Prelims
ISBN: 978-1-78754-200-6, eISBN: 978-1-78754-199-3
Publication date: 28 August 2018
Citation
Newman, J.S. and Wander, S.M. (2018), "Prelims", Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning, Emerald Publishing Limited, Leeds, pp. i-xiii. https://doi.org/10.1108/978-1-78754-199-320181009
Publisher
:Emerald Publishing Limited
Copyright © 2018, Emerald Publishing Limited
Half Title Page
Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning
Title Page
Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning
BY
JOHN STEVEN NEWMAN
STEPHEN M. WANDER
United Kingdom – North America – Japan India – Malaysia – China
Copyright Page
Emerald Publishing Limited
Howard House, Wagon Lane, Bingley BD16 1WA, UK
First edition 2018
Copyright © 2018 Emerald Publishing Limited
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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN: 978-1-78754-200-6 (Print)
ISBN: 978-1-78754-199-3 (Online)
ISBN: 978-1-78754-201-3 (Epub)
Dedication
John Steven Newman
For my Mary, Scott, and Matt
Stephen M. Wander
To my beloved wife Sandy, “Until we meet again.”
And for my children, ShariLynn, TariLee, CJay
Contents
Acknowledgments | ix | |
About the Authors | xi | |
Prologue | xiii | |
Part I | Introduction and Overview | 1 |
Overarching Goals | 2 | |
Layout and Flow | 4 | |
Part II | System Failure Case Studies | 7 |
Case Study Format | 8 | |
Quick-Look Guide | 9 | |
That Sinking Feeling | 12 | |
Lewis Spins Out of Control | 19 | |
Almost Perfect | 27 | |
Two Rods Don’t Make it Right | 34 | |
Supercritical | 40 | |
Submarine Down | 47 | |
Fire in the Cockpit | 52 | |
Derailed | 59 | |
Powerless | 65 | |
Fender Bender | 72 | |
Innovation Pushed Too Far Too Fast | 79 | |
No Left Turns | 86 | |
Forrestal in Flames | 93 | |
Tunnel of Terror | 100 | |
Death on the Steppes | 107 | |
Rocky Mountain Death Trap | 113 | |
Refinery Ablaze – 15 Dead | 120 | |
The Million Mile Rescue | 125 | |
Part III | Recurrent Themes – Integrated Analysis | 133 |
Introduction | 133 | |
Enterprise/Business Management Framework | 136 | |
Enterprise/Business Management: Observations | 138 | |
Engineering Framework | 141 | |
Engineering Framework: Observations | 144 | |
Another Way of Looking at the Data | 145 | |
Part IV | Harnessing the Power… or Not | 147 |
Introduction | 149 | |
Navy SSP – ‘Always Had It and Kept It’ | 149 | |
Navy SUBSAFE – ‘Learning from Early Failure’ | 152 | |
Petrobras – ‘Had It and Gave It Away’ | 155 | |
WMATA Metro System – ‘Lacked Initial Safety Culture but Recovering’ | 155 | |
Metro Renaissance – The Winds of Change | 159 | |
Summary | 161 | |
Part V | Roadmap to Harnessing the Power | 163 |
Introduction | 163 | |
Leadership that Leads | 163 | |
Developing Enterprise Success Factors | 166 | |
Understanding Enterprise Vulnerabilities | 171 | |
People and Culture | 176 | |
Control – Checks and Balances | 181 | |
Embracing the Gift of Failure | 188 | |
Part VI | Applying the Power of Failure | 191 |
Introduction | 191 | |
Organizations/Enterprises | 192 | |
Academia | 195 | |
Summary | 199 | |
Epilogue | 201 | |
Bibliography and References | 203 | |
Acronym List | 221 | |
Index | 225 |
Acknowledgments
The System Failure Case Study (SFCS) concept evolved from the notion of “hind casting,” or learning from failure events - a method Dr. Newman encountered in class at George Washington University in the Fall of 1999 (Risk and Crisis Management). In early 2000, the first prototype system failure case studies were developed based on a series of Titan IV launch mishaps. While addressing other issues, including support to the Columbia Accident Investigation (2003), the authors together evolved the SFCS to incorporate an increasingly sharp systems engineering “lens.” In the post-Columbia accident era, with an increased emphasis on knowledge management and lessons learned activities, the SFCS format underwent further evolution and development. The National Aeronautical and Space Administration (NASA), Review and Assessment Division (RAD) began developing and widely disseminating SFCSs in the 2005 time frame, employing NASA’s first operational knowledge management system. We wish to salute our colleagues in the RAD and the Office of Safety and Mission Assurance (OSMA) who supported SFCS implementation, in particular, Mr. John Castellano, and Mr. Bryan O’Connor, NASA Chief Safety Officer. We would also like to recognize Bryan for his ‘thought leadership’ relevant to safety, mission assurance, and organizational accountability in high reliability organizations (HRO). In developing our roadmap to harnessing the power of failure we draw on HRO philosophy evolved from leaders in the aerospace community but also derived from the joint NASA/Navy Benchmarking Exchange (NNBE) (2000–2003). In particular, we acknowledge our Navy counterparts, Messers Al Ford, Jimmy Lawrence, and Storm Kauffman for their valuable insights related to safety and risk management within the Navy nuclear propulsion and SUBSAFE programs. Most recently, we have had the opportunity to gain deep insights into the Navy Strategic Systems Program high reliability assurance culture and focus on multilevel leadership and human element weakness. We thank Vice Admiral Terry Benedict and Mr. Steve Zavadil for their valued time and effort in meeting with us. Very special thanks is extended to Mr. Don Vecellio, a long-time and valued colleague, for his encouragement and thought-provoking ideas and advice concerning the overall form and structure of the book, and to Mr. Coleman Cunningham for his insights and experience related to undergraduate general business and strategic management curriculum at the Fisher College of Business, The Ohio State University. The authors also wish to acknowledge Dr. Michael Stankosky for his support in encouraging us to move forward with this project and providing us navigational assistance along the challenging road to publication. Finally, the authors are deeply indebted to Ms. Charlotte Maiorana, Mr. Nick Wolterman, and S. Rajachitra of Emerald Publishing for their unwavering faith, guidance, and patience offered during the development and evolution of the themes, ideas, and production of this work.
About the Authors
J. Steven Newman, D.Sc. John Steven Newman had a distinguished 32 year career in government, with the National Aeronautics and Space Administration (NASA) and the Federal Aviation Administration (FAA). His experience base spans the Concorde Supersonic Transport, the Titan IV launch vehicle, the Space Shuttle, the International Space Station, and NASA Space Shuttle / Nuclear Submarine Benchmarking Exchange Program. Dr. Newman served in diverse leadership roles spanning project management, flight test, safety, quality, risk management, environmental management, accident and failure analysis. After retiring from NASA in 2006 Dr. Newman has served as an aerospace consultant, educator, and fine arts student. Dr. Newman holds a Bachelor of Science in Electrical Engineering, a Master of Science in Environmental Engineering from Northwestern University, and a Doctor of Science in Systems Engineering from The George Washington University.
Stephen M. Wander, B.M.E., M.E.A. Steve Wander has over 45 years of engineering management, research and development experience with the National Aeronautics and Space Administration (NASA), Energy Research and Development Administration (ERDA)/Department of Energy (DOE), and the United States Air Force. Since retirement from NASA Mr. Wander has served as a senior consultant in the fields of engineering management, risk management and systems engineering. Mr. Wander has also served as a Professorial Lecturer at George Washington University in the School of Engineering and Applied Sciences teaching graduate courses in engineering management, decision-making and problem-solving and undergraduate courses in probability, statistics, and statistical inference methods. Mr. Wander holds a Bachelor of Mechanical Engineering degree from The Ohio State University, and a Master of Engineering Administration degree from George Washington University.
Prologue
A quick navigational tip – The authors have attempted and intended that each part of this text stand on its own with respect to focus, structure, and informational content. Accordingly, it is not necessary nor required to read or review all the case studies presented in Part II before proceeding to other parts – ‘analysis,’ ‘organizational examples,’ ‘system engineering tools and techniques,’ or ‘teaching models and methods.’ It is, indeed, up to the needs and desires of the reader. So, feel free to pick and choose the cases of greatest interest – then move on through the rest of the book cycling-back at any point to explore additional cases.