COMPLEX PROBLEMSCLASS 6

Can We Really

Learn From Failure?Failure Analysis as a Problem Solving

Tool

Background on Failure Analysis

Engineering Roots (hyperlink to learning from engineering disasters)» NTSB as Example» Sports Example -- “Truth in Video”

Expanding into Organizational Influences» PTD or PED -- Primary Technical (usually

Engineering) Decisions

» PMD -- Primary Management Decisions

» See Failure Analysis Resource Library

Failure Analysis as Problem Solving Works back and forth between analytical and heuristic

problem solving techniques» Modeling components: simplifying, organizing …

» Heuristics: backward-forward; experiments; careful observation ...

Process-Specific Lessons» Solving problems that have occurred: remedies-improvements

indicated that are limited to the particular case at hand and the process, company, or people involved -- often technical in nature

General Lessons» Avoiding problems before they happen: remedies-improvements

suggested for application to other processes, companies, and people – This is the reason for studying failures of non-related companies and

industries

Levels of Failure Analysis Physical Causes

» Tangible causes at the point of failure that explain how something happened, e.g. machine part that fails

– Responses: redesign; sanction, training ..of engineer Human Causes

» Point of Failure: Improper intervention by person directly linked to the problem (operator, pilot, …); focus on how failure occurred

– Responses: sanction of decision maker closest to problem

» Organizational/Management Influences: Considering the factors (systems, incentives, policies) behind the point of failure that may have contributed or almost determined the point of failure causes; focusing on “why” the failure occurred

– This opens the widest possibility for generalizing beyond the specific failure to help avoid other failures

1986 Challenger Disaster

Basic Facts -- see Case Western Website» Past flights -- known O-Ring Problems, scorching, erosion, partial

burn-through

» Contractor written recommendation of no launch below 53 degrees because of loss of O-ring elasticity -- sealing capacity

» July 1985, Thiokol engineer memo warning Flawed design of pressure seal (O-Ring)

» Jan 27-28: Cold temperatures; Thiokol engineers advise against launch; management backs the decision

» Thiokol management reverses -- they & NASA decide to launch

» Jan 28, 1986, NASA Shuttle Challenger Explodes about 150,000 ft. above Earth

1986 Challenger Disaster Physical Causes:

» Failure of the pressure seal (O-Ring)on right solid rocket booster O-Ring Blow-out;

» Booster-Strut Burn-out; » Booster Impacts Hydrogen Tank …» Flawed design of pressure seal (O-Ring)

Solution: Redesign O-rings + reconsider design of Shuttle in general

Challenger Con’t

Human Causes» Point of Failure: Launch decision over

objections in view of low temperatures– Solution: Sanction Thiokol & NASA decision

makers …

Challenger Con’t

Org Policies-Systems-Incentives: why would a manager & NASA make such a decision?

At least 2 answers given:» Incentives to launch

– NASA key customer; NASA pressure to launch because of slow pace of shuttle missions

» “Normalization of deviance”

NASA -- Back to the Future

1967 Fire on Apollo 1» Pure oxygen system; North American

Warnings; Deaths; Tangible cause focus; NASA & NA point managers lose jobs; no focus on why or changes based it

2003 Columbia Shuttle Disaster (in progress)

» Foam debris; Loss of tiles; Decisions not to investigate further at time; More discussion as to why. Results…?

Other Failures with Interesting Org Components

Structural Failures» Kansas City Hyatt Regency ...

Detroit Northwest Airlines Debacle» Planes on Tarmac for 8+ hours out of food,

water, toilet capacity, ... Groopman (Harvard M.D.) Second

Opinions

Organizational/Managerial Causes

Going beyond superficial (Harvard B-school Max Bazerman)

Organizational Incentives » Org goals

» Customer pressures

» Cost pressures

» Flawed links incentives-behavior

» NOTE: Although sometimes portrayed in the media as improper, these kinds of concerns are legitimate and enter into business as well as personal decisions (even for reporters)

Flawed Decision Processes» Lack of Information Sharing -- lack of “informativeness” principle

– Org Politics: Conflicts, Rivalries, Poor Leadership Direction;

» Compartmentalized Decisions (breaking problem into parts), but Tightly Coupled Systems -- Highly Complex Interactive Systems not fully recognized

» Normalization of Deviance

FAILURE ANALYSIS & BUSINESS

Why is failure analysis not more common in business?» Threat to leaders, employees, ...» Ignorance of role-benefits» Organizational Culture

Organizational Architecture for Meaningful Failure Analysis

Buy-in from top leaders Analysis team with technical expertise but not necessarily

led by expert from field» Boiler problem & chemist example

Tradeoff: Punishing failure -- promoting truth» Obviously, price to pay for bad decisions

» People looking over shoulder perform poorly

» Recognize that some factor(s) beyond reasonable foresight -- cannot become witch hunt

– WTC Collapse; OK City Bombing Collapse;

Critical Lessons Failure analysis is not just an engineering matter

» Technical, Decision, Managerial Issues Failures frequently surface from organizational

flaws» Incentives out of balance

– goals; consumers; costs; incentives-behavior linkages

» Decision Processes– lack of information sharing-transparancy– decisions compartmentalized-systems highly integrated– normalization of deviance

Mini-Assignment

Find an example of a workplace failure» Try to identify the point of failures (physical;

decisons)» Consider whether the failure is linked to

organizational incentive or decision process problems