5c33dc4df62492b436c19626be6dd9ff

QUALITY, LEAN &
SIX SIGMA EDITION
QHSEFOCUSMAGAZINE-Issue15ISeptember2013
focus
QHSE
MAGAZINE
IDENTIFYING
CASCADE
EFFECT
RISKS IN
ORGANIZATION
Learning from Shuttle
Challenger and
Columbia Disasters
HOW DO YOU
KNOW IF A
COMPANY IS
OPERATIONALLY
EXCELLENT?
The 7 Drivers of
Operational Excellence
SIMPLE STEPS TO A
LEAN EMAIL
Encasing Productivity
by Reducing Emails
THE TLS CONTINUUM
The New Focus for the
Quality Movement

Tap & Hold the screen to show the TOP BAR
Home Tap to return to the home page
How to
use this
app?
Tap & Hold the screen to show the BOTTOM BAR
Swipe Horizontally to quickly navigate pages
Tap selected page to View
Swipe Horizontally to go to
the next page

CHIEF EDITOR’S NOTE
Warm Welcome To Our Magazine!
06
18
22
27
06
18
22
27
30
IDENTIFYING CASCADE EFFECT
RISKS IN ORGANIZATION
Learning from Shuttle Challenger
and Columbia Disasters
HOW DO YOU KNOW IF A
COMPANY IS OPERATIONALLY
EXCELLENT?
The 7 Drivers of Operational
Excellence
SIMPLE STEPS TO A LEAN
EMAIL
Encasing Productivity
by Reducing Emails
THE TLS CONTINUUM
The New Focus for the Quality
Movement
MEASURING COPQ REDUCTION
RATHER THAN RAW SAVINGS
“The Gold In The Mine”

CHIEF EDITOR’S NOTE
All rights reserved. No part of this publication may be reproduced or redistributed in any form without written permission of the publisher.
© QHSE Focus Magazine 2012-2013
QHSE FOCUS MAGAZINE TEAM
Roman Gurbanov - CEO, Art Direction and Design
Dave Weber- Chief Editor, Health & Safety Edition
Rick Andrews - Chief Editor, Quality, Lean & Six Sigma Edition
As discussed in earlier issues of QHSE Focus, Six Sigma looks at reducing defects and Lean looks at
improving efficiency and reducing waste. But they are both “reactive” improvement strategies that only
come into play AFTER we have defects and/or waste. Then there’s Design for Six Sigma to
preemptively design new defect-free processes. But no matter how well we design our processes, there
are always risks outside the processes that can still cause us to fail. Our first article describes a new
methodology developed by the author that complements Six Sigma, Lean, and other quality approaches.
It addresses Organizational Risk and how to deal with it BEFORE we see defects and waste.
If that’s not enough innovation for you, one of this month’s articles introduces another new methodology
towards improving quality that the author calls the TLS Continuum. It describes an intelligent approach
to combining the best of our existing methodologies into something more effective.
One of the things I’m frequently confronted with in my own process improvement work is defining metrics
and KPIs to measure an organization. I’m always surprised at how often organizations want to measure
themselves by how well they adhere to the process rather than their actual performance. We have an
article for you that takes a different look at Operational Excellence. I often hear about companies and
organizations measuring themselves based on things like the number of hours of training each employee
gets, the number of certified Black Belts, or, one of my favorites, the number of meetings they have. This
article identifies 7 value drivers that we can all consider in helping us establish metrics and KPIs that
truly measure our performance, rather than just our processes.
Our next article is a fun one that shows us how we can make our email processes more Lean. Who
hasn’t experienced frustration with email? This article should be valuable to all of us.
Finally, the last article for this month looks at our financial measurements and tries to explain why
measuring COPQ reduction is more effective than just measuring savings as a driver towards greater
productivity.
As always, I hope you enjoy this month’s articles. If you do, let us know, and, please let us know what
other topics about Quality, Lean, and Six Sigma you’d like to see in future editions! editions!
Dear Quality Friends, Readers, and Professionals,
Welcome to the September 2013 issue of the Quality, Lean, and Six Sigma
Edition of QHSE Focus Magazine.
I really enjoyed working with this month’s authors. Their articles display
innovation, creativity, and new ways for us to look at Quality and process
improvement.
Rick Andrews

SUBSCRIBE NOW
SUBSCRIBE TO QHSE FOCUS MAGAZINE
AND GET THE BEST OF LEAN SIX XIGMA
FROM INDUSTRY LEADERS
Get new issue every month with 25% discount and
FREE access to “Subscriber Only” Editions!
MUST-HAVE MAG FOR
BLACK BELTS! ★ ★ ★ ★ ★
By DeanAmado - May 22, 2013
On my way to black belt I've gone through
whole lot of lean mags but QHSE Focus
Magazine is the ﬁrst mag on my way written
by professionals for professionals. Got
monthly subscription and have it on my iPad
wherever I go. Look forward for coming
issues.
Brought to you by
www.qhsefocus.com
AWESOME MAGAZINE APP ★ ★ ★ ★ ★
By Shere.GR - May 24, 2013
Fantastic! Finally, a six sigma magazine with
stunning illustrations, videos and comes with
great bonuses inside each issue.

© 2012-2013 qhsefocus.com - All rights reserved 06
IDENTIFYING
CASCADE
EFFECT
RISKS IN
ORGANIZATIONSBY DAVID
PATRISHKOFF
Cascade
Effects are the
result of
interacting
decisions,
actions and
behaviors
throughout the
whole chain of
command and
supply base
for an
organization.
are unforeseen events created by
various risks that are linked in successive stages, which can
produce a cumulative or exponential impact on an organization,
their customers and even society. When epic Cascade Effects
unfold, they do so without warning and the result is usually met
with surprise, shock and awe. Cascade Effect risk can be
accentuated if a complete inventory of undisciplined leadership
practices, a dysfunctional work culture, risky work habits and a
weak response to warning signals are also present.
The potential triggers and elements of risk in Cascade Effects
can be hidden anywhere in an organization. Cascade Effects are
different from Ripple Effects or Domino Effects, which are the
product of one trigger event. Cascade Effects are the result of
interacting decisions, actions and behaviors throughout the
whole chain of command and supply base for an organization.
Cascade Effects

8+ years of the author's research has
identiﬁed 5 waves of threats that are
often present in a given organizational
Cascade Effect (Figure 1). Each of the
5 waves is populated by 57 elements of
risk. When a critical selection and
number of these risks become active,
their linked risk can create very
unpredictable and unintended negative
consequences.
The author's Patent Pending Pictorial
Risk Assessment and Mitigation
The Anatomy of Destructive Organizational
Cascade Effect
Figure 1
Techniques will be introduced in this
article. These new techniques apply a
unique deck of 57 cards (Figure 2) to
assess and address the elements of
risk in organizational Cascade Effects.
What's the difference between a
"Highly respected Engineering or
Business Marvel" and an "Engineering
or Business Disaster of Epic
Proportions"? The answer to that
question is the following question:
"Were the organizational risk factors in
the cascade effects in control or out of
control?".

15 Aces
11 Kings
Figure 2 :The 57 elements of risky leadership practices, work
culture, work habits, bad results and ﬁnal ﬂawed responses
serious situations

20 Queens
serious situations

9 Jacks
2 Jokers
serious situations

4. Performance report cards that are
screaming "red alert" due to the
resulting serious business and
customer issues (aka the Jacks),
which can shockingly result in…
5. The final awful decision to either a)
ignore all obvious warning signals
or b) launch a series of useless
whack-a-mole activities, which just
increases threat levels for all
concerned while thrusting the
organization into the jaws of
blinding mediocrity and self-
destruction (aka the Jokers)
As beneficial as many of the popular
business improvement initiatives can be
to organizations, they are not designed
to identify and address all of the
organizational and cultural risks that can
create negative cascade effects. The
author's research of many business
disasters reveals that the organizations
responsible for these calamities
appeared solid and robust from the
outside. However, upon closer
inspection, these organizations could
best be described as "Swiss Cheese"
with critical voids of good business
practices and so-called "common
sense". This research into "why things
go wrong" was directed at many
unpublished business cases as well as
on many other highly publicized human-
initiated and avoidable disasters, of
which 10 examples are listed below.
1. The Iroquois Theatre Fire Of 1903
2. Sinking of the Titanic in 1912
3. The USS Indianapolis Sinking in 1945
4. Banqiao Reservoir Dam failure,
China, in 1975
5. Union Carbide gas explosion in
Bhopal, India, in 1984
What is Organizational Risk?
"Risk", in this article, is defined as multiple
hidden pockets of undesirable and
potentially hazardous business practices
scattered throughout the organization,
from top to bottom and from side to side.
Cascade Effects can have mild to severe
consequences as listed here:
• Basic organizational mediocrity
• Missed project or business targets
• Irate internal and external customers
• Business blunders & massive loss of
competitiveness
• Disasters that harm employees,
customers and/or society
• Self-destruction of the organization or
business
Organizational Cascade Effects
The mentioned card deck describes and
defines the 57 elements of risk in an
organization that populate cascade effects.
A worst-case scenario of escalating
negative consequences is described
below, which can signal a rather serious
and looming Organizational Cascade
Effect.
1. Bad things can happen when the best
business leadership practices are
remarkably absent in an organization
(aka the Aces), which can result in…
2. A highly ineffective, non-motivating
and dysfunctional work culture (aka
the Kings), which can result in…
3. Work processes that are full of chaos,
inefficiency and risk (aka the
Queens), which can result in…

6. NASA Space Shuttle Challenger disaster
in 1986
7. Alaska Airlines Flight 261 crash in 2000
8. Petrobras 36 Oil Rig sinking in 2001
9. NASA Space Shuttle Columbia disaster in
2003
10.Deepwater Horizon Oil Spill in the Gulf of
Mexico in 2006
The organizational risk factors in the 10
mentioned disasters were clearly out of
control, as historical documents and robust
investigations verified. The victims in all of
these cases were innocent employees,
customers or society who had no hand in the
flawed and cascading bad decision-making
that led to the disaster. This research also
revealed that big disasters are created by
internal threats, not by external threats or
competitors. These disasters were self-
inflicted and avoidable but the proper
level of organizational risk assessment
was not carried out before the disaster.
Research Findings: The
Principles of Destructive
Cascade Effects
The 57 elements of risk in the above
mentioned 5 chain reactions are ever-
present in organizations. Sometimes they
are active and sometimes they are dormant
with the potential of flaring up at any time,
without warning. These risk factors need to
be assessed for activity level and counter-
measured when risk levels flair up.
When the USA NTSB (National
Transportation Safety Board) investigates a
serious airplane accident, they always
investigate cascade effect risks in the
organization and work culture in addition to
the wreckage, hardware and black box flight
recordings. Such efforts have contributed to
remarkable insights and are aimed at
keeping that industry at a very high safety

certification and did not meet the
requirements of the Lloyd's Registry for a
vessel of that size. Historical analysis, recent
scientific investigations and forensic analysis
of the Titanic remains recovered from the
ocean floor have clearly uncovered grave
risks that contributed to the titanic's sinking.
Figure 3 shows a depiction of the 3
interacting cascade effects that came
together that fateful night in April of 1912 to
sink a mighty ship in just over 2 hours, a fact
which drove up the death toll, since rescuing
ships could not reach their location before
their sinking to rescue more survivors. Only
32% of the Titanic passengers survived the
journey. A detailed assessment of the
Titanic's design, construction and operating
practices identified 100+ self-inflicted and
avoidable risks that the cards in Figure 2
identified.
level. When specially appointed investigation
boards investigated the Space Shuttle
Challenger and Columbia Disasters, they
found flawed organizational decision making
and risk assessments in the management
ranks. Their investigation focused on
organizational and cultural flaws and not just
hardware and design flaws.
What Really Sank the Titanic
Icebergs are highly overrated. They are no
match against flawed management
practices, lower than expected specifications
chosen for rivet materials, substandard rivet
materials from suppliers, a flawed design
and reckless vessel operating practices.
According to the Lloyds Register, the grand
Titanic did not seek their classification /

The 3 Fatal Cascade Effects That Sank The Titanic
Figure 2

Students of the LPAT methodology will learn
to re-create famous Disaster Cascade
Effects, like the ones that sank the Titanic.
"Learning Games" with a deck of
organizational risk cards are also used to
practice and appreciate the effects of
interacting risks. Professionals will also learn
how to assess their organizational Cascade
Effect risks with a variety of pictorial tools
and address those risks with realistic and
measurable actions.
The LPAT Organizational
Transformation Process
The author has created a unique Business
Improvement Process summarized in Figure
4. The LPAT (Learn-Practice-Assess-
Transform) method is specifically designed to
identify and mitigate organizational risks that
can create active Cascade Effects.
Assessing &
Addressing Cascade
Effects Risks with
the LPAT Process
(USA Patent
Pending)
1) Learn how Multiple Interacting Risks can lead
to destructive Cascade Effects
2) Practice how to address Risks in Cascade
Effects with Simulation Card Games
3) Asses yourself for an organization for the
threat level of Cascade Effects
4) Transform yourself and other from Ordinary
to Extraordinary
Figure 4:Top level explanation of the LPAT process to address cascade effects risks
The LPAT process includes tools that can
assess various types of Organizational
Cascade Effect risks assessments, such as:
• Cascade Effect Maps - These are pictorial
displays of the risk cards that apply to
disaster analysis or risk mitigation
efforts. Comments are made below
each card when a real risk is identified
that has either contributed to a disaster
or can create one. Download an
example of a Cascade Effect Map for the
Titanic Sinking on the next page.
• Organizational Failure Modes and Effects
Analysis (OFMEA) - OFMEA is a
modification of the FMEA technique
widely used in the engineering and
manufacturing world to assess design
and manufacturing world to assess
design and manufacturing risks. The
OFMEA specifically solicits inputs from

The before-mentioned risk assessment tools
can be applied to various levels and areas of
an organization as listed below. The
assessment tools can be used for reactive
root cause analysis of problems or for
proactive attempts to avoid future problems.
• Top level management
• Departments
• Suppliers
• Business processes
• On products or customer services
team brainstorming about the organizational
cascade effects that can possibly result from
each of the 57 risks shown on the cards. A
total risk score is calculated on the OFMEA
spreadsheet based on 3 different risk ratings
for each potential threat. Risk mitigation
actions are also solicited and rated for their
ability to reduce total risk.
• The 360 Organizational Risk Survey - This is
an anonymous pictorial employee and
management questionnaire asking
participants to rate the level of presence
for the 57 different risks. Comparing
management with employee
perceptions of cascade effect risks is
very useful. Any discrepancy in risk
assessments between different levels in
the organization should be further
investigated. For example, NASA
engineer's assessments of the Space
Shuttle Disaster risk was 100 to 200-
fold higher than management's opinions
on the risk. As it turned out, the
engineer's risk estimates were quite
accurate.
• Pictorial Process Analysis (PPA) - PPA is a
unique method created by the author 10
years ago. It has been used by many
companies to identify and mitigate
organizational inefﬁciencies and risks
that hold them back from reaching their
goals. Download an example of PPA
on the next page. This simple example
of this process on a small generic
process. Usually, the process maps
created for a real PPA event will take up
20 to 40 foot of wall space in a
conference room. It acts as a
penetrating X-ray picture of a targeted
process with its 10 layers of efﬁciency
and risk analysis.
TAP HERE
FREE DOWNLOAD
A Detailed
Cascade Effect
Map describing
the organizational
and cultural risks
that played a part
in the Titanic
sinking and its
great loss of life

Conclusion
The research and analysis of
Organizational risks and the
negative Cascade Effects they can
create are rare topics of
discussion. However, business
improvement techniques that just
focus on solving issues and
problems in the trenches, no
matter how much they are
empowered, will not be able to
transform the work culture and
leadership practices that created or
allowed the problems to exist in the
first place. Various techniques
were briefly introduced here that
can help to make invisible threats
visible. A cascade effect structure
was presented that shows how
these risks can interact and feed
off of each other to create
spontaneous eruptions of shock
and awe effects that negatively
affect the business, employees and
customers. This technique does
not attempt to compete with other
techniques, like TQM, Six Sigma,
Lean and others. It focuses on the
voids that those techniques do not
address.
TAP HERE
Download The
Pictorial Process
Analysis Example
FREE DOWNLOAD
David Patrishkoff is a Lean Six Sigma Master
Black Belt and expert problem solver. He is
President of E3 - Extreme Enterprise
Efficiency® LLC, a management consulting
and training company that he founded in
2001. In 2013, he also founded The Institute
for Cascade Effect Research™ (ICER), an
organization dedicated to the study of
complex organizational Cascade Effects that
holds companies back from Greatness. He
has trained over 3,000 professionals in
advanced problem solving topics and
regularly helps customers solve mission
critical problems that their own experts cannot
solve. Dave's efforts have greatly benefited
his clients from over 55 different industries
worldwide. Prior to his full-time consulting
career, Dave held various senior worldwide
executive positions. He has a patent pending
for a gamified business improvement process
based on unique decks of cards, learning
games and unique pictorial tools, which
identify organizational cascade effect risks.
ABOUT
DAVID
PATRISHKOFF
Mind Mapping the Path to Success:
5-Day Class – Sept. 23-27, 2013
Design of Experiments: 5-Day class
Sept. 30 – Oct 4, 2013
Detailed Process Mapping:
5-Day Class – Oct. 7-11, 2013
Contact davepatrishkoff@aol.com for more details
Join us for our new classes for early fall
being offered in Orlando, Florida:

5c33dc4df62492b436c19626be6dd9ff

Recommended

Recommended

More Related Content

Similar to 5c33dc4df62492b436c19626be6dd9ff

Similar to 5c33dc4df62492b436c19626be6dd9ff (20)

Recently uploaded

Recently uploaded (20)

5c33dc4df62492b436c19626be6dd9ff