The problem with many of the problems we find ourselves having to contend with at any given time is that we learn of their existence after the fact (when the damage is done) or after discovering that the results we were looking for simply didn’t materialize. As we learned from Michael A. Roberto’s book, “Know What You Don’t Know“, there are a number of reasons why problems don’t surface until after the fact. I highly recommend reading “Know What You Don’t Know” as well Steven J. Spear’s “Chasing the Rabbit” as both books present numerous examples and extensive research that span across a wide variety manufacturing and service industries.
In many cases, the pathology of a given problem reveals that much of the information surrounding a given failure, or series of failures, is “common” knowledge. In isolation, many of the contributing factors appear to be insignificant or irrelevant. However, when we review all of the “insignificant” bits and pieces of evidence as part of the whole, we discover that it is these “pieces” that make the puzzle complete. This was certainly the case with 9-11, Three Mile Island, The Challenger, and perhaps even the most recent economic collapse.
The expression, “If it ain’t broke, don’t fix it”, comes to mind as I think of problem solving in the general sense. Even today, we find this philosophy is embedded deep within the culture of many corporations. In some cases, the designs are so fragile, that any deviation from normal or intended use may result in failure. Broken plates and glasses remind us that they are not intended to be dropped – either intentionally or by accident. We are also painfully aware that the absence of past failures does not automatically exclude or make the process or product immune from future failure. There are too many examples of failure where past successes are suddenly shattered by a catastrophic failure.
Of course, many products are subject to numerous hours of testing in varying degrees of severity and exposure limits. Yet somehow, these tests still do not capture all of the possible failure modes that are observed in practice. Too many product recalls are evidence of our inability to anticipate the vast array of problems that continue to haunt manufacturer’s around the globe. Just maybe the the “If it ain’t broke” expression needs a little rework itself. If it ain’t broke please break it – or at least try! Computer hackers around the world having been giving Microsoft and other major corporations their fair share of problems as they continually find and develop “new” ways to break into very sophisticated and high tech systems.
Our Foundations of Failure model is based on the premise that every failure has a known and identifiable root cause. The challenge for today’s companies is to learn how to identify problems before the product makes it to market or the process is released to manufacturing for production. The objective is to instill an innate ability to constructively critique your concepts and designs to identify and anticipate the “What if …” scenarios that your product or service may be subject to.
Perhaps an even greater skill to be learned is to identify and anticipate how the product or process may be used or abused – with or without intent or malice. From this perspective, lean manufacturing principles and standardized work can certainly help us to map our road to success. Technically, if the ideal process and it’s inherent steps are performed as specified, then any deviations from the prescribed process or design are subject to a system breakdown or product failure. As discussed in “Chasing the Rabbit“, this was (and is) certainly the case for the US Nuclear Submarines.
Are your system, process, and product specifications documented to the extent that deviations from their intended purpose or function can be, or are, readily identified? Is it even possible to forecast or anticipate every possible failure mode? Is it fair to suggest that prescribing a solution to a problem suggests that the original scope of the problem was or is fully understood?
As we have learned from the numerous failures in our financial markets and the collapse of many high profile businesses and companies around the globe, common symptoms and effects of failure may be the result of radically different root causes: ignorance, negligence, willful misconduct, and even fraud. We need to implement systems and processes that are robust and assure our future successes are built on solid fundamental business practices. When the foundation is faulty, the entire business enterprise is at risk.
In summary, the first step is the most critical step. The first few steps of any new initiative, process, product, or service, form the foundation of all decisions that follow. Just as a building requires a solid foundation, so do our future successes. I recall a little sign that was posted in a retail store that read as follows:
Lovely to look at,
Lovely to Hold,
But if you drop it …
Consider it Sold!
Until Next Time – STAY lean!
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