Jim Martin Final Version Unexpected Consequences Short Version Presentation 10 28 10
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Transcript of Jim Martin Final Version Unexpected Consequences Short Version Presentation 10 28 10
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Unexpected Consequences Overview
Of the more than forty catastrophic events worldwide, cognitive and organizational
failures are associated with ~98% of all deaths, property damage and financial losses.
• The 40+ catastrophic events discussed in the book (and many other minor events)
represent more than 18 million deaths and $675,000,000 (US) in property damage
worldwide.
• 80% of property damage and financial losses were due to environmental poisoning
i.e. oil spills, natural disasters and regulatory failures.
• 77% of the deaths and property damage are associated with organizational issues.
• 20% of the deaths and property damage are associated with cognitive issues.
• More than 150 references are included…all information is public.
• Events: I-35W Mississippi River Bridge (Minnesota), April 25th 1986 Chernobyl’s Reactor 4 disaster, Denver Int'l Airport baggage
system delay, 2009 Pitot tube failures on Airbus planes, Air France A430-300 (F-GLZL), Air France A340-300 (F-GLZN) and possibly Air
France Flight 447 as well as other planes., Toyota 2010 recall, Ford cruise switch control fires-Late 1990's, 2001 Ford/ Bridgestone tire
failures, AMR reservation system for Budget's hotel and car bookings , Conversion to new order entry system from Baan Co. at Snap-On,
Anderson SAP ERP issues for Fox-Meyer, Food contamination 1996-1998, 2003 SARS in Asia, Production problems with the H1N1
Swine Flu Virus, Infectious and parasitic diseases worldwide, 2005 Hurricane Katrina (New Orleans), 2008 Sichuan earthquake, 1989
San Francisco earthquake, 2010 Haiti earthquake, 2010 BP GoM oil spill and others…
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
1. Prior to 1980’s: Focus on allowable defect levels within
manufacturing.
2. 1980’s: Quality philosophies proliferate i.e. zero defects, Juran,
Deming, continuous improvement, ISO, Malcolm Baldrige, total
quality management etc.
3. 1990’s: Lean, Six Sigma (DMAIC) and related methodologies are
deployed to improve current process workflows.
4. Past 10 years: Deployment of Lean and Six Sigma is expanded
around the world into different industries...
5. Quality improvement methods continue to evolve.
A short history of process improvement
What’s next?
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Chapter 1: Designing products and services is a process
• There are many
places where
failures can
occur …
everything
must be done
very well.
Design is the method of putting form and content together. Design, just as art, has multiple definitions; there is no single
definition. Design can be art. Design can be aesthetics. Design is so simple, that's why it is so complicated- Paul Rand
Market Segment
Direct (Users) and Indirect Customers (Regulatory)
Design Attributes
Sta
keh
old
er
Req
uir
emen
ts +
Inte
rnal
D
esig
n E
nvir
onm
ent
Cust
om
er R
equir
emen
ts +
E
xte
rnal
Ap
pli
cati
on E
nvir
onm
ent
Exte
rnal
A
pp
lica
tio
n E
nvir
onm
ent
•People
•Materials
•Methods
•Machines
•Measurements
•Individual perception
•Group dynamics
•Project management
•Team dynamics
•Organizational culture
Customer Requirements
•How it is used?
•Where it is used?
•When it used?
•Why it is used?
•Who uses it?
•Unknown environmental factors?
Inte
rnal
D
esig
n E
nvir
onm
ent
Psy
cho
logic
al a
nd
Org
aniz
atio
n F
acto
rs
Pro
toty
pin
g a
nd
Pro
duct
ion F
acto
rs
Stakeholder Requirements
Kano needs and Values
•Function
•Features
•Structural form and aesthetics
•Production ready
•Enabling tools and methods
•Distribution
•Maintenance
•Upgradability
•Disposal/ recycle
•Thermal
•Vibration
•Physical impact
•Physical creep
•Chemical
•Radiation
•Etc.
Product
•Demand
•Supply constraints
•Information
constraints
•Etc.
Service
Failures
Project Risks
•Scheduling
•Cost
•Technology
•Performance
•Market demand
•Supply and capacity
•Legal
•Regulatory environment
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Chapter 2: Behavior influences the design process
Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social
environment. Most people are even incapable of forming such opinions. -Albert Einstein
Akiyoshi KITAOKA, Professor, Department of Psychology,
Ritsumeikan University, Kyoto, Japan
studying visual perception, visual illusion, optical illusion,
trompe l'oeil AIC2009 ICP 2016
http://www.ritsumei.ac.jp/~akitaoka/index-e.html
(Not incorporated into the book)
• Cognition and group behavior
influence how products and
services are designed and
used…
• This picture
is not
moving!
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Cognitive factors and group behavior
Attitudes: Expressions of approval or disapproval
Personal prejudices and biases which determine beliefs influencing the types of work activities, their priority and how
they should be performed. In the absence of facilitation, incorrect work activities will be selected, prioritization will be
ineffective and required information may not be acquired or analyzed correctly.
Persuasion: Methods used to influence adoption of an attitude
Facilitative methods are used to obtain consensus for team behavior, members are removed or added to a team,
members are counseled regarding their behavior. Correct persuasive methods will move a team to a high performance
stage otherwise it becomes dysfunctional and fails to achieve its goals in a timely and efficient manner.
Social cognition: Perception formation of others or patterns including filtering of environmental stimuli
Teams which are not diverse, balanced with respect to required work activities or do not use facilitative tools will filter out important
information. Incorrect goals will be selected and information will be incorrect interpreted resulting in wrong conclusions.
Self-concept: Comparisons to others or standards which contribute to self-esteem
Some team members have low self-esteem and others are egotistical. Failure to propose correct ideas, engage in group
activities, and oppose incorrect ideas or behavior. Incorrect goals will be selected, not prioritized and team issues will not be
effectively facilitated.
Cognitive dissonance: Inconsistencies between personal actions and beliefs
Team members have not been persuaded to agree with group’s goals and work activities. Cannot support the group.
Information is leaked. Work tasks not completed. Dysfunctional behavior occurs, People may leave the team.
There are cognitive, group and organizational influences acting on a design process …
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Cognitive factors and group behavior (continued)
Social influence: Influence of group size, beliefs and status on individual behavior.
Team cohesiveness and its maturity stage depend on group cultural norms and values. Flexibility is required for multi-
cultural teams. Group size must be managed to control dynamics. People may engage in dysfunctional behavior if social
norms and values can not be effectively communicated to them.
Group dynamics: Rules, norms and relationships which people within a group use to influence each
other, differentiate themselves from other groups
The dynamics of a group change as its membership changes as a result group norms, values must be clearly communicated and
facilitated. If not properly facilitated the group may break up into subgroups and engage in dysfunctional behavior.
Interpersonal relationships: The ways in which people interact with each other both positively and
negatively
Related to group dynamics, interpersonal interactions must be facilitated to manage personal attitudes, social influence and
group dynamics. If not properly facilitated the group may break up into subgroups and engage in dysfunctional behavior.
Interpersonal attraction: Factors which influence the desire of people to associate
People have different reasons for wanting to join a development team based on perceived value of rewards and
recognition. People need to see an advantaged of associating otherwise other priorities receive their attention.
Cognitive, group and organizational influences also influence how customers use products and services …
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Mental models (cognitive factors) influence
design decisions
Are zoos safe?
• Have you ever thought how well zoos were designed or how many deadly
animal escapes occur from zoos?
According to the International Fund for Animal Welfare
(IFAW), “there are an estimated 5,000-7,000 tigers living in
captivity in the United States - as well as another 10,000 or
more lions, leopards, cheetahs, jaguars and cougars.” Only
one half of these animals are kept in United States
Department of Agriculture (USDA) approved enclosures.
Many of these enclosures are in poor condition. According
to IFAW between 2003 and 2005, fifty-six big cats have
escaped and thirty eight people have been mauled and
bitten. Five additional people have been killed - Fatal
Attractions Big Cats in the USA IFAW Report on Dangerous
Safety Violations at USDA-Licensed Wildlife Facilities,
copyright IFAW International Headquarters: 411 Main Street
Yarmouth Port, MA 02675
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
I wondered how safe was this Gorilla enclosure? I later
found that Gorilla escapes are not uncommon. As an
example, according to a CBS news report on May 19th 2004
from Dallas, Texas, a gorilla, named Jabari, escaped from his
enclosure which “had been in the award-winning gorilla-
conservation area, surrounded by a 16-foot concave wall,
before the attack.... The animal injured four people, including
a toddler, before being shot and killed by police” …"He had to
have scaled the wall," said zoo director Rich Buickerood. But
"this habitat is among the best in the country. This blows our
minds."
Microsoft® Clip Art Collection
“the gorilla can’t jump over the
wall i.e. I have never seen or
heard of one doing so before”
ø
Chapter 3: Universal principles for good design
• Influence
• Learning
• Usability
• Appeal
• Decision making
How often have I said to you that when you have eliminated the impossible, whatever remains, however
improbable, must be the truth? (Sherlock Holmes) -Arthur Conan Doyle
Effective designs accentuate the positive and neutralize the negative influences of cognition and
group behavior…there are perhaps more than 100 non-technical factors to consider…
Alignment Issue
Alignment Issues
http://australianpolitics.com/news/2000/00-11-12.shtml
(Not incorporated into the book)
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Cognition influences the design process and how
customers use and misuse products and services
Law of Pragnanz (Interpret ambiguous images as simple and complete)
http://www.marsartgallery.com/pragnanzlaw.html
Interpret ambiguous images
as simple and complete
(Not incorporated into the book)
Same color! Perception Issues
http://www.lottolab.org/articles/illusionsoflight.asp
http://picocool.com/culture/color--the-brain-beau-lottos-optical-
illusions/
(Not incorporated into the book)
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Chapter 4: Successful designs depend on
organizational culture
Organizational Structure
• Organizational culture, norms, values
• Team organization and dynamics
• Personal attitudes, concept of self,
values, norms
• Bureaucratic, functional, divisional,
matrix, collaborative, virtual
•Laws, Regulations
•Competition
•Demand constraints
•Supply constraints
External Environment
Of all human inventions the organization, a machine constructed of people performing interdependent
functions, is the most powerful. -Robert Shea
•Arbitrary goals
•Conflicts of interest
•Tolerating a violation of organizational policies, procedures or laws and regulations.
•Tolerating incompetence
•Violations of law or regulations
•Lying and falsifying information
•Making threats to others
•Engaging in disruptive or demoralizing conduct with peers, employees, customers or suppliers
•Leaking or misusing confidential information
•Stealing property
•Misrepresenting intellectual capital and other rights
•Making untrue claims regarding product or service features
Dysfunctional Individual and Group Behaviors
•Performance, schedule,
cost, customer, suppliers
and other project risks and
issues
Stress Factors
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
• Organizational
dysfunctions
derail the
design process
and increase
the likelihood of
failure events
Chapter 5: Why the things we trust fail
A problem well defined is a problem half-solved. - Charles Kettering
Swiss Cheese Model
Failure condition A
Failure condition B
Failure condition C
Failure condition D
James Reason, The Human
Contribution- Unsafe Acts, Accidents
and Heroic Recoveries, copyright
2008, Ashgate Publishing Company,
Burlington, VT, page 102.
Catastrophic failures occur when contributing factors align … We must detect weak signals
and “near misses” … and apply failure analysis to products, services and logistical systems
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Failure
Chapter 6: Catastrophic failures have common causes
How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must
be the truth? (Sherlock Holmes) -Arthur Conan Doyle
Several risk recurrence factors were identified … Some industries and
organizations have a higher risk of experiencing a catastrophic event than others
because they fail to do an effective root cause analysis or implement solutions
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
• Isolated technical failures: (I-35W Mississippi River Bridge (Minnesota); April 25th 1986
Chernobyl’s Reactor 4 disaster; Denver Int'l Airport baggage system delay; 2009 Pitot tube
failures on Airbus planes, Air France A430-300 (F-GLZL), Air France A340-300 (F-GLZN) and
possibly Air France Flight 447 as well as other planes; Toyota 2010 recall; Ford cruise switch
control fires-Late 1990's; 2001 Ford/ Bridgestone tire failures)
• Isolated project failures: (AMR reservation system for Budget's hotel and car bookings;
Conversion to new order entry system from Baan Co. at Snap-On; Anderson SAP ERP issues
for Fox-Meyer; Greyhound Bus trips reservation and bus dispatch system issues; Hershey
Foods IBM issues SAP Manugistics; Norfolk Southern integration issues; Consolidated Rail;
Oxford health plans billing processing UNIX and Oracle; Grainger SAP issues; Trivalley
Growers Oracle ERP integration)
• Chronic failures: (Food contamination 1996-1998; 2003 SARS in Asia; Production
problems with the H1N1 Swine Flu Virus; Infectious and parasitic diseases worldwide)
• Major events and natural disasters: (2005 Hurricane Katrina (New Orleans); 2008
Sichuan earthquake; 1989 San Francisco earthquake;2010 Haiti earthquake; 2010 BP GoM oil
spill).
• Several new and current methods are
discussed for preventing or mitigating
the impact of catastrophic events.
Chapter 7: Rethinking unexpected consequences
Never make forecasts, especially about the future- Samuel Goldwyn
Shell Oil used one method, scenario planning, to effectively manage several crises and
leap-frog its competitors …new methods are discussed to predict catastrophic failures
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Summary
The future: Expansion of new quality improvement
methodologies to organizations around the world to prevent
death, injury, property damage and environmental catastrophes.
• Use best-in-class design and manufacturing practices
• Understand people and organizational factors
• Sort out weak and strong signals i.e. “near misses”
• Do scenario planning
• Do risk recurrence analysis
• Use contingency planning
• Plan for crisis management
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.
Questions?
James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.