WEBINAR: How to Avoid Unintended Project Consequences Using FMEA
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During this 1-hour webinar you'll learn about some famous unintended consequences and how we can avoid them in our own worlds. See more from this webinar including expert answers and tools referenced here: https://goleansixsigma.com/webinar-effectively-avoid-unintended-consequences-using-fmea/
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WEBINAR: How to Avoid Unintended Project Consequences Using FMEA
- 1. 10/31/2017 1 Presented by Elisabeth Swan Managing Partner & Executive Advisor at GoLeanSixSigma.com How to Avoid Unintended Project Consequences Using FMEA
- 2. 10/31/2017 2 • Managing Partner & Executive Advisor at GoLeanSixSigma.com • Master Black Belt • GE Certified Black Belt Instructor • Burnham Rosen Group certified Leadership Coach • BA in English Literature from Columbia University/Barnard College • Born in the UK Our Expert: Elisabeth 2
- 3. 10/31/2017 3 How to Interact • Ask a question • Answer polls 3
- 4. 10/31/2017 4 Let’s Interact! Where are you from? Share your location in the Questions area in your Control Panel! 4
- 5. 10/31/2017 5 Who Is GoLeanSixSigma.com? GoLeanSixSigma.com makes it easy for everyone everywhere to build their problem-solving muscles. We provide the most practical, easy to understand and enjoyable Lean and Six Sigma resources available. 5
- 6. 10/31/2017 6 We’ve Helped People From… 6
- 7. 10/31/2017 7 Today’s Agenda 7 • The role of risk in process improvement • Introduction to the FMEA • How to address risk with the FMEA • A history of unintended consequences
- 8. 10/31/2017 8 Where Does Risk Come In? 8 Process changes have ripple effects – the goal is to plan for them
- 9. 10/31/2017 9 Lessons Learned 9 New York Daily News Chicago Daily News EastlandTitanic
- 10. 10/31/2017 10 Types of Risk 10 BRAND 😣
- 11. 10/31/2017 11 Cause For Alarm 11
- 12. 10/31/2017 12 A Gift From NASA 12 NASA
- 14. 10/31/2017 14 Plain Speak 14 What are we discussing here? What could go wrong? How bad Would That be?
- 15. 10/31/2017 15 How Bad Would That Be? 15
- 16. 10/31/2017 16 Adapting the Scale 16 What would a “10” be in your process? 1. Potential to violate a government regulation 2. Failure exposes people to bodily harm 3. Risk of financial loss 4. May expose private information 5. Could aggravate the customer POLL
- 17. 10/31/2017 17 Rating the Severity 17
- 18. 10/31/2017 18 What’s the Cause? 18 Why would that happen?
- 19. 10/31/2017 19 How Often Would It Happen? 19
- 20. 10/31/2017 20 Rating Occurence 20 How often would it happen? 1. More than once per day 2. Once every 3-4 Days 3. Once every week 4. Once every month 5. Once every 3 months POLL
- 22. 10/31/2017 22 Would We Know In Time? 22 Is there any way to know about this before it impacts the customer?
- 24. 10/31/2017 24 Bottom Line That For Me 24 Risk Priority Number
- 26. 10/31/2017 26 What Changed? 26 = Still not great
- 28. 10/31/2017 28 Addressing Risk 28 Contingency Plans Preventive Actions QUESTION
- 30. 10/31/2017 30 Types of Poka Yokes 30
- 31. 10/31/2017 31 Unintended Consequences •More public versions •Historic and current •How we dealt with them •How they could have been prevented – or not 31
- 32. 10/31/2017 32 Wi-Fi Kiosks in NYC 32
- 34. 10/31/2017 34 Wolves in Yellowstone 34
- 35. 10/31/2017 35 Templates & Tools 35 FMEA Mistake-Proofing (AKA Poka Yoke)
- 36. 10/31/2017 36 Today We Covered •The Role of risk in process improvement •Introduction to the FMEA •How to address risk with the FMEA •A history of unintended consequences 36
- 37. 10/31/2017 37 Q & A 37
- 38. 10/31/2017 38 Getting Started Learn more by starting some more training! • Yellow Belt training is FREE at GoLeanSixSigma.com • Green Belt Training & Certification • Black Belt Training & Certification • Lean Training & Certification 38
- 39. 10/31/2017 39 Upcoming Webinars Register today at GoLeanSixSigma.com/webinars We’ll select upcoming webinars based on your feedback, so please share your feedback on the survey at the end of close of this webinar. 39
- 40. 10/31/2017 40 Just-In-Time Podcast Tune in at GoLeanSixSigma.com/cafe for the latest Lean Six Sigma news, easy ways to apply Lean Six Sigma and interviews with process improvement leaders like you! 40
- 41. 10/31/2017 41 Q & A 41
- 42. 10/31/2017 42 Thank you for joining us! • More Questions? • Ask us at contact@goleansixsigma.com! • Click here to download free tools, templates, infographics and more! 4142
Editor's Notes
- Moderator (Tracy) Hello And Welcome to GoLeanSixSigma’s webinar: An Introduction to Lean. I am Tracy O’Rourke from GoLeanSixSigma.com, and I will be your moderator today. Transition: Our presenter today is...
- Moderator (Tracy) Elisabeth, VP of Content Development at GoLeanSixSigma.com. For over twenty five years, Elisabeth has been a Lean Six Sigma process improvement consultant helping diverse organizations in industries such as hospitality, healthcare, financial services, manufacturing and retail. Elisabeth has been with GoLeanSixSigma since it’s inception. GoLeanSixSigma is on a mission to make it easy for everyone everywhere to build their problem-solving muscles. Elisabeth lives on Cape Cod, Massachusetts with her husband, his cat and a lot of fruit trees. She enjoys biking, hiking and clamming while kayaking.
- Moderator (Tracy) Before we begin, let’s review the GoToWebinar participant window, so all of you know how to be interactive. First let’s review how to ask a question: (FILL IN) We will also ask you to participate in some polls, Here’s how you answer the poll: (FILL IN) You can type questions at any time and I’ll either ask them of Tracy or I’ll hold them until the end.
- Moderator (Tracy) So, our 1st interactive poll session is to find out where you are from! We have XXX count of attendees! People from all over the world on this webinar, and let’s see how early or late people are up to come to this webinar! Please click on “Ask a question” and type in where you are from! SHARE...
- (Presenter: Elisabeth) Thank you Tracy for the warm introduction! I am happy to be here with all of you from all over the world, and thanks for joining GoLeanSixSigma.com’s webinar. As Elisabeth said earlier, Elisabeth and I have been with GoLeanSixSigma.com since it’s inception. GoLeanSixSigma.com was founded on a couple of guiding principles: We believe in simplifying complex concepts, and believe that complexity just confuses people! WE believe that effective training is practical, accessible AND enjoyable! We have made it our mission to transform how people learn about Lean Six Sigma and we want to share it with you! our training at Bahama Bistro Which is a dreamy, relaxing training facility, a place our team created to What other training program brings you to the Bahamas to learn? Sounds enticing, doesn’t it? And finally, GoLeanSixSigma.com makes it easy for everyone everywhere to build their problem solving muscles. Transition: And thankfully, many organizations agree with our philosophy, because here are some of the organizations that we’ve helped!
- Today’s topic is about Project Bloopers & Blunders and besides talking about them, so strategies to avoid them. Transition: But first let’s define what we mean by bloopers and blunders
- Today’s topic is about Project Bloopers & Blunders and besides talking about them, so strategies to avoid them. Transition: But first let’s define what we mean by bloopers and blunders
- https://www.iris.edu/hq/files/programs/education_and_outreach/poster_pilot/waterdrip.jpg
- In 1915, due to the disaster of the Titanic, the government passed the federal Seaman’s Act, which required The Eastland, a Great Lakes passenger steamer, to retrofit its upper decks with a complete set of lifeboats. The additional weight of the lifeboats worsened the existing issue of the Eastland being too top heavy. When passengers congregated on the port side, the Eastland rolled over and sank 20 feet from the wharf on Southbank of the Chicago River – just 3 years after the wreck of the Titanic.
- Money: The change might lose the company money - [need example] – Offer a 2 for 1 to build volume but demand outstrips supply – co loses money or reputation for running out Hacker: The change might expose customers to fraud - Common issue in financial services – customer convenience = hacker convenience Safety: The change might expose workers or customer to physical harm - Latest issue with the Galaxy Phone – (overheats when charging and explodes) Aggravation - New iPhone and loss of port for earbuds Reputation - Any hits to the above can result in a loss of reputation
- Personal Story: YEAR: 2008 – iPhone just released in fall of 2007 Staying at Westin – nicer Starwood property When I got to my room I noticed they had replaced all the old “Alarm A/Alarm B” bedside clocks with large, sleek, stainless columns of technology that served as both alarm clock and musical docking station. Just looking at them I felt privileged, pampered and sophisticated. What could go wrong? In terms of my own habits at the time (I had no iPhone – yet), I systematically requested a wake-up call. Wake-up calls hadn’t been automated yet and, not having received the wake-up call a few crucial times, I made it a practice to both request a wake-up call and set the bedside alarm clock. I approached this attractive new gizmo and scanned it for some telltale “Alarm” buttons but quickly decided I was out of my league. I called the front desk to get some help, and they sent a lovely woman from Housekeeping to help me. We both gave it the college try to no avail so she called a few of her colleagues in to see if they could help. After a few more attempts we flagged down a gentleman from Maintenance – the guy with a belt full of keys and tools. He came in, took one look and said he’d be right back. He returned with one of those “Alarm A/Alarm B” relics from a supply room somewhere. Problem solved. , what about the other guests? Did they know how to work the mini R2D2? Did they try and fail? Did they do what I did and engage the very willing Front Desk, Housekeeping and Maintenance for the better part of an hour? What else could have gone wrong? This is exactly the thinking behind the Failure Modes and Effects Analysis or FMEA.
- Think about the manned space missions Trial and Error was not an option - think about launching astronauts to test if they could make it back safely Had to get a man to the moon and bring him home “safely” Had to think through all the possibilities and risks Plan ahead – led to all the backup systems you saw in the Apollo 13 Movie BUT – everyone can plan ahead, think through potential risks
- It’s a spreadsheet It’s can seem rather daunting – what’s a “failure mode”? The name gets confused with FEMA – the org. responsible for Hurricane Katrina trailers – not good Instead of walking through it to explain it – we’ll use an example
- In my case that would mean I’m late to teach a class…or run a webinar
- The FMEA comes with scales There are many standards out there but they need to address the process being considered On a scale from 1 – 10 (where 10 is the worst) how would you rate that? In my case, it would expose me to disruption – and there would be no warning – that’s a 10 – worst case But some process failures could result in bodily harm so the scale has to be adapted to your process Let’s see what your scales might look like…
- There are a lot of scales out there to choose from so Google FMEA Severity Scale to get some examples to work with.
- Let’s take a look at our current progress. We’ve assed one failure mode and one potential effect. And we’ve rated the severity – according to our scale – as a 10 Let’s move on to the next phase of risk assessment
- Potential Causes provide clues to how often it would happen. In this case it’s user error, or user inexperience. I needed training!
- Now we go to the Occurrence Scale to assess how often it might happen Based on the cause – in this case user inexperience, On a Scale of 1-10 – How often would that happen? Occurrence Scales are different from Severity There don’t need as much customization Here you can either go by Time Period Or you can go by “per item failure rate” – which would apply to production Take a look at this scale and think about the Ranking for this situation…
- Let’s use the poll to come to a conclusion This is similar to what you would do with your own teams Go to the scale and discuss the proper ranking based on the cause of the failure In this case, there would be inexperienced guests more than once per day – another “10”
- Now we enter that into the FMEA and move on to the issue of “detection”
- They key here is figuring out if there is a way to know about the failure before it impacts the guest Is it obvious? Do we conduct some kind of monitoring of this process? Would it show up in a system somewhere? The harder it is to detect the failure the higher the score Let’s go to the Detection Scale…
- What about our ability to detect this failure? Would the hotel know about this problem before a guest came racing through the lobby, hair in disarray proclaiming, “I’m late!”?… On a scale from 1 – 10 how would you rate that? 10 – almost impossible to detect And monitoring would be intrusive – can you imaging housekeeping knocking on your door to come check if you’d set your alarm properly? And in this case, housekeeping didn’t know how to work these gadgets either!
- The template automatically multiples Severity x Occurrence x Detection to get something called a Risk Priority Number The worst it can be is 1000 – and this this case, it’s the worst it can be! As you assess all the potential failure modes and all the effects, this RPN will help to prioritize which risks to address first The next steps would be to come up with some plans for reducing the risk.
- One idea is to leave the guests instructions We’ve assigned it to the Housekeeping Manager And we also need to record what was done and when This should reduce the severity, the frequency or improve the detection – let’s assess
- In this case: It’s still just as bad if a guests misses their appointment But with instructions we’re able to drop the occurrence to a 7 – maybe it would happen once a month if a guest missed the instructions Detection is still a 10 – nobody is checking on the guests Shortly thereafter I read about another hotel chain that had tried installing a similarly upscale bedside clock and had quickly opted to replace them with earlier models. Starwood eventually followed suit as well. If I use another Lean Six Sigma Tool, The 5 Whys, my guess would be that their main clientele were a little older and still not as comfortable with emerging technology. If teenagers had the cash to stay at the Westin they would probably have nailed it.
- Work from left to right Work through all the different ways a step or feature could fail Prioritize the risks (higher numbers = greater risks) Address the biggest risks first Design action steps to deal with the risk Make those part of the process Reassess the Risk Priority Number This is only one row – most FMEAs include multiple potential ways to fail and lots of different effects The RPN helps the user to focus their efforts to the biggest risks
- I want you to think about something – Imagine you’re in charge of fire safety for a small hotel chain What kinds of things are you going to be concerned with? Think for a moment and then write in the question area the one of the elements you’d be dealing with – take a second So I’m looking and I can see things like: Fire extinguishers Smoke alarms Escape routes But now lets think about two ways to deal with fire (click) Most of these are contingency plans – how to lessen the impact of the fire What about preventing the fire in the first place? A few of you mentioned: - Building materials - Storage of flammable liquids The goal is to build prevention right into the process where possible -
- Based on the idea that almost all errors are human errors 10 Error Types: Forgetfulness – lack of concentration Misunderstanding – jumping to conclusion Misidentification – poor labeling (Visual Management) Lack of Skill – inadequate training (MY ISSUE!) Willful Errors – using shortcuts (taping the handle of the lawnmower) Inadvertent Errors – absentmindedness (hit send instead of spellcheck) Slowness – delayed reaction or judgment (Driver errors) Lack of Standards – Inconsistent methods (why we use Standard Work in LSS) Surprise Errors – Unexpected situations (pilots practicing stalls) Intentional Errors – Sabotage (rare)
- Hard Poka Yokes prevent people from making the mistake or error in the first place so it will never lead to a defect Soft Poka Yokes warn people not to make the mistake but can’t stop them if they choose to do it anyway Imagine the alarm that goes off until you fasten your seat belt – you can ignore it and drive unbuckled - Soft Or the light that goes on to tell you you’re low on gas – you can ignore that too - Soft But you can’t take the keys out until the car is in park - And you can’t fit a diesel nozzle in your gas tank unless the car takes diesel – those are hard poka yokes Topical issue is the risk of texting while driving The failure mode is an accident so the severity is a 10, and it’s happening more and more there’s no warning to remind drivers that looking at their phone could cause an accident A recent article pointed out the makers of cell phones have the ability of creating a Hard Poka Yoke to prevent people from texting while driving (Apple has a patent for technology designed to prevent texting while driving, but it has not deployed it.)
- The wreck of the Eastland was one from the last century, Let’s take a look at some truly famous and public cases of unintended consequences What if they had used the FMEA? What if they had come up with Poka Yokes? What if they built preventive measures or contingency plans?
- Prohibition This is hard to imagine, but worth considering, as we continue to battle drug trafficking. Basically, the enactment of the National Prohibition Act of 1919 led to a large underground network of back room distilleries, illicit supply chains and vast quantities of illegal alcohol all facilitated by increasingly organized crime syndicates. The immense profits enabled the expansion of criminal enterprises and precipitated such an increase in violence that President Roosevelt saw fit to repeal the act in 1933. But organized crime had already created deep lasting roots. Unlike the kiosks, they couldn’t repeal the new mob structure
- Wolves This is a case with very positive unintended consequences. By 1995, the deer population of Yellowstone park, without predators, had grown to such an extent that they had wiped out most of the vegetation. Efforts to control the deer had failed so they reintroduced a small number of wolves Just the presence of the wolves changed the behavior of the deer – they steered clear of open valley’s and gorges which resulted in the immediate regrowth of vegetation – trees alone grew to five times their height in 3 years. This created a habitat for mice, rabbits and birds and profoundly improved the eco-system. But the biggest surprise was that the new vegetation reduced erosion, narrowed the banks and changed the path of the rivers. A small number of wolves managed to change the physical geography of Yellowstone Park! We’ll leave you a link to the short video showing the transformation if you’re interested – it’s very wild to see it.
- So now you have two new tools to deal with risk FMEA and Mistake-Proofing are great combo tools. I recommend using them both any time you make changes to a process You can also use it on an “as is” process to determine if there are current risks you could modify It’s not just for NASA anymore!
- Presenter (Elisabeth) It’s time to hear some of your questions. We’re going to give you some time to submit your questions – and while you’re doing that – we’ll give you some info about what’s available to you. So go ahead and write you questions now. Moderator (Tracy) Tee up questions, and Elisabeth will answer
- Presenter (Elisabeth) Learn more about Leader Standard Work training in the Lean Training and Certification Secondly, get more training! As we said earlier, this webinar may be just the start of your journey into Lean, and Lean is a whole new world! So, learn more about Lean culture, Lean & Six Sigma tools and concepts with more training. Moderator (Tracy) Send the Yellow Belt training link to participants in the chat window
- Presenter (Elisabeth) Tracy – would you like to tell us a little bit about our next Webinar?
- Presenter (Elisabeth) Tracy, can you give us a little background on our featured guest on on our next “Just-in-Time” Podcast? Moderator (Tracy) – describe
- Presenter (Elisabeth) Let’s come back to our Q&A and see what kinds of questions our you’ve go for us today...Tracy, what kinds of questions have come up? Moderator (Tracy) Tee up questions, and Elisabeth will answer