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 Florida
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 cbaird@lsicg.com, or
661-332-0382. Visit http://lsicg.com/lean-transformation
for more details.
