Business Transformation

Six Sigma Integration, Inc.

Serving clients since 1995

Six Sigma Integration, Inc.

Lean Six Sigma Training and Consulting Solutions

Reducing Operational Risk

A two-day workshop to reduce process complexity for safer operations...

Complexity is seen in the proliferation of parts and work tasks, high percentages of non-value adding operations, long lead-times, high demand variation, low productivity, low asset utilization, high unit costs as well as near misses and accidents. The workshop goals are to help people become aware of risks (recurrence risks) to identify opportunities to lower risk processes.  Important topics are the social psychological effects upon safety including design practices, the creation of error conditions, culture influences and ethics failures and strategies to reduce process and design risks. The workshop closes with an important risk mitigation method e.g. scenario planning.

Key outcomes from the workshop include brainstorming the relevant causes for higher complexity, evaluating your organization’s risk maturity, identifying recurrence risk gaps and learning where to focus improvement efforts.

The workshop is based on our book titled, Unexpected Consequences. This book was researched over several years. It discusses more than forty examples of recent catastrophic failures in construction and commercial aviation as well as systems in healthcare, information technology, health care, regulatory agencies, security systems and political systems. They include project management of the design process, translation of customer requirements and the impact of social psychological and organizational factors on the design of products and services. Social psychological factors are relevant for understanding individual and group perceptions in the context of product and service failures. The discussions are also interwoven with forty case studies of recent catastrophic events. It expands failure analysis to include human error as well as technology failures to explain catastrophic failures. It also discusses the effects of service and logistical failures on the loss of human life and property damage. Its conclusion is that when failures occur, they are often due to human error rather than technology.


    • Presents the technical, cognitive, and organizational factors associated with the design and failure of products and services
    • Introduces new topics related to social psychology, as well as organizational culture and ethics, to explain product and service failures
    • Shows that when failures occur, they are often due to human error rather than unknown technology
    • Provides helpful advice for preventing failures of products and services
    • Over 40 case studies
    • Easy to grasp figures, tables, and templates to help the readers understand the concepts
    • A glossary of relevant terms
    • A bibliography

This book describes some of the underlying attitudes and behavior of individuals and groups from a social psychological perspective. This discussion has applications within a new product development team as well as with its customers, stakeholders and the people using a product or service. Organizational structure and culture also directly impact the design of products and services. First they create project management procedures and policies. In this context, some organizations manage their design processes well whereas others do not. Important factors affecting how well organizations manage design activities include their organizational structure, strategy, culture, policies, procedures, communications and their ethical implementation. It also analyzes twenty-five recent catastrophic examples of product and service failures.

Each incident is analyzed using the tools and methods to identify the causes of failure. The case studies include well known incidents which have occurred in construction, aviation, information technology, health care, security and others known to almost everyone. Examples of construction failures include the recent San Francisco Bay Bridge repairs, the catastrophic collapse of the I-35W Mississippi River Bridge in Minnesota, Hurricane Katrina in New Orleans and the Chernobyl disaster. Aviation failures include Air France Flight 447 and Continental Connection Flight 3407 near Buffalo, New York. Information technology failures include the Mariner I Space Probe explosion, the National Cancer Institute; Panama City miscalculated radiation dosages and similar incidents. Health care failures include SARS in Asia and production problems associated with the H1N1 Swine Flu Virus. Regulatory failures include Security and Exchange (SEC) regulatory issues, Fannie and Freddie issues and food contamination. Security failures include the constant assault of software viruses on information technology systems and the difficulty of identifying terrorists. Political failures include energy policies and management, healthcare coverage and other examples. The human and property costs of each incident are identified and analyzed to demonstrate that failure prevention is usually both feasible and economic.


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