In slide show mode: slides advance automatically, fade-in, fade-out. Enjoy!

or

REALITY CHECK: Each of these disasters involved a

process flaw Systemkey™ competitors’ failed to catch.

If “their way” worked, we wouldn’t have:

Tacoma Narrows Bridge, Nov 1940$8MM cost to construct, lasted 4 months!Residual Risk: invalid scientific theories

Thalidomide, 1957-1962est. 1500 died/15,000 birth defects, $20MM trust fund

Residual Risk: invalid scientific theories

Tenerife, Mar 1977583 died, $110MM settlements, loss of two planes

Residual Risk: early take-off/lack of standard phraseology

Chernobyl, Apr 1986est. 985,000 event-driven, cancer-related deaths 1986-2004, cleanup

est. $605MM to-dateResidual Risk: failed communication, lack of training

Piper Alpha North Sea, July 1988167 died, $3.4B cleanup

Residual Risk: violated design parameters, lack of full maint status sit-rep

Mars Climate Orbiter, Sep 1999$125MM loss of spacecraft

Residual Risk: mix-up between English & metric units

Enron, Dec 2001$63.4B bankruptcy

Residual Risk: financial deception/fraud

MCI Worldcom, July 2002$107B bankruptcy

Residual Risk: financial deception/fraud

Fannie Mae/Freddie Mac, Sep 2008$291B takeover

Residual Risk: financial incompetence/deception/fraud

Lehman, Sep 2008$613B bankruptcy

Residual Risk: financial deception/fraud

AIG 2008-2009$182.5B bailout

Residual Risk: financial incompetence/deception/fraud

BP Deepwater, Apr 2010$40B cleanup+settlements

Residual Risk: untested, unproven processes

Costa Concordia Jan 201217 confirmed dead, 15 missing, $800MM vessel lost

+ ?? in settlements?Residual Risk: multiple process violations, lack of feedback (false

negative) on switching off approved route monitor

Three Mile Island, Mar 1979$1B cleanup, $1MM fine each day didn't deliver powerResidual Risk: confusing signage; faulty ergonomics

Kansas City Hyatt, July 1981114 died, 216 severely injured $140MM cleanup+settlements

Residual Risk: poor communication, fail to validate new drawings

Bhopal, Dec 19843,787 died, est. 3,900 injuries+birth defects

$470MM settlement, remaining envir cleanupResidual Risk: malfeasance, safety systems turned off

Questions?Thank you for your interest!

Matthew E. WeilertSystems Thinking Institute LLC

systhink@systemkey.net+1-866-288-0530 North America+1-847-227-3006 International