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Jim Martin Final Version Unexpected Consequences Short Version Presentation 10 28 10

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New book describing how to prevent catastrophic failures of product and service systems using design, social psychology, lean, scenario planning and other methods....

New book describing how to prevent catastrophic failures of product and service systems using design, social psychology, lean, scenario planning and other methods....

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  • 1. 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.
  • 2. Unexpected Consequences Overview • 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 Intl 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 1990s, 2001 Ford/ Bridgestone tire failures, AMR reservation system for Budgets 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… Of the more than forty catastrophic events worldwide, cognitive and organizational failures are associated with ~98% of all deaths, property damage and financial losses.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.
  • 3. A short history of process improvement 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. 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.
  • 4. Chapter 1: Designing products and services is a process 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, thats why it is so complicated- Paul Rand Market Segment Failures Direct (Users) and Indirect Customers (Regulatory) Service Product Kano needs and Values •Demand •Thermal •Supply constraints •Vibration •Information •Physical impact Customer Requirements constraints •Physical creep External Application Environment Customer Requirements + External •Etc. •Chemical • There are many •Radiation Application Environment •Etc. •How it is used? places where •Where it is used? •When it used? •Why it is used? failures can •Who uses it? •Unknown environmental factors? occur … Design Attributes everything •Function •Features must be done Stakeholder Requirements •Structural form and aesthetics •Production ready •Enabling tools and methods very well. •Distribution •Maintenance Organization Factors •Upgradability Psychological and •Individual perception •Disposal/ recycle •Group dynamics •Project management Internal Design Environment Internal Design Environment Stakeholder Requirements + •Team dynamics •Organizational culture Project Risks •Scheduling •Cost Production Factors Prototyping and •People •Technology •Materials •Performance •Methods •Market demand •Machines •Supply and capacity •Measurements •Legal •Regulatory environmentJames 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.
  • 5. 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 • Cognition and group behavior influence how products and services are designed and used… • This picture is not moving! Akiyoshi KITAOKA, Professor, Department of Psychology, Ritsumeikan University, Kyoto, Japan studying visual perception, visual illusion, optical illusion, trompe loeil AIC2009 ICP 2016 http://www.ritsumei.ac.jp/~akitaoka/index-e.html (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.
  • 6. 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.
  • 7. 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.
  • 8. Mental models (cognitive factors) influence design decisions • Have you ever thought how well zoos were designed or how many deadly animal escapes occur from zoos? 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 “the gorilla can’t jump over the from Dallas, Texas, a gorilla, named Jabari, escaped from his wall i.e. I have never seen or enclosure which “had been in the award-winning gorilla- heard of one doing so before” 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 ø minds." 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 Microsoft® Clip Art Collection 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 Are zoos safe?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.
  • 9. Chapter 3: Universal principles for good design 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 Alignment Issue • Influence • Learning • Usability • Appeal • Decision making Alignment Issues http://australianpolitics.com/news/2000/00-11-12.shtml (Not incorporated into the book) 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…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.
  • 10. Cognition influences the design process and how customers use and misuse products and services Interpret ambiguous images Same color! Perception Issues as simple and complete Law of Pragnanz (Interpret ambiguous images as simple and complete) http://www.marsartgallery.com/pragnanzlaw.html (Not incorporated into the book) 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.
  • 11. Chapter 4: Successful designs depend on organizational culture Of all human inventions the organization, a machine constructed of people performing interdependent functions, is the most powerful. -Robert Shea Organizational Structure • Bureaucratic, functional, divisional, matrix, collaborative, virtual Stress Factors External Environment • Organizational culture, norms, values •Performance, schedule, •Laws, Regulations cost, customer, suppliers •Competition • Team organization and dynamics and other project risks and •Demand constraints issues •Supply constraints • Personal attitudes, concept of self, values, norms Dysfunctional Individual and Group Behaviors •Arbitrary goals • Organizational •Conflicts of interest dysfunctions •Tolerating a violation of organizational policies, procedures or laws and regulations. •Tolerating incompetence derail the •Violations of law or regulations design process •Lying and falsifying information •Making threats to others and increase •Engaging in disruptive or demoralizing conduct with peers, employees, customers or suppliers the likelihood of •Leaking or misusing confidential information failure events •Stealing property •Misrepresenting intellectual capital and other rights •Making untrue claims regarding product or service featuresJames 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.
  • 12. 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 Failure 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 systemsJames 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.
  • 13. 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 • Isolated technical failures: (I-35W Mississippi River Bridge (Minnesota); April 25th 1986 Chernobyl’s Reactor 4 disaster; Denver Intl 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 1990s; 2001 Ford/ Bridgestone tire failures) • Isolated project failures: (AMR reservation system for Budgets 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 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 solutionsJames 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.
  • 14. Chapter 7: Rethinking unexpected consequences Never make forecasts, especially about the future- Samuel Goldwyn • Several new and current methods are discussed for preventing or mitigating the impact of catastrophic events. Shell Oil used one method, scenario planning, to effectively manage several crises and leap-frog its competitors …new methods are discussed to predict catastrophic failuresJames 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.
  • 15. Summary • 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 The future: Expansion of new quality improvement methodologies to organizations around the world to prevent death, injury, property damage and environmental catastrophes.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.
  • 16. 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.

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