Basic principals of resilient system design

1. Design Resilient Systems

2. Core Competency Resilient Systems
How do Complex Systems Fail?
There is a gap between the system as imagined and the system as is.
Imagined
System
System
as Is
Drift
Imagined Systems are:
1. Static
2. Deterministic
3. Result of design
development
4. Assumes system
discipline.
As Built Systems are:
1. Stochastic: Driven by random
variables
2. Constantly require maintenance
3. Hard to predict.
Source: Richard Cook

3. Core Competency Resilient Systems
How do Complex Systems Fail?
Why does drift occur?
Imagined
System
Random Events
Weakness in
System Design
System Change
Normal System
Variation
Increased costs
Time pressure
Safety problems
Quality problems

4. Core Competency Resilient Systems
How to improve complex systems
Richard Cook
Resilient System Design Controls
Imagined
System
Random Events
Weakness in
System Design
System Change
Normal System
Variation
1. Create process for
continuous system
maintenance.
2. Reveal system controls
to operators
3. Reveal the leverage in
the system –lift points
4. Simulate failures
5. Create prevention
methods
Source: Richard Cook
Root Causes

5. Core Competency Resilient Systems
Where do we apply Resilient Systems Design?
Production Systems:
Standards, Takt times, Setups, Maintenance, Training, Documents, etc.
Quality Systems:
Process Controls, Measurement Systems, Corrective Actions, Training,
Inspection Systems
Safety Systems:
Machines, Building Systems, Support Systems, Training
Information Systems:
Standards, Product Codes, Schedules, Routing, Customer information

6. Core Competency Resilient Systems
Time for Planning, Quality
Safety, and Information
Time for production
For maximum profit we want to minimize the non-value added
activities --- but they must be executed in a robust way.
When the non-value activities have a failure they cause
rebound problems on production

7. Core Competency Resilient Systems
System is in balance, Time available for production, information, planning, quality and safety
The four support systems have time to prevent production problems and are not causing production
Problems.
Market
force
Market
force
Market forces increase pressure: Time for production squeezes out time for information, Planning
Quality and Safety------ Risks of failures increase

8. Core Competency Resilient Systems
When a system problem occurs it will blowback and erode production time
Increasing costs and affecting customers.
The focus is to create systems that can withstand the pressure and
Still minimize risks.

9. Core Competency Resilient Systems
Random Events will develop and push back against any part of the system.
The system must be able to detect these events quickly and deal with the
Problems before they get out of hand.

10. Core Competency Resilient Systems
System Design Characteristics System Tools to accomplish Design
and to control processes
Create process for continuous
maintenance of the system.
Regular system audits.
Production system, quality system, safety
system and information system
Reveal System Controls to operators Train all employees
Audits, Corrective Actions, Process
Controls, FMEA’s, Variation reduction
Leverage the system
Identify the lift points
Ask the question– where is the leverage in
out systems. Focus on ongoing variation
reduction
Simulate failures Regular tests of the system.
Design and implement failure tests.
Fire drills, first aid response drills, gage
failure drills, machine failure drills
Develop a prevention system Apply QS APQP
New product process review
Control plans, FMEAs, MSA, Process
Controls, SPC, Pre-Control, Variation
Reduction

11. Core Competency Resilient Systems
Four causes of drift in systems.
1. Weak systems design
2. Changes to the system
3. Normal variation in systems
4. Random variables.
What are some examples of actual activities that we can us to
address these problems.

12. Core Competency Resilient Systems
Weak System Design
In most factories some systems will be stronger than others.
Production is usually the strongest with safety the weakest.
Production System: Audit the system to TS standards, are there control plans, are
they being followed. Work instructions, training records, PM records, scheduling
systems
Quality System: Use the ISO, TS or AS audits. Are they being done regularly.
Procedures, work instructions, training records.
Safety System: Is there a safety system. Are OSHA audits done regularly. Are
there written procedures, work instructions, training records, are there
ongoing open safety problems.
Information system: Audit critical routers, are they correct? Is the coding correct.

13. Core Competency Resilient Systems
System Change
In a strong system there will be a process to introduce new materials, new
parts, new machines, new processes.
Production System: There should be something that aligns with a QS APQP
system for introducing new products. Is there a process and is it being
followed.
Quality System: Are all the documents required to support new products in
place? New measurement systems, new process controls, etc.
Safety Systems: Are new machines and processes reviewed for safety and
hazardous material issues? Is this documented.
Information Systems: Is the information system adjusted for the new
information? Is this change part of the APQP process?? Is it documented
and reviewed. Is it tested?

14. Core Competency Resilient Systems
Normal Variation
Variation occurs in every process. In some cases we have data to
document it and in some cases we not. Our goal is to reduce the variation in
our processes all the time.
Production System: Do we know the amount of variation in our machines,
our standards, our cycle times, our setup times. We need to be
improving these all the time.
Quality Systems: Do we have the skills to reduce our variation? Do we have
the data from all of our processes?
Safety Systems: Need to gather data from our safety systems to begin to see
variation.
Information Systems: Need to gather data from our information systems to
begin to see the variation in our system.

15. Core Competency Resilient Systems
Random Events that affect our system
Random events can cause significant disruption. How we deal with them
will make our system stronger.
There are two key elements that help address random events in the system.
1. Ongoing monitoring of the system that reveals changes in the system and
the active measurement of system drift. This can be through SPC, audit
results or other active methods.
2. The active participation of trained operators who understand the monitoring
that they are doing. People need to be trained to react to random events
and to notify other people to get help to deal with them immediately.

16. Core Competency Resilient Systems
Measuring Drift
Managers should want to know how much their system as drifted from the
original design.
Monitoring this drift reveals a lot about the risk inherent in the business at any
point in time.
There are four key elements supporting production.
Quality, Safety, Planning and Information --- failure in any one of these
will rebound back on production.
Resilient systems theory tells us that any system is subject to the four key
problems. Random events, normal variation, poor system design or changes
in the system.

17. Core Competency Resilient Systems
Measuring Drift
The economics of monitoring
Monitoring the value added portion of the factory is most
important to generating cash flow.
The production system and the factory output get the most attention.
The primary metric is the standard costs income statement supplemented
by daily KPI and cash flow.
The non-value added portions need just enough resources to
insure that production is not affected by system failures.
There are institutional requirements such as ISO, TS and AS systems that
require auditing to meet standard requirements.
There are OSHA requirements that require regular activities and should
lead to regular audits
.

18. Core Competency Resilient Systems
Four separate audits are conducted
on an ongoing basis and then presented at random
to management for review.

19. Core Competency Resilient Systems
Alternative method to reduce costs of audits and to improve direct reporting of
drift.
Audit the plant by key product lines starting with the largest and progressing to
the smallest.
( Review existing ISO and Safety audits– separate work cell specific
material from plant wide material)
Create one audit that integrates Quality, Safety, Information and Planning into
one audit.

20. Core Competency Resilient Systems
Resilient Value Stream Audit
Production: Takt time to output, work
standards, setup time, PM, 5S, training
records
Quality: SPC, Gage R&R, Cpk of
output, training records, Process
controls, corrective actions on key parts.
Information: Router accuracy,
standards, product coding review,
Raw material review, prior approvals.
Planning: Cycle times, on time delivery
Safety: Lockout, machine guarding,
ergonomics, noise, PPE, electrical,
training

21. Core Competency Resilient Systems
How do Systems Fail?
Resources:
How Complex Systems Fail: Richard Cook Univ. of Chicago
Resilience Engineering: Erik Hollnagel, David Woods, Nancy
Leveson
A New Accident Model for Engineering Safer Systems
Nancy Leveson, MIT

22. Core Competency Resilient Systems

23. Core Competency Resilient Systems