Saf. Heath Care 13 2004:
249-50. Print.
[13.]
Nicholson, John. "Vehicle Fire Problem." NFPA
Journal Jan/Feb 2007. Print.
REFERENCES
[1.]
"NFPA 921: Guide for Fire and
Investigations." NFPA. Web. 16 Nov. 2010.
[14.]
Long, Jr, R. T., Jeff D. Colwell, Rose Ray, Helene L.
Grossman, Ben Thomas, and Robert Strassburger. "Section
21, Chapter 1: Passenger Vhicle Fires." Fire Protection
Handbook 2008. 2008 ed. Vol. I. Quincy, MA: National Fire
Protection Association, 2008. Print.
Explosion
[2.]
"NFPA
1033:
Standard
for
Professional
Qualifications for Fire Investigator." NFPA. Web. 16 Nov.
2010.
[15.]
Tewarson, Archibald, James G. Quintiere, and David
Purser. Fire Behavior of Materials in Vehicle Crash Fires and
Survivability of the Passengers. Tech. no. 2005-01-1555.
Warrandale, PA: SAE International, 2005. Print. SP-1939.
[3.]
Chrysler Corporation, Ford Motor Company and
General Motors, 1998, Quality System Requirements QS-9000
3rd Edition, AIAG
[16.]
Tewarson, Archibald. Fire Behavior of Automotive
Polymers. Tech. San Fransisco: 8th International Fire and
Materials Conference, 2003. Print.
[4.]
Procedure for Performing a Failure Mode Effect and
Criticality Analysis, November 9, 1949, United States Military
Procedure, MIL-P-1629
[17.]
Colwell, Jeff D., and Ali Reza. "Hot Surface Ignition
of Automotive and Aviation Fluids." Fire Technology 41.
Second Quarter 2005. Print.
[5.]
(R) Potential Failure Mode and Effects Analysis in
Design (design FMEA), Potential Failure Mode and Effects
Analysis in Manufacturing and Assembly Processes (process
FMEA), Warrendale, PA: Society of Automotive Engineers
for Advancing Mobility Land Sea Air and Space, 2002. Print.
[18.]
Kirk, Paul Leland, and John D. DeHaan. Kirk's Fire
Investigation. Upper Saddle River, NJ: Brady, 1997. Print.
[19.]
Digges, Kennerly H., and R. Rhoads Stephenson.
Fire and Toxicity Properties of Underhood Fluids and Plastics.
Tech. MVFRI Research Summary. Print.
[6.]
"Quality." Automotive Industry Action Group. AIAG.
Web. 20 Apr. 2011. <http://www.aiag.org>.
[7.]
Potential Failure Mode and Effects Analysis:
Reference Manual. Southfield, MI: Automotive Industry
Action Group, 1995. Print.
[20.]
Routhier, Brian. "Section 21, Chapter 2: Fire Safety
in Commercial Vehicles." Fire Protection Handbook 2008.
2008 ed. Vol. I. Quincy, MA: National Fire Protection
Association, 2008. Print.
[8.]
Parker, Sybil P. McGraw-Hill Dictionary of
Scientific and Technical Terms. New York: McGraw-Hill
Book, 1989. Print.
[21.]
Lindland, John. System and Design Failure Mode and
Effects Analysis. Ann Arbor: QualSAT, 2005. Print. Q-25.3.
[9.]
Mattes, Pat. "FMEA Methods Seminar." FMEA
Methods Seminar. Hypersonic Technologies, Fort Wayne. 26
Oct. 2010. Lecture.
[22.]
Fire Investigator: Principles and Practice to NFPA
921 and 1033. Sudbury, MA: Jones & Bartlett Learning, 2012.
Print.
[10.]
Lindland, John L. 7fm: the Seven Failure Modes.
[S.l.]: Bella Group, 2007. Print.
[23.]
Mifsud, L. The Scientific Method. The National Fire
Investigator. NAFI, 2001. Print.
[11.]
Cote, Arthur E., John Raymond Hall, Pamela A.
Powell, Casey C. Grant, and Robert E. Solomon. "Section 3.8
Fire Risk Analysis." Fire Protection Handbook. Vol. 1.
Quincy, MA: National Fire Protection Association, 2008. 3135. Print.
[24.]
no, Taiichi. Toyota Production System: beyond
Large-scale Production. Cambridge, MA: Productivity, 1988.
Print.
10
Effect
Observed
Alternator
positive
1 cable short
Alternator
2 negative
cable short
Failure
Short to
bracket
Short to
bracket
2nd Order
Cause
Oil spray
on turbocharger
or
exhaust
manifold
4th Order
Cause
5th Order
Cause
Stop.
Harness tied
down in 8"
increments good repair
1. Wear through
wire insulation
Wear through
harness covering
relative motion
between
harness and
bracket
Harness loose
2. Wire insulation
melted in fire
3. Environmental
causes
Harness covering
melted in fire
Stop. (vehicle
inspected daily)
Exposed to fire
Stop. (effect,
not cause)
a. Wear through
wire insulation
Wear through
harness
covering
b. Wire insulation
melted in fire
Harness
covering
melted in fire
Stop. (vehicle
inspected daily)
1. Stop. Ground
not energized
2. Ground
energized by prior
short
1. Leak at
turbocharger
a. Leak at shaft
seal
b. Leak at oil
supply
c. Leak at oil
return
2. Leak from
engine block
3. Leak from oil
cooler
Probable
Root
Cause
NO
NO
NO
NO
c. Environmental
causes
3 Engine low
on oil
3rd Order
Cause
11
relative
motion
between
harness and
bracket
Exposed to a
fire
Stop.
Harness tied
down in 8"
incrementsgood repair
Stop. (effect
not cause)
NO
NO
Stop.
Turbocharger
OK
Stop.
Turbocharger
OK
Stop.
Turbocharger
OK
NO
NO
NO
NO
Design change
in material
thickness
Stop. Seams
are OK
YES
NO