PICTORIAL RISK ASSESSMENT OF CASCADE EFFECTS David J. Patrishkoff President - E3 Extreme Enterprise Efficiency® LLC Email:
[email protected] SUMMARY We live in a fragile world filled with partial solutions and weak defenses against the most threatening of all invisible risks, those which come from within an organization itself. Six Sigma reduces defects and Lean improves efficiency while reducing wasteful activities after they happen. Design for Six Sigma (DFSS) attempts to design defect-free products and processes. However, no matter how well we design our products and troubleshoot our processes, stealthy risks still manage to create unexpected problems that hold us back from greatness. Upon closer inspection, we will find that these invisible barriers to greatness are a network of spoken and unspoken elements of risks throughout an organization that very often obstructs the path to success. Individually, these Risks might just seem annoying but not necessarily destructive. However, as a linked network of taboo talk rules, inefficiencies, undesirable behaviors and flawed management practices, they can create highly disruptive and threatening Organizational Cascade Effects. These cascading risks can cause continuous improvement efforts to flounder or fail and can transform any organization into an ineffective Whack-A-Mole machine that creates an endless stream of lackluster performances and frustrated employees and customers. This paper will present a new patent pending technique developed by the author that can identify and address the 56 invisible gatekeepers that holds any organization back from greatness. This innovative methodology can identify the elements of organizational cascade effect risk and addresses these cascading risks before they strike by countering them with best practice countermeasures. These Cascade Effect Risk Mitigation Techniques compliment other quality concepts such as Six Sigma, Lean, DFSS and others. The introduction to these new risk mitigation techniques starts with two unique decks of cards that describe personal and organizational hierarchical cascading Risks and Best Practices. These decks of cards help visualize the complex and mostly invisible Cascade Effects that determine Success or Failure for individuals and organizations. These new concepts have been developed and used to transform many organizations since 2004. This paper will shed light on the hidden elements of risk and best Proceedings from ASQ’s World Conference on Quality and Improvement, Dallas, TX, May 5-7, 2014, http://asq.org/wcqi/
practices that battle for dominance in a hierarchical manner of a card game (Aces, Kings, Queens, Jacks and Jokers). These cards are utilized in a variety of learning simulation War Games, risk assessments and mitigation techniques. Simple game card principles and domino effect metaphors are applied to help visualize and explain the extraordinary complexities and invisible risks we are all exposed to every day at work or in non-work life.
KEYWORDS Cascade effects, business transformation, risk assessment INTRODUCTION Let's start with the unique definition of risk applied in this paper. Risk is any self-inflicted action, attitude, barrier, behavior or external condition that separates individuals or organizations from Success. A description of Cascade Effects within the scope of this paper is as follows: Cascade Effects are different from single point trigger effects such as domino effects, ripple effects, chain reactions, etc. They can have multiple dependent and independent triggers, accelerators or inhibitors, anywhere in the chain. They have five levels of hierarchy under which all elements of a cascade are organized. There are several types of cascade effects, which can create a variety of results such as positivity, mediocrity, negativity, baiting, group-think, bubbles and panic. Cascades can work independent of other cascades, in unison or clash, which creates very complex dynamics that can be hard to visualize and analyze. MIT2 research concluded that the behavioral complexity of modern organizations and civilizations now surpasses the behavioral complexity of any individual human. That MIT research is an indication of the challenges modern business leaders are up against. Research experiments from the University of California and Harvard3 have also proven that good, bad and even herd mentality behaviors4 can be passed on to others with three degrees of separation from the initial act. Good and bad actions can thereby get replicated hundred and even thousand-fold stemming from the first act. The final result is a complex mix of forces emanating from various dependent and independent triggers that determines the Success, failure or mediocrity of a system. Figure 1 shows the hierarchical levels of influence common in any Cascade Effect. The effects radiate from Leadership to the Work Culture to Work Habits, which determines Performance, which is followed by a response to Performance issues. All of the before-mentioned actions, lack of actions, behaviors and attitudes determine the fate or good fortune of employees, customers and citizens impacted by an organization. Cascade Effects also create feedback loops to Leadership. If Leadership is attuned to the feedback signals, they have the opportunities to improve the final result. However, this assumes that Leadership knows how to effectively manage and direct cascade effects to create the desired performance.
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Figure 1. The 5 levels of Cascade Effect Hierarchy that affects employees and customers in many ways
LPAT BUSINESS TRANSFORMATION PROCESS The author has developed a Risk assessment and mitigation technique to directly address organizational Cascade Effect Risks. The process is named LPAT, which stands for Learn, Practice, Assess & Transform. Figure 3 summarizes the methodology. A deeper explanation of the LPAT Process follows. LEARN is the first step of the LPAT process, where professionals are exposed to the Organizational Cascade Effect theories summarized in Figure 1. They will also learn the 56 elements of Risk that populate negative cascade effects (Figure 3) and the 56 Best Practices that can counter these risks (Figure 4). Part of the LPAT learning process is to appreciate experimental research findings that verify that good, bad and mediocre behaviors and actions can spread to 3 degrees of separation from the initiator of such actions (Figure 5). The study of several well known historical disasters caused by cascade effects are covered in this Learning phase. Professionals also learn how to describe organizational dynamics as cascades and not as simple "one cause and one effect" scenarios. The Learning process also involves understanding the differences between true root causes and symptoms masquerading as problems (Figures 7, 8 & 9).
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Figure 2. The elements of the LPAT Organizational Risk Identification, Mitigation and Transformation Technique
PRACTICE is the second step in the LPAT process. This is where professionals will be engaged in theoretical "War Game Scenarios" to hypothetically defend their organizations from the 56 different cascading Risks (Figure 3). A wide variety of War Game scenarios are practiced in this phase. Random hands of risk cards from the deck of 56 cards will be dealt to teams who are tasked to create short, mid and long-term counter-risk action plans. Teams will also practice how to create counter-risk action plans (Figure 4) to control threatening risks. Each professional or group of professionals must successfully counter all of the risks in the deck before they can move to the next phase of the LPAT process. LPAT students will also practice how to avoid theoretical and actual documented disasters. ASSESS is the third step in the LPAT process. Professionals will now work with top management to assess the presence and severity levels of real organizational risks. These assessments can be conducted for the whole organization or for specific sites, departments or for specific key business processes. Such risk assessments can be conducted using Cascade Effect Maps, Pictorial Process Analysis, Value Stream Maps, Organizational Failure Modes and Effects Analysis (OFMEA), anonymous surveys for the whole organization (Figures 5, 6 & 10) and detailed assessments of key business processes (Figure 11). The Delphi Method5 can be customized to anonymously collect and debate different risk assessment opinions between various levels or individuals in the organization to attempt consensus building on perceived risks. The Delphi Method allows initial anonymous assessments, summary responses distributed to the team, reassessment based on collected feedback and possible changes in initial assessments. This all happens without the scrutiny, peer pressure and management domination drawbacks involved in many face-to-face discussions or debates on sensitive issues.
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TRANSFORM is the final step in the LPAT process. It assumes that honest and acccurate organizational, department level and process level risks have been previously identified. Best Practices (Figure 4 & 5) are identified and implemented to improve Leadership practices, Work Culture, Work Habits, Performance and Responses to critical situations. A series of tools and techniques are employed (Figure 11 & 12), which are followed up with disciplined organizational transformation task identification, monitoring and execution. The Delphi Method can also be applied here to anonymously debate which best Practices will create the biggest transformation improvements. Rapid Innovation Team Events can be effectively applied to identify new and improved business processes. Business transformations that only affect work habits and do not drive meaningful improvements in Leadership and Work Culture practices will not create lasting and meaningful tranformations.
ORGANIZATIONAL CASCADE EFFECTS Success, mediocrity or failure is defined by the content of organizational cascade effects. Total Business Risk equals Financial Risks (easier to measure) plus other Organizational Cascade Risks (often invisible and hard to measure). Internal organizational risks can be more dangerous than external competitive threats. Positive, Neutral and Negative forces can populate cascades. These forces work in a state of unison or conflict to either reinforce or cancel out each other’s efforts. Figure 5 shows the many known names for a variety of forces that can convert the simple actions of individuals and amplify them in a contagious replicating manner with up to three degrees of separation3,4. The top of the graph shows the most positive forces and the bottom shows the most negative ones. In the middle are the forces that spread the status quo and mediocrity.
RESEARCH THAT IDENTIFIED ORGANIZATIONAL CASCADE EFFECTS RISKS This Risk Assessment and Best Practice concepts were developed during the author’s extensive research, which were supplemented by his senior executive / consulting experiences in over 55 different industries. The Grounded Theory Research Method1 was applied to help answer the question "What's Going on Here?" relative to why bad things happen to seemingly good companies. It was also used to investigate why so many business improvement initiatives fail. Normal cause and effect thinking was incapable of identifying the risks and set the rules that would avoid organizational blunders. The Grounded Theory Research Method was used to
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Figure 3. The 5 waves of a destructive cascade are populated with these 56 elements of high risk
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Figure 4. The 5 waves of a beneficial cascade are populated with these 56 Best Practices World Conference on Quality and Improvement, May 2014, http://asq.org/wcqi/
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Figure 5. The psychological, social and behavioral forces that amplify risky, best practice or mediocre actions
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identify and document repeating patterns in well known published disasters and many other nonpublished business mishaps and disasters. Disaster stories were studied in search of common Risks / Root Causes. Discovered Risks were categorized and grouped into a theorized Cause & Effect Hierarchy. After several years of research and successful organizational problem solving efforts applying this knowledge, the Cascade Effect theories established from this research were integrated in new business improvement and transformation techniques. The following disaster examples listed below are in sequential historical order. Research confirmed that they all displayed very prominent Cascade Effect tendencies and had very high risk content in those cascades. These and many other published and unpublished disaster stories were used to confirm the constantly repeating cascade effects that threaten businesses at many different levels. 1. The Iroquois Theater Fire in Chicago, 1903 - 605+ deaths6 2. Sinking of the Titanic, 1912 - 1,502 deaths7 3. The USS Indianapolis Sinking, 1945 - 880 deaths8 4. Banqiao Dam failure, China, 1975 - 171,000 deaths9 5. Union Carbide gas explosion, India, 1984 - 3,787+ deaths10 6. NASA Space Shuttle Challenger Loss,1986 - 7 deaths11 7. Alaska Airlines Flight 261 Crash, 2000 - 88 deaths12 8. Petrobras 36 Oil Rig sinking, 2001 - 11 deaths13 9. NASA Space Shuttle Columbia Loss, 2003 - 7 deaths14 10. Deepwater Horizon Oil Spill - 2006 - 11 deaths15 11. 2007-9 USA Recession – Millions suffering16 Too often, small, mid-sized and major disasters are treated as unique events that will never repeat themselves again in that manner. With that mind-set, such failures have happened in vain. Life and business surrounds us with immense learning opportunities if we only take the time to learn from them to pave a safer way for the future. Business failures of any magnitude offer great learning opportunities. They can motivate the addition of process safeguards, added errorproofing and updating of risk mitigation plans.
EXAMPLES OF ORGANIZATIONAL CASCADE EFFECTS In the Challenger and Columbia NASA Space Shuttle disasters, Presidential and Congressional investigation boards11,14 found that engineers perceived tenfold risk levels higher than management. That situation can be threatening if present in any industry. Risks can be assessed (Figures 6 & 10) for different levels of management anonymously to see if such cultural anomalies exist. If they do, something is wrong, which needs to be further investigated.
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Assuming that management is always right can be a fatally flawed assumption. The Titanic sinking and loss of life7 could have been avoided or minimized if the following cascading Leadership failures would have been addressed:
Radio warnings from other ships in the area were ignored. The California ship, 21 miles from where the Titanic sank, was stopped for the night because they were surrounded by very dense field ice. They sent Titanic a warning of their situation. Unfortunately, not all additional warnings later in the fateful night were passed to the Titanic bridge because the radio operator was too busy sending personal passenger messages to Cape Race, Newfoundland. The risky Management goal of suspected attempts to break a speed record across the Atlantic in addition to flawed radio operator priorities proved to be fatal for 1.502 Titanic passengers. Titanic would not have sunk so fast if it would have specified the use of steel for rivets instead of second rate wrought iron. The result was poor quality and brittle rivet materials from an over-extended supply base, which Titanic rivet material recovery and analysis confirmed decades later. Cost saving efforts cancelled the plans to provide enough evacuation boats for everyone on Titanic. A flawed evacuation plan only filled the limited amounts of lifeboats to 61% of their capacity. The so-called unsinkable Titanic did not have high barriers between the water-tight compartments nor did it have a double bottom that stretched up to the waterline, a design flaw that was immediately corrected with its sister ship, the Olympic. The Titanic builders never sought the Lloyds Registry of the ship. After the sinking, Lloyds officially announced that the Titanic would have never met their quality and design standards for a vessel of that size. The pursuit of such Lloyds Registry standards might have saved many lives.
According to NTSB (National Transportation Safety Board) report12, the Alaska Airlines flight #261 in 2000 that killed 88 crew members and passengers could and should have been avoided. Many short-cuts, aircraft design flaws, flawed maintenance procedures, under-staffed maintenance crews and out of specification thread wear measuring devices contributed to that disaster. In general, an overdose of over-confidence, false optimism, no back up plans, shortcuts, sacrificing quality for speed and profits combined with dozens of other common risks created the 11 mentioned disasters. Figure 6 shows an organizational survival matrix2. When the severity of the challenges that face an organization outweigh the safeguards and Best Practices in place,
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failure is possible. If they match each other, the chances of success or failure are 50/50. Applying more effective counter-risk activities can improve the odds of success and survival. Deciding factors depend on the quality of the crisis response and how often those safeguards are challenged. Frequent episodes of crisis can make an organization weary and weak.
Figure 6. The threshold between survival and failure is when the challenges equals the response
ASSESSING AND MITIGATING ORGANIZATIONAL RISK Figure 9 illustrates institutionalized Cascade Effects that create organizational problems, which keeps the talents of an organization busy and distracted by fire-fighting efforts. These "Problems" shown in the illustration are really symptoms of the risks that are allowed to exist in the organizational cascades. Lean, Six Sigma and other celebrated problem solving techniques are typically chartered to address these problems created by cascade effects. However, their stated scope of problem solving efforts usually ignores risky leadership and cultural issues. Therefore, their efforts are just addressing symptoms. Taboo talk rules also need to be identified, exposed and addressed, since they are capable of continually creating new problems that distract the organization. Figure 8 shows two popular Ishikawa brainstorming techniques17 used for problem / symptom solving in business. However, these techniques are rarely allowed to be focused on the resolution of leadership (The Aces) and cultural issues of an organization (The Kings). Employees are often "empowered" to focus on lower tier elements of organizational cascades but taboo talk rules
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hinder them from focusing on the powerful Leadership and Cultural issues that can trump everything else and hold an organization back from greatness.
Figure 7. Negative Cascades distract the organization’s talents by constantly generating newly created problems
Figure 8. Classic root cause brainstorming efforts often focuses on symptoms that are masquerading as problems World Conference on Quality and Improvement, May 2014, http://asq.org/wcqi/
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Figure 9 shows a symbolic representation of the unique organizational Cascade Effect brainstorming required to impact the real underlying causes of low business performance issues hidden in the cascades. The symptoms masquerading as problems need to be resolved (Figure 8). The conditions in the organization that generate such symptoms also needs to be addressed (Figure 9) so that the talent of the organizations can eventually shift their efforts from problem solving to problem prevention.
Figure 9. Angry Fish Brainstorming addresses the cascades that continually fabricate new problems Cascade Effect risks can be quantified with the help of Organizational Failure Modes and Effects Analysis (OFMEA) and on various visual risk grids (one example shown in Figure 10). It is often helpful to rate such risks separately by management level to understand the perceptions of top and middle management versus non-management groups of employees. Key business process risks and inefficiencies can be identified on a top level with Cascade Effect Maps18, Value Stream Maps and other techniques. Once these inadequate and risky business processes have been identified in the work culture19, detailed process mapping (Figure 11) is the suggested way to assess and address the weaknesses of individual processes at a more detailed level. The use of 3-5 day Rapid Innovation Events is an exciting and dynamic option that empowers process experts to transform a business process, while also identifying the leadership and cultural aspects that hold the process back from greatness. Figure 13 shows a current-state
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Pictorial Process Analysis (PPA) of a very simple process20. PPA was developed by the author in 2004 and has been successfully applied to many businesses from dozens of different industries. PPA defines ten layers of process risk and inefficiency for each process step, such as cycle time range, first time yield, value-added percent, data collection points, number of redo loops required, individual process risks (cards) as well as the leadership and work culture risks that hinder process success. An overall process scorecard is also created to show the overall process lead time, total value-added process time and Rolled Throughput Yield (RTY). RTY is the probability that that a manufactured product or customer service request will make it through the whole process without being scrapped, reworked, corrected or redone in any way.
Figure 10. These assessments are best surveyed for non-management, mid-management and top management to compare potentially different risk perceptions
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Figure 11. Pictorial Process Analysis is a detailed method of process mapping that exposes all organizational and process inefficiencies and risks Future-state PPA brainstorming would also be conducted (not shown here) to create the new and improved process, which addresses organizational and process inefficiencies and risk. Prior to new process creation, extensive "Wish Lists" for the new process and Opportunities for Improvement Matrices (Figure 12) should be created by team brainstorming. Improvement ideas and Best Practices should then be prioritized and executed to transform this process to greatness.
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Figure 12. The Opportunity for Improvement Matrix used to prioritize improvement suggestions
CONCLUSION Risk assessment is the tedious but very necessary task of identifying risks in the following 3 risk discovery categories, which could be overlapping in nature: 1: The Known Known's (Obvious or semi-obvious risks that need to be mitigated) 2: Known Unknowns (Risks that are suspected but not fully investigated or understood yet) 3: Unknown Unknowns (Risks that have not been perceived or realized yet, aka: Black Swans) Too often, risk assessment is left in the hands of "Experts" or a specific group, which may not engage or solicit the opinions of the organization at various levels. The methods described in this paper solicit organizational risk assessments from all levels in the organization. It is important to note here that risk assessments are not intended to blame people but to blame flawed business processes and the possible lack of personal coaching and mentoring programs. Cascade Effect analysis is rarely applied as a formal method of risk assessment within organizations. Cascades are often referred to in a casual conversational sense without acknowledging the fact that they are very strong organized forces that are under-researched, less understood and even less applied
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for risk assessments. One phrase we assign to unexpected and big impact events is a "Black Swan". The author believes that Black Swans are just "Black Holes of Knowledge" that cascade effect logic could help to predict. The risk assessment and mitigation techniques introduced here can help discover and address new areas of risk that have been overlooked in classical risk assessment and mitigation methods. The gamified approach demonstrated is intended to break down defense barriers that normally arise when sensitive organizational topics are investigated, such as leadership practices, taboo talk rules, work culture shortcomings, performance issues and ineffective responses to obvious performance issues. Applications of these gamified techniques have provided rapid insights and organizational innovations to not only avoid undesirable events but to also break the barriers that held organizations back from achieving their stretch goals. The successes have been achieved by helping organizations to look harder and more accurately in the mirror instead of looking out the window to assign blame to competitors, suppliers or others inside the organization. Serious investigations of known disasters by certain congressional committees and the National Transportation Safety Board (NTSB) has shown that more often than not, internal organizational cascade effect risks played a much bigger part in disasters than might have been previously assumed. The techniques shown here offer a disciplined and standard approach to assess and address organizational cascade effect risks. The author's realworld experience in applying these methods to solve “Mission Impossible” problems has encouraged him to continue broader applications of these methods. The future might look back at us in astonishment that we did not understand that Cascade Effects are an important Behavioral Science that can explain the outcomes of almost every aspect of life and business. Those that build on this body of knowledge and start to manage the cascades will be far better poised to avoid pitfalls in the pursuits of personal and business success. A more appropriate name for these powerful cascading complexities could be "Destiny Cascades."
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6. Brandt, Nat (2006) Chicago Death Trap: The Iroquuois Theater Fire of 1903, SIU Press 7. Hooper, Jennifer, (2008) What Really Sank the Titanic, Citadel Press, NY, NY 8. Stanton, Doug, (2001) In Harm's Way, The Sinking of the U.S.S. Indianapolis and the Extraordinary Story of Its Survivors, Henry Holt & Company, NY, NY 9. Fish, Eric, (2008) The Forgotten Legacy of the Banqiao Dam Collapse, The Economic Observer, http://www.eeo.com.cn/ens/2013/0208/240078.shtml 10. Broughton, Edward (2005) The Bhopal disaster and its aftermath: a review, PMC US National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1142333/ 11. Investigation of the Challenger Accident, Committee on Science and Technology, (1986), US Government, http://www.gpo.gov/fdsys/pkg/GPO-CRPT-99hrpt1016/pdf/GPO-CRPT99hrpt1016.pdf 12. NTSB Aircraft Accident Report NTSB/AAR-02/01 (2001) Loss of Control and Impact with Pacific Ocean Alaska Airlines Flight 261 McDonnell Douglas MD-83, N963AS About 2.7 Miles North of Anacapa Island, California. January 31, 2000, Washington DC, USA 13. Whelan, Sara (2013) Petrobras P-36 Accident Rio de Janeiro, Brazil, Memorial University of Newfoundland St. John’s, NL, Canada 14. Columbia Accident Investigation Board, (2003) Washington DC, USA 15. Deep Water, The Gulf Oil Disaster and the Future of Offshore Drilling, (2011)Report to the President, National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling 16. The Financial Crisis Inquiry Report, (2011) Final Report of the National Commission on the Causes of the Financial and Economic Crisis in the United States, Washington DC, USA 17. Juran, Joseph (1998) Juran's Quality handbook, McGraw Hill, NY, NY 18. Patrishkoff, David (2013) Identifying Cascade Effect Risks in Organizations, QHSE Focus Magazine, Quality, Lean and Six Sigma Edition, Issue 15, September, 2013, http://leansixsigmaandbeyond.com/my-lead-article-in-the-september-issue-of-qhse-focusmagazine/ 19. Patrishkoff, David (2014) Creating a High Performance Work Culture, QHSE Focus Magazine, Quality, Lean and Six Sigma Edition, Issue 19, January, 2014, http://leansixsigmaandbeyond.com/my-2nd-lead-article-in-the-qhse-focus-magazine-january2014-issue/ 20. Patrishkoff, David (2013) Identifying Organizational Inefficiencies with Pictorial Process Analysis (PPA) Independent Journal of Management and Production, Vol. 4, No 2 (2013), http://www.ijmp.jor.br/index.php/ijmp/article/view/82
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