Harnessing the Power of Failure
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Harnessing the Power of Failure

John Steven Newman, Stephen M. Wander

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eBook - ePub

Harnessing the Power of Failure

John Steven Newman, Stephen M. Wander

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About This Book

Failure informs more generously and reliably than success. Failure is the best indicator of what's working and what's not in any complex system or enterprise. All failures will inevitably reveal latent defects and/or failure modes that are invariably buried within the people, processes, materials, design, manufacturing, and management that comprise the complex system. In this new framework from former NASA aerospace professionals, Newman and Wander employ a unique system failure case study (SFCS) paradigm, originally developed to stimulate systems thinking and lessons learning at NASA, that combines storytelling and systems engineering designed to enhance organizational learning.
The authors employ the SFCS approach to explore a vast array of failure events in multiple sectors of transportation, industry, aerospace, construction, and critical infrastructure. They provide an Integrated Analysis seeking trends, patterns, and universally applicable insights that readers can use to recognize areas of potential vulnerability within their own activities. The authors then identify specific actions within the span of control of enterprise leaders, project managers, process owners and operators which can be implemented to manage risk in high consequence, high risk activities.

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Year
2018
ISBN
9781787542013
Part I

Introduction and Overview

Failure informs. Failure informs as no analytical method can. Failure informs more generously and reliably than success. Failure is the best indicator of what’s working and what’s not in any system or enterprise. Certainly, it is never the intent to set out to fail, however, when failure events do occur, the opportunity will exist to learn something very important. Clearly, any failures that occur in a benign way with no injury, loss of life, or catastrophic damage are truly gifts. However, all failures will inevitably reveal latent defects and/or failure modes that are invariably buried within the people, processes, materials, design, manufacturing, and management that comprise and define any complex system. As will be described subsequently, the authors, whose combined 85+ years of experience in engineering, engineering management, systems engineering, system safety, and failure analysis, developed the system failure case study (SFCS) concept to entertain and inform and more importantly to assist individuals in developing a systems perspective in thinking about failure events. The intent is also to present this ‘way of thinking’ to a broad range of organizations and institutions (business, engineering, and academia) as an important element in evolving high reliability performance and failure avoidance.
“The Greatest Teacher, Failure Is”
Jedi Master Yoda
The SFCS concept blends systems thinking and systems engineering with storytelling. Our approach draws on two previous works (1) Charles Perrow’s (1999), “Normal Accidents” that projects a certain fatalistic notion that failures are inevitable in complex, tightly coupled systems, and (2) James Reason’s, “Managing the Risks of Organizational Accidents” that offers an optimistic belief that failures are understandable and preventable. The storytelling dimension is a very important and empowering aspect of our approach. Certainly, storytelling has been an essential element in the evolution of human kind. Long before the invention of the printing press, much less the Internet, storytelling was the only means of transferring important and critical information and knowledge from one group to another, from one generation to the next and has thus been fundamentally engrained in human nature. Consequently, we have endeavored to make each case study a truly engaging story designed to enhance what we believe to be a very important and necessary learning experience.

Overarching Goals

Entertain

Failure events are thought-provoking, subtle and, in most cases, highly nuanced. Failure events are often tragic. Most failures are action thrillers. One instinctively looks for heroes and villains which may or may not exist. Nevertheless, the interaction of human nature and technological aspects of failures is often deeply interesting. Subsequent fact-finding and failure analysis can be a drama in and of itself. Results of investigations are often contested and subject to endless “spin.” The legal and political finger-pointing can go on for years. Beyond these considerations, we have more serious goals that follow.

Understand the Lessons of Failure

As previously noted, and as many failure analysts have suggested, we invariably learn more from our failures than our successes. Thus, it is the stated purpose and objective of this text to present improved processes and techniques – based on detailed analysis of actual failures spanning a wide range of disciplines – that will expand our capability to better understand how failures often originate in system design and enhance our ability to learn from the failures that occur during operations.

Develop a Systems Perspective

A primary goal is to assist the reader in developing a systems perspective and if possible a systems safety and systems engineering way of thinking. Looking for interconnections, developing the “what-if?” mindset, embracing graphical tools and structured logic to think about how the elements in a system or system of systems may function or fail.

Recognize Danger

Our goals include illuminating recurrent themes and providing insight into the process of recognizing danger – vulnerability to potentially catastrophic failure events and the need to take early action to eliminate or mitigate their likelihood of occurrence.

Improve Decision Making

Failure events typically result from a chain of cascading conditions and/or actions (nonactions). Whether these are conditions that are uncontrollable (i.e., a weather event) or the direct result of active decisions (or both), action/nonaction is almost always the result of a deliberate decision or decision making process. In any event, decision making is deeply embedded in the causal web of most failure events. Thus, the study of recurrent themes in system failures will illuminate decision points that may seem mundane or inconsequential at the time but are ultimately critical decisions to the success of the enterprise.

Provide Action-based Response to Failure Events

This work develops the idea that decision makers, managers, technical process owners, politically appointed boards, need to assign emphasis, prominence, and priority, to understanding failure events, close-calls, near-misses, quality assurance issues, performance issues, and their underlying causes. Ideally, a better understanding of failures should lead to action – adjustment, re-design, re-training, change, process re-engineering, or corrective action.

Facilitate Organizational Development

Finally, a primary objective of this book is to provide a readily accessible and user-friendly data base, that is, “starter kit” for organizations to begin integrating the study and discussion of failure as an integral element in their organizational development – assessing the applicability of failure events to their own activities and operations. Employing failure case studies on a recurrent basis will clearly assist an organization in developing and sustaining a safety culture. Associated benefits typically include enhanced organizational learning and team development as employees analyze and discuss each case.

Layout and Flow

Figure 1.1 provides a graphical snapshot of the content flow. A brief introduction to each part is provided in the following paragraphs. In Part II, System Failure Case Studies, the authors explore a broad array of failures in technologically/managerially complex systems and the inherent power of learning embedded in a focused and detailed analysis of those failures. Some events are well known, others more obscure – but each vignette serves to illuminate one or more key elements to harnessing the power of failure. There is always the question of how deep and how wide to examine the abundance of failure cases. We have chosen to cast a wide net considering failure events in multiple sectors of transportation, industry, aerospace, construction, and other critical infrastructure endeavors. Our case studies employ a format (discussed in detail in Part II) that has evolved and expanded from concepts we originally developed at NASA in the 2000–2003 time-frame.
image
Fig. 1.1:    Road Map to Harnessing the Power of Failure.
In Part III, Recurrent Themes – Integrated Analysis, several frameworks for analysis are presented looking across the case study data presented in Part II seeking trends, patterns, and universally applicable insights. The reader is encouraged to translate the emergent failure modes to potential vulnerabilities within their own businesses, enterprises, and organizational activities. Part III also serves as a springboard for proactive failure prevention measures the reader may consider and which are more fully developed and described in subsequent parts.
In Part IV, Harnessing the Power 
 or Not, provides examples of organizations that reflect a range of approaches, abilities, and willingness (or lack thereof) to prevent or learn from failures. As the reader will observe some organizations intensively study failures to establish sustainable safety and risk aware cultures. On the other hand, there are noted cases where organizations seem to never look back – much less forward – even as failures continue to plague their operations.
In Part V, Road Map to Harnessing the Power, presents a practical guide for organizations – in broadly diverse fields of endeavor – seeking to harden themselves against potential failure. The guide draws from the most simple, powerful, and highly transferable elements of systems engineering. The chapter presents methods – typically within the span of control of enterprise leaders, project managers, process owners, and operators – that will assist in identifying and understanding risks and potential ways to obviate failures within their activities.
Part VI, Applying the Power of Failure, provides detailed examples of SFCS-based learning activities. Tailored options are provided specifically for a business context and other options are presented for academic/classroom application. Commercial business training/teaching options range from a short (30 minutes) SFCS orientation and familiarization briefing to a half-day Knowledge CafĂ© (multiple case studies) and decision making seminars. On the academic side, generally applicable for both graduate- and undergraduate-level instructions, we offer a “blended learning” approach integrating video content with face-to-face interaction involving active student participation. In summary, the authors reflect on the importance of becoming students and critical observers of failure and the often-untapped reservoir of knowledge embedded in failure events.
Part II

System Failure Case Studies

The development and use of case studies has long standing as a method for teaching and instruction as evidenced by its extensive use and application in many graduate and undergraduate university curricula – most prominently in the fields of business and engineering. As noted in the previous section, it has essentially evolved from the fundamental concept of ‘telling a story’ and hence, it holds a natural attraction for most people as an effective means to be informed, to learn, and to understand, particularly when faced with subjects that are technically challenging and complex.
The case study approach is now firmly embedded in leading business schools and has served as the basis for noted works in the business press such as the seminal work by Tom Peters and Robert Waterman ‘In Search of Excellence.’ Case studies are also employed in ‘When Technology Fails’ (by Neil Schlager) a compendium of engineering-related failure cases. Our approach is to implement a storytelling format that effectively combines technical accuracy, readability and brevity in a manner that will not only resonate with the business community and meet academic standards but will also appeal to the casual reader.
As previously mentioned, one of the principle strengths of this book is embodied in the breadth and scope or multidomain nature of the case studies. The case studies offered represent the following general areas:
  • Aerospace/aeronautics
  • Military operations
  • Transportation
  • Emergency response
  • Petro-chemical
  • Construction
  • Power generation
  • Environmental
What follows is an overall description of the format and outline that have been developed for the...

Table of contents