Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

The 1986 Challenger disaster killed seven astronauts and consumed more than $5 billion as the shuttle broke apart less than two minutes into flight, sending fragments of the craft hurtling into the ocean and putting the nation’s space program on ice for nearly three years. But what caused it? Was it the O-ring failure or that the NASA operational officials’ ignored the warnings of the engineering experts? Was it the absence of clear goals for launching the shuttle? Or was it a problem in their policies? As COE Executive Director Peg Pennington and Senior Lecturer and Executive-in-Residence Gary Butlertold our MBOE students in their final session this weekend, there were multiple causes to the problem – just as there are with any. 

The 1986 Challenger

The 1986 Challenger explosion, captured in this National Geographic photo, killed seven crew members and launched a massive investigation

In a previous blog, I mentioned the importance of defining what your problem really is, whether it’s an exploded space shuttle or a missing file. In hunting the causes, most of us simply go after that root cause that led to the problem. But there’s never just one cause. Problems occur because of multiple causes that underlie the entire system.

Cause mapping, which you’ve read about here before, is a retrospective tool that helps you find out why something happened. This weekend Gary Butler introduced students to a new one – Failure Mode Effects Analysis, or FMEA – that helps you proactively look for when and how things can go wrong before they go wrong. 

How much time do organizations spend on assessing their processes with an FMEA or other tools? If they install new information systems, do they go beyond the cost-benefit analysis? Do they think about the impact they will have on staff, customers or suppliers?  Many organizations have a very narrow-minded outlook and forget to plan for the catastrophes that could be avoided with detailed analysis.

Discuss: Have an incident to share that led to extensive root-cause analysis? Any FMEA stories of your own?



1 Comment so far

  1.    Matthew Burns on February 6, 2012 4:10 pm

    Thanks for the insight. A great point that the tools are only tools until they become an active change agent in the culture.

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