PREPARING TO FAIL We re leaders in problem solving. Based on works by Lawrence, John. Rigorous Problem Investigation. Accessed 2008.
MEET THE TEAM Shane Chagpar Senior Consultant, Kepner-Tregoe David Frank Client Relationship Manager/ Consultant, Kepner Tregoe
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White Star Line Incident Report 6
Selected facts from 31 pages of investigation results Described as practically unsinkable in both design and construction Maiden voyage began April 10 th, 1912 with 2,229 passengers and crew Last voyage for the retiring Captain Smith Director of White Star Line was onboard and insists on a 6 day crossing Weather is clear, calm, moonless 7 Iceberg warnings were issues on April 14 th Titanic entered icefield at 8pm with an estimated speed of 23 knots 11:40PM - Night lookout spots icebergs 500 yards straight ahead Titanic attempts to turn, orders to reverse engines 11:41PM - Collision occurs Multiple ships in vicinity including the Californian 11:55PM - Radio distress call issues 12:05AM Passengers begin boarding life boats (16 lifeboats for 1200) 12:40AM Flares launched to signal distress Californian sees flares but takes no action 4:10AM - First ship to respond the Carpathia 7
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 8
01: Method: Describing an Event Chain 9
01: Method: Describing an Event Chain Effect Titanic Sinks Why? Cause Hit an Iceberg 10
Undesired outcome Titanic Sinks Effect 01: Method: Describing an Event Chain Intermediate Causes Flooded Hull Breach Exceeded Hull Strength Root Cause and Direct Cause Hit an Iceberg Cause 11
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 12
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 13
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 14
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 15
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 16
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 17
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 18
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 19
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 20
Assets Product Safety RMS Titanic Lost Cargo Lost Lives Lost 01: Method: Describing an Event Chain Hypothermia & Drowning People exposed to frigid water Many hours until rescue Insufficient Lifeboat Capacity Lifeboats not properly loaded Lifeboat loading took too long Titanic Sinks Nearby ship fails to assist Additional boats would minimize deck area Passengers did not want to leave Egress for lower classes not known Flooded Does not respond to distress signals Turned radio off for the night Hull design would act as lifeboat No outward signs of being in danger Hull Breached Water containment exceeded Crew fails to act after seeing rocket flares Operator went to bed Regulations based on gross tonnage Hit an iceberg Could Not Steer Clear Hull Strength Exceeded Customer modified design, reducing it All 8 attempts used white rockets not color Icebergs nearby Not enough time to react Steel plate for hull made of alloy that is brittle at low temp Did not want to wake radio operator Course Chosen (Ironically to avoid icebergs) Speed and Rudder Design Shipbuilder ordered iron rivets of lower quality Failed to receive iceberg warnings from other ships Competition to make a 6 day crossing 21
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 22
02: Storytelling with Circumstances 23
Safety (+) Water temperatures had dropped to near freezing (-) Several ships responded to and recognized the emergency Lives Lost Hypothermia & Drowning 02: Storytelling with Circumstances (+) Titanic operator was using the older SOS, CQD for quite some time (+) 2 nd Nearest ship was 4 hours away (+) Told the operator of the nearby ship to shut up earlier in the night (+) Nearby ship sent Morse lamp signals that the Titanic didn t respond to earlier (+) Nearby ship didn t realize their lamp was not strong enough to be seen (+) Late at night and Captain exhausted Does not respond to distress signals Crew fails to act after seeing rocket flares Many hours until rescue Nearby ship fails to assist All 8 attempts used white rockets not color Turned radio off for the night Operator went to bed Did not want to wake radio operator 24
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 25
03: Elevating Weak Controls 26
Safety Lives Lost (+) Water temperatures had dropped to near freezing (-) Several ships responded to and recognized the emergency (+) Titanic operator was using the older SOS - CQD (+) 2 nd Nearest ship was 4 hours away Hypothermia & Drowning Many hours until rescue Lifeboats failed to keep passengers safe Nearby ship fails to assist 03: Elevating Weak Controls (+) Told the operator of the nearby ship to shut up earlier in the night (+) Nearby ship sent Morse lamp signals that the Titanic didn t respond to earlier (+) Nearby ship didn t realize their lamp was not strong enough to be seen (+) Late at night and Captain exhausted Does not respond to distress signals Crew fails to act after seeing rocket flares All 8 attempts used white rockets not color Turned radio off for the night Operator went to bed Rockets failed to convey the right message Did not want to wake radio operator 27
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 28
03: Elevating Weak Controls 29
Causes of Major Incident Direct Cause / Triggering Event Vulnerabilities Circumstances Breached Barriers 30
Causes of Major Incident Direct Cause / Triggering Event Vulnerabilities Circumstances Breached Barriers Ship Speed Unsuitable alloy for steel hull Course Chosen Defective Iron Rivets Organizational Pressure via Competition Low Life boat capacity Low Water containment capacity Undefined Egress Paths Poor Rudder Design 31
Causes of Major Incident Direct Cause / Triggering Event Vulnerabilities Circumstances Breached Barriers Ship Speed Unsuitable alloy for steel hull Course Chosen Defective Iron Rivets Organizational Pressure via Competition Low Life boat capacity Low Water containment capacity Undefined Egress Paths Poor Rudder Design 32
Causes of Major Incident Direct Cause / Triggering Event Vulnerabilities Circumstances Breached Barriers Ship Speed Unsuitable alloy for steel hull Freezing water temperatures Course Chosen Defective Iron Rivets Ultra calm conditions Organizational Pressure via Competition Low Life boat capacity Moonless night Low Water containment capacity Had to rely on 2 nd closest ship Undefined Egress Paths After crew bedtime Poor Rudder Design 33
Causes of Major Incident Direct Cause / Triggering Event Vulnerabilities Circumstances Breached Barriers Ship Speed Unsuitable alloy for steel hull Freezing water temperatures Flare signaling and response Course Chosen Defective Iron Rivets Ultra calm conditions Evacuation procedures Organizational Pressure via Competition Low Life boat capacity Moonless night Life boat preparedness Low Water containment capacity Had to rely on 2 nd closest ship On Ship Alarm Undefined Egress Paths After crew bedtime Iceberg warning communications Poor Rudder Design Hull design did not act as lifeboat 34
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 35
05: Mastering Risk Planning 36
Select a cause, concern, plan, or project within your control 05: Mastering Risk Planning Brainstorm: What could go wrong? PREVENT CONTAIN Ask: What are the triggering events that would cause this? Brainstorm: Possible triggering events with various levels of impact For each triggering event Brainstorm: How can we prevent this? Ask: What action(s) will you take to prevent further damage? Implement all reasonable preventative measures Implement via documentation, communication, and practice drills 37
Direct Causes & Triggers 05: Mastering Risk Planning Speed Course Competition Vulnerabilities Steel Alloy Defective Rivets Lifeboat Capacity Water Containment Circumstances Freezing Temps Lack of visibility Breached Barriers Distress Signals Evacuation Procedure Preparedness Alarms Communications Ship Design PREVENT TITANIC CAUSES All vessels must be equipped with radios, backup power and 24/7 monitoring CONTAIN Standardize RED as the color for emergency flares Safety training and drills now mandatory All vessels must have 110% of passenger and crew capacity Critical construction materials have mandatory inspection Egress paths must have appropriate signage No competitions with passengers aboard Maximum speed of 10 knots in iceberg fields Construction requirements modified 38
Lesson Plan 01 02 03 04 05 06 Method: Describing an Event Chain In any field of endeavor, anything that can go wrong, will go wrong. Mastering the Art of Storytelling with Circumstances Left to themselves, things always go from bad to worse. Method: Elevating Weak Controls Nature always sides with the hidden flaw. Method: Documenting causes The starting point to improvement Mastering Risk Planning If multiple things can go wrong, the one that will is the one that creates the most damage. Closing: Putting it all together Wrap up your Masterclass with a few final words of encouragement from Shane. 39
05: Mastering Risk Planning 40
Direct Cause / Triggers Human error, change activity, roll outs, hardware failure, storage exceeded, firewall rules, security and authentication, upgrades 05: Mastering Risk Planning Vulnerabilities Rollout and integration plans, procedures, processes, location, data security, redundancy, mirroring, software age, platform, architecture Circumstances Resourcing, skill level, team maturity, infrastructure, tooling, escalation, KB Barriers and Controls Policy and procedures, work scheduling, change management process, architecture review process, security reviews, audit 41
PREPARING TO FAIL A KT Masterclass by Shane Chagpar We re leaders in problem solving. Based on works by Lawrence, John. Rigorous Problem Investigation. Accessed 2008.
Leaders in Problem Solving Shane Chagpar Senior Consultant, Kepner-Tregoe schagpar@kepner-tregoe.com David Frank Client Relationship Manager/Consultant, Kepner-Tregoe dfrank@kepner-tregoe.com linkedin.com/company/kepner-tregoe twitter.com@ktclearthinking facebook.com/kepnertregoe