1. COMPLEX PROBLEMS CLASS 6
Can We Really
Learn From Failure?
Failure Analysis as a Problem Solving Tool

2. Background on Failure Analysis
Engineering Roots (hyperlink to learning from engineering disasters)
NTSB as Example
Sports Example -- “Truth in Video”
Expanding into Organizational Influences
PTD or PED -- Primary Technical (usually Engineering) Decisions
PMD -- Primary Management Decisions
See Failure Analysis Resource Library

3. Failure Analysis as Problem Solving
Works back and forth between analytical and heuristic problem solving techniques
Modeling components: simplifying, organizing …
Heuristics: backward-forward; experiments; careful observation ...
Process-Specific Lessons
Solving problems that have occurred: remedies-improvements indicated that are limited to the particular case at hand and the process, company, or people involved -- often technical in nature
General Lessons
Avoiding problems before they happen: remedies-improvements suggested for application to other processes, companies, and people
This is the reason for studying failures of non-related companies and industries

4. Levels of Failure Analysis
Physical Causes
Tangible causes at the point of failure that explain how something happened, e.g. machine part that fails
Responses: redesign; sanction, training ..of engineer
Human Causes
Point of Failure: Improper intervention by person directly linked to the problem (operator, pilot, …); focus on how failure occurred
Responses: sanction of decision maker closest to problem
Organizational/Management Influences: Considering the factors (systems, incentives, policies) behind the point of failure that may have contributed or almost determined the point of failure causes; focusing on “why” the failure occurred
This opens the widest possibility for generalizing beyond the specific failure to help avoid other failures

5. 1986 Challenger Disaster Basic Facts -- see Case Western Website
Past flights -- known O-Ring Problems, scorching, erosion, partial burn-through
Contractor written recommendation of no launch below 53 degrees because of loss of O-ring elasticity -- sealing capacity
July 1985, Thiokol engineer memo warning Flawed design of pressure seal (O-Ring)
Jan 27-28: Cold temperatures; Thiokol engineers advise against launch; management backs the decision
Thiokol management reverses -- they & NASA decide to launch
Jan 28, 1986, NASA Shuttle Challenger Explodes about 150,000 ft. above Earth

6. 1986 Challenger Disaster Physical Causes:
Failure of the pressure seal (O-Ring)on right solid rocket booster O-Ring Blow-out;
Booster-Strut Burn-out;
Booster Impacts Hydrogen Tank …
Flawed design of pressure seal (O-Ring)
Solution: Redesign O-rings + reconsider design of Shuttle in general

7. Challenger Con’t Human Causes
Point of Failure: Launch decision over objections in view of low temperatures
Solution: Sanction Thiokol & NASA decision makers …

8. Challenger Con’t
Org Policies-Systems-Incentives: why would a manager & NASA make such a decision?
At least 2 answers given:
Incentives to launch
NASA key customer; NASA pressure to launch because of slow pace of shuttle missions
“Normalization of deviance”

9. NASA -- Back to the Future
1967 Fire on Apollo 1
Pure oxygen system; North American Warnings; Deaths; Tangible cause focus; NASA & NA point managers lose jobs; no focus on why or changes based it
2003 Columbia Shuttle Disaster (in progress)
Foam debris; Loss of tiles; Decisions not to investigate further at time; More discussion as to why. Results…?

10. Other Failures with Interesting Org Components
Structural Failures
Kansas City Hyatt Regency ...
Detroit Northwest Airlines Debacle
Planes on Tarmac for 8+ hours out of food, water, toilet capacity, ...
Groopman (Harvard M.D.) Second Opinions

11. Organizational/Managerial Causes
Going beyond superficial (Harvard B-school Max Bazerman)
Organizational Incentives
Org goals
Customer pressures
Cost pressures
Flawed links incentives-behavior
NOTE: Although sometimes portrayed in the media as improper, these kinds of concerns are legitimate and enter into business as well as personal decisions (even for reporters)
Flawed Decision Processes
Lack of Information Sharing -- lack of “informativeness” principle
Org Politics: Conflicts, Rivalries, Poor Leadership Direction;
Compartmentalized Decisions (breaking problem into parts), but Tightly Coupled Systems -- Highly Complex Interactive Systems not fully recognized
Normalization of Deviance

12. FAILURE ANALYSIS & BUSINESS
Why is failure analysis not more common in business?
Threat to leaders, employees, ...
Ignorance of role-benefits
Organizational Culture

13. Organizational Architecture for Meaningful Failure Analysis
Buy-in from top leaders
Analysis team with technical expertise but not necessarily led by expert from field
Boiler problem & chemist example
Tradeoff: Punishing failure -- promoting truth
Obviously, price to pay for bad decisions
People looking over shoulder perform poorly
Recognize that some factor(s) beyond reasonable foresight -- cannot become witch hunt
WTC Collapse; OK City Bombing Collapse;

14. Critical Lessons Failure analysis is not just an engineering matter
Technical, Decision, Managerial Issues
Failures frequently surface from organizational flaws
Incentives out of balance
goals; consumers; costs; incentives-behavior linkages
Decision Processes
lack of information sharing-transparancy
decisions compartmentalized-systems highly integrated
normalization of deviance

15. Mini-Assignment Find an example of a workplace failure
Try to identify the point of failures (physical; decisons)
Consider whether the failure is linked to organizational incentive or decision process problems