Learning from failure, and removing the causes behind it, vastly contributes to both profitability, and culture. Employees engaged in these environments routinely contribute to identifying various business conditions that negatively impact it. Ignoring employees input can have fortuitous outcomes.
Profits come from improvements, and costs come from causes. Costs are clues to causes we need to investigate, and eliminate. If cause remains unabated, changing dynamics can destroy our ability to recover from cumulative effects of stress placed upon the system. Employees closest to where work occurs have valuable knowledge relating to these conditions.
What Does History Teach Us About What Not To Do?
When NASA requested okay to launch Space Shuttle Challenger from Solid Rocket Booster (SRB) manufacturer Morton Thiokol, there were clues from previous missions that O Ring failures were developing regularly. While the causes were not understood at the time, they continued to occur in certain climatic conditions.
Because of predicted cold weather, Morton recommended no launch. NASA, under increasing pressure to meet an aggressive production schedule, asked them to reconsider. Morton did so, and agreed launch was safe. Morton's leadership team ignored many voices of those with grave concerns about what they didn't know.
After each mission, SRB engineers disassembled, methodically removed parts of the rocket boosters, then looked for conditions not part of the system's intended design. Even with each successful touch down, evidence of failure was clear. After six previous missions, O Rings showed evidence of erosion eight times, and blow by four times. *1 Visual and Statistical Thinking Edward Tufte Page 44 (Blow by is a condition where heated gases blow by the O Ring seal and escape). Why the erosion, why the blow by? Neither was an intended outcome of the system, each incident was instead a clue of a cause needing
identification, that something was not functioning properly. However, these failures became acceptable to those in control who could have instead chosen not to ignore them. With each progressive and successful mission, NASA seemed less, and less concerned, over confident if you will. Freezing weather in south
didn't seem to
change their thinking either, even though the variable clearly fell outside the
parameters contemplated by O Ring designers.
As cold weather arrived at Kennedy Space Center (KSC), visible, and invisible changes at the molecular level occurred. Ice appeared on the launch pad, and as rubber seals inside fuel tanks got colder, they lost resiliency. A compressed O-ring at 75 degrees is five times more responsive in returning to its uncompressed shape than a cold O-ring at 30 degrees. http://er.jsc.nasa.gov/seh/explode.html As heated gases caused the SRB tanks to expand, gases were escaping past the compressed seals. Nobody could stop what was about to take place. Twelve clues indicated management should have.
On the morning of January 28th, 1986 at 11:39 Eastern Standard Time, at a velocity of 2900 feet per second, the words "Roger, go at throttle up", were the last five words heard from the seven team members. The dreams of many of us were lost. As a member of the program, this was very personal.
The effect of freezing weather on O Ring seals was not understood because the conditions had never been experienced during previous launches. NASA and Morton lacked knowledge, but made assumptions since the system had not failed at 53 degrees, it would not fail at 32. In fact, there were 8 previous clues the system was failing each time below 66 degrees, yet they remain largely unchecked, and led to catastrophe. Management failed to ask the key question, why.
What simple techniques can we use to improve?
(1) When the pressure is on, people look to what they think they know. In his book Conversational Capacity, friend and author Craig Weber suggests “Our minds jump to narrow, error-prone conclusions without our permission”. This isn't necessary. If teams can learn how to balance candor and curiosity, they can learn to treat advocacy and illustration of ideas as hypotheses rather than truths. This enables them to transform differing perspectives into rich sources of improvement. Had leadership teams at NASA and Morton learned more from one another, they could have made better decisions.
(2) Problems develop and when they do, don't ignore them. Consider them opportunities to go see, and experience things for yourself. Data may be available, but the job site is where the greatest value is added. See Using Genchi Genbutsu as the Ultimate ERP and Management http://chiefexecutive.net/using-genchi-genbutsu-as-the-ultimate-erp-and-management-system#sthash.QJgns7sC.dpuf
(3) Develop a failure and root cause analysis strategy using the 5 why technique pioneered by Dr. W. Edwards Deming. This technique involves diving deeply into a problem with a recurring theme of asking why at least 5 times. http://www.fastcodesign.com/1669738/to-get-to-the-root-of-a-hard-problem-just-ask-why-five-times
Continuously find the root causes of problems in your business, remove them, and gain market dominance while competitors manage their own crisis. Ignore them, and physics will catch up to you.
Organizations and executives seeking change hire Colin and his team to help learn what’s possible tomorrow using analytics and other lean tools to understand how their culture and operations are performing today. As a management consultant, speaker, and trust advisor, individuals and teams first learn what to measure, develop strategies for improvements, and then drive down operating expenses through flawless executive of Deming’s 14 Point Philosophy, and Principle of Lean Six Sigma Leadership.
Colin can be reached at firstname.lastname@example.org, or 661-332-0382. Visit http://lsicg.com/lean-transformation for more details.