Jim Martin Final Version Unexpected Consequences Short Version Presentation 10 28 10

James William Martin (2011), Unexpected Consequences,- Why The Things We Trust Fail, Copyright 2011 by Praeger Publications . Not to be reproduced or modified without written permission from Praeger Publications.

Unexpected Consequences Overview

Of the more than forty catastrophic events worldwide, cognitive and organizational

failures are associated with ~98% of all deaths, property damage and financial losses.

• The 40+ catastrophic events discussed in the book (and many other minor events)

represent more than 18 million deaths and $675,000,000 (US) in property damage

worldwide.

• 80% of property damage and financial losses were due to environmental poisoning

i.e. oil spills, natural disasters and regulatory failures.

• 77% of the deaths and property damage are associated with organizational issues.

• 20% of the deaths and property damage are associated with cognitive issues.

• More than 150 references are included…all information is public.

• Events: I-35W Mississippi River Bridge (Minnesota), April 25th 1986 Chernobyl’s Reactor 4 disaster, Denver Int'l Airport baggage

system delay, 2009 Pitot tube failures on Airbus planes, Air France A430-300 (F-GLZL), Air France A340-300 (F-GLZN) and possibly Air

France Flight 447 as well as other planes., Toyota 2010 recall, Ford cruise switch control fires-Late 1990's, 2001 Ford/ Bridgestone tire

failures, AMR reservation system for Budget's hotel and car bookings , Conversion to new order entry system from Baan Co. at Snap-On,

Anderson SAP ERP issues for Fox-Meyer, Food contamination 1996-1998, 2003 SARS in Asia, Production problems with the H1N1

Swine Flu Virus, Infectious and parasitic diseases worldwide, 2005 Hurricane Katrina (New Orleans), 2008 Sichuan earthquake, 1989

San Francisco earthquake, 2010 Haiti earthquake, 2010 BP GoM oil spill and others…


1. Prior to 1980’s: Focus on allowable defect levels within

manufacturing.

2. 1980’s: Quality philosophies proliferate i.e. zero defects, Juran,

Deming, continuous improvement, ISO, Malcolm Baldrige, total

quality management etc.

3. 1990’s: Lean, Six Sigma (DMAIC) and related methodologies are

deployed to improve current process workflows.

4. Past 10 years: Deployment of Lean and Six Sigma is expanded

around the world into different industries...

5. Quality improvement methods continue to evolve.

A short history of process improvement

What’s next?


Chapter 1: Designing products and services is a process

• There are many

places where

failures can

occur …

everything

must be done

very well.

Design is the method of putting form and content together. Design, just as art, has multiple definitions; there is no single

definition. Design can be art. Design can be aesthetics. Design is so simple, that's why it is so complicated- Paul Rand

Market Segment

Direct (Users) and Indirect Customers (Regulatory)

Design Attributes

Sta

keh

old

er

Req

uir

emen

ts +

Inte

rnal

D

esig

n E

nvir

onm

ent

Cust

om

er R

equir

emen

ts +

E

xte

rnal

Ap

pli

cati

on E

nvir

onm

ent

Exte

rnal

A

pp

lica

tio

n E

nvir

onm

ent

•People

•Materials

•Methods

•Machines

•Measurements

•Individual perception

•Group dynamics

•Project management

•Team dynamics

•Organizational culture

Customer Requirements

•How it is used?

•Where it is used?

•When it used?

•Why it is used?

•Who uses it?

•Unknown environmental factors?

Inte

rnal

D

esig

n E

nvir

onm

ent

Psy

cho

logic

al a

nd

Org

aniz

atio

n F

acto

rs

Pro

toty

pin

g a

nd

Pro

duct

ion F

acto

rs

Stakeholder Requirements

Kano needs and Values

•Function

•Features

•Structural form and aesthetics

•Production ready

•Enabling tools and methods

•Distribution

•Maintenance

•Upgradability

•Disposal/ recycle

•Thermal

•Vibration

•Physical impact

•Physical creep

•Chemical

•Radiation

•Etc.

Product

•Demand

•Supply constraints

•Information

constraints

•Etc.

Service

Failures

Project Risks

•Scheduling

•Cost

•Technology

•Performance

•Market demand

•Supply and capacity

•Legal

•Regulatory environment


Chapter 2: Behavior influences the design process

Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social

environment. Most people are even incapable of forming such opinions. -Albert Einstein

Akiyoshi KITAOKA, Professor, Department of Psychology,

Ritsumeikan University, Kyoto, Japan

studying visual perception, visual illusion, optical illusion,

trompe l'oeil AIC2009 ICP 2016

http://www.ritsumei.ac.jp/~akitaoka/index-e.html

(Not incorporated into the book)

• Cognition and group behavior

influence how products and

services are designed and

used…

• This picture

is not

moving!


http://www.psy.ritsumei.ac.jp/index-e.html

http://www.ritsumei.ac.jp/eng/

http://www.city.kyoto.jp/koho/eng/index.html

http://www.kantei.go.jp/foreign/index-e.html

http://www.psy.ritsumei.ac.jp/~akitaoka/AIC2009.html

http://www.psych.or.jp/english/event/ICP2016.html




Cognitive factors and group behavior

Attitudes: Expressions of approval or disapproval

Personal prejudices and biases which determine beliefs influencing the types of work activities, their priority and how

they should be performed. In the absence of facilitation, incorrect work activities will be selected, prioritization will be

ineffective and required information may not be acquired or analyzed correctly.

Persuasion: Methods used to influence adoption of an attitude

Facilitative methods are used to obtain consensus for team behavior, members are removed or added to a team,

members are counseled regarding their behavior. Correct persuasive methods will move a team to a high performance

stage otherwise it becomes dysfunctional and fails to achieve its goals in a timely and efficient manner.

Social cognition: Perception formation of others or patterns including filtering of environmental stimuli

Teams which are not diverse, balanced with respect to required work activities or do not use facilitative tools will filter out important

information. Incorrect goals will be selected and information will be incorrect interpreted resulting in wrong conclusions.

Self-concept: Comparisons to others or standards which contribute to self-esteem

Some team members have low self-esteem and others are egotistical. Failure to propose correct ideas, engage in group

activities, and oppose incorrect ideas or behavior. Incorrect goals will be selected, not prioritized and team issues will not be

effectively facilitated.

Cognitive dissonance: Inconsistencies between personal actions and beliefs

Team members have not been persuaded to agree with group’s goals and work activities. Cannot support the group.

Information is leaked. Work tasks not completed. Dysfunctional behavior occurs, People may leave the team.

There are cognitive, group and organizational influences acting on a design process …


Cognitive factors and group behavior (continued)

Social influence: Influence of group size, beliefs and status on individual behavior.

Team cohesiveness and its maturity stage depend on group cultural norms and values. Flexibility is required for multi-

cultural teams. Group size must be managed to control dynamics. People may engage in dysfunctional behavior if social

norms and values can not be effectively communicated to them.

Group dynamics: Rules, norms and relationships which people within a group use to influence each

other, differentiate themselves from other groups

The dynamics of a group change as its membership changes as a result group norms, values must be clearly communicated and

facilitated. If not properly facilitated the group may break up into subgroups and engage in dysfunctional behavior.

Interpersonal relationships: The ways in which people interact with each other both positively and

negatively

Related to group dynamics, interpersonal interactions must be facilitated to manage personal attitudes, social influence and

group dynamics. If not properly facilitated the group may break up into subgroups and engage in dysfunctional behavior.

Interpersonal attraction: Factors which influence the desire of people to associate

People have different reasons for wanting to join a development team based on perceived value of rewards and

recognition. People need to see an advantaged of associating otherwise other priorities receive their attention.

Cognitive, group and organizational influences also influence how customers use products and services …


Mental models (cognitive factors) influence

design decisions

Are zoos safe?

• Have you ever thought how well zoos were designed or how many deadly

animal escapes occur from zoos?

According to the International Fund for Animal Welfare

(IFAW), “there are an estimated 5,000-7,000 tigers living in

captivity in the United States - as well as another 10,000 or

more lions, leopards, cheetahs, jaguars and cougars.” Only

one half of these animals are kept in United States

Department of Agriculture (USDA) approved enclosures.

Many of these enclosures are in poor condition. According

to IFAW between 2003 and 2005, fifty-six big cats have

escaped and thirty eight people have been mauled and

bitten. Five additional people have been killed - Fatal

Attractions Big Cats in the USA IFAW Report on Dangerous

Safety Violations at USDA-Licensed Wildlife Facilities,

copyright IFAW International Headquarters: 411 Main Street

Yarmouth Port, MA 02675


I wondered how safe was this Gorilla enclosure? I later

found that Gorilla escapes are not uncommon. As an

example, according to a CBS news report on May 19th 2004

from Dallas, Texas, a gorilla, named Jabari, escaped from his

enclosure which “had been in the award-winning gorilla-

conservation area, surrounded by a 16-foot concave wall,

before the attack.... The animal injured four people, including

a toddler, before being shot and killed by police” …"He had to

have scaled the wall," said zoo director Rich Buickerood. But

"this habitat is among the best in the country. This blows our

minds."

Microsoft® Clip Art Collection

“the gorilla can’t jump over the

wall i.e. I have never seen or

heard of one doing so before”

ø

Chapter 3: Universal principles for good design

• Influence

• Learning

• Usability

• Appeal

• Decision making

How often have I said to you that when you have eliminated the impossible, whatever remains, however

improbable, must be the truth? (Sherlock Holmes) -Arthur Conan Doyle

Effective designs accentuate the positive and neutralize the negative influences of cognition and

group behavior…there are perhaps more than 100 non-technical factors to consider…

Alignment Issue

Alignment Issues

http://australianpolitics.com/news/2000/00-11-12.shtml








Cognition influences the design process and how

customers use and misuse products and services

Law of Pragnanz (Interpret ambiguous images as simple and complete)

http://www.marsartgallery.com/pragnanzlaw.html

Interpret ambiguous images

as simple and complete


Same color! Perception Issues

http://www.lottolab.org/articles/illusionsoflight.asp

http://picocool.com/culture/color--the-brain-beau-lottos-optical-

illusions/



http://www.marsartgallery.com/pragnanzlaw.html

Chapter 4: Successful designs depend on

organizational culture

Organizational Structure

• Organizational culture, norms, values

• Team organization and dynamics

• Personal attitudes, concept of self,

values, norms

• Bureaucratic, functional, divisional,

matrix, collaborative, virtual

•Laws, Regulations

•Competition

•Demand constraints

•Supply constraints

External Environment

Of all human inventions the organization, a machine constructed of people performing interdependent

functions, is the most powerful. -Robert Shea

•Arbitrary goals

•Conflicts of interest

•Tolerating a violation of organizational policies, procedures or laws and regulations.

•Tolerating incompetence

•Violations of law or regulations

•Lying and falsifying information

•Making threats to others

•Engaging in disruptive or demoralizing conduct with peers, employees, customers or suppliers

•Leaking or misusing confidential information

•Stealing property

•Misrepresenting intellectual capital and other rights

•Making untrue claims regarding product or service features

Dysfunctional Individual and Group Behaviors

•Performance, schedule,

cost, customer, suppliers

and other project risks and

issues

Stress Factors


• Organizational

dysfunctions

derail the

design process

and increase

the likelihood of

failure events

Chapter 5: Why the things we trust fail

A problem well defined is a problem half-solved. - Charles Kettering

Swiss Cheese Model

Failure condition A

Failure condition B

Failure condition C

Failure condition D

James Reason, The Human

Contribution- Unsafe Acts, Accidents

and Heroic Recoveries, copyright

2008, Ashgate Publishing Company,

Burlington, VT, page 102.

Catastrophic failures occur when contributing factors align … We must detect weak signals

and “near misses” … and apply failure analysis to products, services and logistical systems


Failure

Chapter 6: Catastrophic failures have common causes

How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must

be the truth? (Sherlock Holmes) -Arthur Conan Doyle

Several risk recurrence factors were identified … Some industries and

organizations have a higher risk of experiencing a catastrophic event than others

because they fail to do an effective root cause analysis or implement solutions


• Isolated technical failures: (I-35W Mississippi River Bridge (Minnesota); April 25th 1986

Chernobyl’s Reactor 4 disaster; Denver Int'l Airport baggage system delay; 2009 Pitot tube

failures on Airbus planes, Air France A430-300 (F-GLZL), Air France A340-300 (F-GLZN) and

possibly Air France Flight 447 as well as other planes; Toyota 2010 recall; Ford cruise switch

control fires-Late 1990's; 2001 Ford/ Bridgestone tire failures)

• Isolated project failures: (AMR reservation system for Budget's hotel and car bookings;

Conversion to new order entry system from Baan Co. at Snap-On; Anderson SAP ERP issues

for Fox-Meyer; Greyhound Bus trips reservation and bus dispatch system issues; Hershey

Foods IBM issues SAP Manugistics; Norfolk Southern integration issues; Consolidated Rail;

Oxford health plans billing processing UNIX and Oracle; Grainger SAP issues; Trivalley

Growers Oracle ERP integration)

• Chronic failures: (Food contamination 1996-1998; 2003 SARS in Asia; Production

problems with the H1N1 Swine Flu Virus; Infectious and parasitic diseases worldwide)

• Major events and natural disasters: (2005 Hurricane Katrina (New Orleans); 2008

Sichuan earthquake; 1989 San Francisco earthquake;2010 Haiti earthquake; 2010 BP GoM oil

spill).

• Several new and current methods are

discussed for preventing or mitigating

the impact of catastrophic events.

Chapter 7: Rethinking unexpected consequences

Never make forecasts, especially about the future- Samuel Goldwyn

Shell Oil used one method, scenario planning, to effectively manage several crises and

leap-frog its competitors …new methods are discussed to predict catastrophic failures


Summary

The future: Expansion of new quality improvement

methodologies to organizations around the world to prevent

death, injury, property damage and environmental catastrophes.

• Use best-in-class design and manufacturing practices

• Understand people and organizational factors

• Sort out weak and strong signals i.e. “near misses”

• Do scenario planning

• Do risk recurrence analysis

• Use contingency planning

• Plan for crisis management


Questions?


Jim Martin Final Version Unexpected Consequences Short Version Presentation 10 28 10

Documents

praeger publications

unexpected consequences

property damage

design attributes

organizational failures

written permission

bookjames william martin

design processfew people