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by Matthew Barsalou, guest blogger
For want of a nail the shoe was lost,
For want of a shoe the horse was lost,
For want of a horse the rider was lost
For want of a rider the battle was lost
For want of a battle the kingdom was lost
And all for the want of a horseshoe nail. (Lowe, 1980, 50)
According to the old nursery rhyme, “For Want of a Nail,” an entire kingdom was lost because of the lack of one nail for a horseshoe. The same could be said for the Galactic Empire in Star Wars. The Empire would not have fallen if the technicians who created the first Death Star had done a proper Failure Mode and Effects Analysis (FMEA).
A group of rebels in Star Wars, Episode IV: A New Hope stole the plans to the Death Star and found a critical weakness that lead to the destruction of the entire station. A simple thermal exhaust port was connected to a reactor in a way which permitted an explosion in the exhaust port to start a chain reaction that blew up the entire station. This weakness was known, but considered insignificant because the weakness could only be exploited by small space fighters and the exhaust port was protected by turbolasers and TIE fighters. It was thought that nothing could penetrate the defenses; however, a group of Rebel X-Wing fighters proved that this weakness could be exploited. One proton torpedo fired into the thermal exhaust port started a chain reaction that led to the station reactors and destroyed the entire battle station (Lucas, 1976).
Why the Death Star Needed an FMEA
The Death Star was designed by the engineer Bevil Lemelisk under the command of Grand Moff Wilhuff Tarkin; whose doctrine called for a heavily armed mobile battle station carrying more than 1,000,000 imperial personnel as well as over 7,000 TIE fighters and 11,000 land vehicles (Smith, 1991). It was constructed in orbit around the penal planet Despayre in the Horuz system of the Outer Rim Territories and was intended to be a key element of the Tarkin Doctrine for controlling the Empire. The current estimate for the cost of building of a Death Star is $850,000,000,000,000,000 (Rayfield, 2013).
Such an expensive, resource-consuming project should never be attempted without a design FMEA. The loss of the Death Star could have been prevented with just one properly filled-out FMEA during the design phase:
The Galactic Empire’s engineers frequently built redundancy into the systems on the Empire’s capital ships and space stations; unfortunately, the Death Star’s systems were all connected to the main reactor to ensure that power would always be available for each individual system. This interconnectedness resulted in thermal exhaust ports that were directly connected to the main reactor.
The designers knew that an explosion in a thermal exhaust port could reach the main reactor and destroy the entire station, but they were overconfident and believed that limited prevention measures–such as turbolaser towers, shielding that could not prevent the penetration of small space fighters, and wings of TIE fighters–could protect the thermal exhaust ports (Smith, 1991). Such thinking is little different than discovering a design flaw that could lead to injury or death, but deciding to depend upon inspection to prevent anything bad from happening. Bevil Lemelisk could not have ignored this design flaw if he had created an FMEA.
Assigning Risk Priority Numbers to an FMEA
An FMEA can be done with a pencil and paper, although Minitab’s Companion software for executing and reporting on process improvement has a built-in FMEA form that automates calculations, and shares data with process maps and other forms you’ll probably need for your project.
An FMEA uses a Risk Priority Number (RPN) to determine when corrective actions must be taken. RPN numbers range from 1 to 1,000 and lower numbers are better. The RPN is determined by multiplying severity (S) by occurrence (O) and detection D.
RPN = S x O x D
Severity, occurrence and detection are each evaluated and assigned a number between 1 and 10, with lower numbers being better.
Failure Mode and Effects Analysis Example: Death Star Thermal Exhaust Ports
In the case of the Death Star’s thermal exhaust ports, the failure mode would be an explosion in the exhaust port and the resulting effect would be a chain reaction that reaches the reactors. The severity would be rated as 10 because an explosion of the reactors would lead to the loss of the station as well as the loss of all the personnel on board. A 10 for severity is sufficient reason to look into a redesign so that a failure, no matter how improbable, does not result in injury or loss of life.
The potential cause of failure on the Death Star would be attack or sabotage; the designers did not consider this likely to happen, so occurrence is a 3. The main control measure was shielding that would only be effective against attack by large ships. This was rated as a 4 because the Empire believed these measures to be effective.
The resulting RPN would be S x O x D = 10 x 3 x 4 = 120. An RPN of 120 should be sufficient reason to take actions, but even a lower RPN requires a corrective action due to the high rating for severity. The Death Star’s RPN may even be too low due to the Empire’s overconfidence in the current controls. Corrective actions are definitely needed.
Corrective actions are easier and cheaper to implement early in the design phase; particularly if the problem is detected before assembly is started. The original Death Star plans could have been modified with little effort before construction started. The shielding could have been improved to prevent any penetration and more importantly, the interlinks between the systems could have been removed so that a failure of one system, such a an explosion in the thermal exhaust port, does not destroy the entire Death Star. The RPN needs to be reevaluated after corrective actions are implemented and verified; the new Death Star RPN would be 5 x 3 x 2 = 30.
Of course, doing the FMEA would have had more important impacts than just achieving a low number on a piece of paper. Had this step been taken, the Empire could have continued to implement the Tarkin Doctrine, and the Universe would be a much different place today.
Do You Need to Do an FMEA?
A simple truth is demonstrated by the missing nail and the kingdom, as well as the lack of an FMEA and the Death Star: when designing a new product, whether it is an oil rig, a kitchen appliance, or a Death Star, you’ll avoid many future problems by performing an FMEA early in the design phase.
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Lucas, George. Star Wars, Episode IV: A New Hope. New York: Del Rey, 1976. http://www.amazon.com/Star-Wars-Episode-IV-Hope/dp/0345341465/ref=sr_1_2?ie=UTF8&qid=1358180992&sr=8-2&keywords=Star+Wars%2C+Episode+IV%3A+A+New+Hope
Opie, Iona and Opie, Peter. ed. Oxford Dictionary of Nursery Rhymes. Oxford, 1951, 324. Quoted in Lowe, E.J. “For Want of a Nail.” Analysis 40 (January 1980), 50-52. http://www.jstor.org/stable/3327327
Rayfield, Jillian. “White House Rejects ‘Death Star’ Petition.” Salon, January 13, 2013. Accessed 1anuary 14, 2013 from http://www.salon.com/2013/01/13/white_house_rejects_death_star_petition/
Smith, Bill. ed. Star Wars: Death Star Technical Companion. Honesdale, PA: West End Games, 1991. http://www.amazon.com/Star-Wars-Death-Technical-Companion/dp/0874311209/ref=sr_1_1?s=books&ie=UTF8&qid=1358181033&sr=1-1&keywords=Star+Wars%3A+Death+Star+Technical+Companion.
Research out of the Juran Institute, which specializes in training, certification, and consulting on quality management globally, reveals that only 30 percent of improvement initiatives succeed.
And why do these initiatives fail so frequently? This research concludes that a lack of management support is the No. 1 reason quality improvement initiatives fail. But this is certainly not a problem isolated to just continuous improvement, as other types of strategic initiatives across the organization face similar challenges. Surveys of C-level executives by the Economist Intelligence Unit concur—sharing that lack of leadership buy-in and support can stop the success of many strategic initiatives.
Why Else Do Quality Initiatives Fail?
Evidence shows that company leaders just don’t have good access to the kind of information they need about their quality improvement initiatives.
Even for organizations that are working hard to assess the impact of quality, communicating impacts effectively to C-level executives is a huge challenge. The 2013 ASQ Global State of Quality report revealed that the higher people rise in an organization’s leadership, the less often they receive reports about quality metrics. Only 2% of senior executives get daily quality reports, compared to 33% of front-line staff members.
So why do so many leaders get so few reports about their quality programs? Scattered, and inaccessible project data makes it difficult to piece together the full picture of quality initiatives and their impact in a company. Because an array of applications are often used to create charts, process maps, value stream maps, and other documents, it can be very time consuming to keep track of multiple versions of a document and keep the official project records current and accessible to all key stakeholders.
On top of the difficulty of piecing together data from multiple applications, inconsistent metrics across projects can make it impossible to evaluate results in an equivalent manner. And even when organizations try quality tracking methods, such as homegrown project databases or even full-featured PPM systems, these systems become a burden to maintain or end up not effectively supporting the needs of continuous quality improvement methods like Lean and Six Sigma.
Overcoming Limited Visibility
Are there ways to overcome the limited visibility stakeholders have into their company’s quality initiatives? For successful strategic initiatives, it has been identified that planning and good communication are drivers for success. These drivers also positively impact successful continuous improvement projects.
1. Ensure efficiency. Utilize a complete platform for managing your continuous improvement program to reduce inefficiencies. Using one platform to track milestones, KPIs, and documents addresses redundancies of gathering key metrics from various sources needed to report on projects, saving teams hours of valuable time. Looking past the current project at hand, one platform can also make it easy to quickly replicate processes such as roadmaps and templates that were useful in previous quality initiatives.
2. Aim for consistency. Centralize your storage by making all relevant documents accessible to all team members and stakeholders. As teams grow and projects become more complex, the benefit of having all team members aligned can prevent confusion and reduce the number of back and forth emails that tend to happen.
3. Real-time visibility for all. Visibility into the progress of your quality project facilitates the day–to–day management of tracking results and addressing any challenges. Utilize dashboards to provide a quick “snapshot” of your project’s progress. Cloud-based capabilities takes your dashboard to the next level—instantly communicating real-time results.
Drive for Excellence
For quality professionals and leaders, the challenge is to make sure that reporting on results becomes a critical step in each project and that all projects are using consistent metrics that are easily accessible. Teams that can do this will find reporting on their results a manageable task—facilitating the needed visibility to all key stakeholders that’s necessary for leadership buy-in.
Welcome to the Linkedin Monthly Webinar Series!
January Webinar: What is Lean Six Sigma?
This webinar answers the question of what lean six sigma is and how non-manufacturing companies use lean six sigma to improve their operational and financial performance. It also presents a lean six sigma case study for a large service organization and how it used the method to save more than $1.4 million dollars.
Who: Gerald M. Taylor LSSMBB and Managing Consultant of The Performance Management Group LLC
When: 08:30 AM USPST Friday, January 18, 2013
Where: Virtual Session Online
This series is a free series sponsored by two linkedin groups:
1. Linkedin Performance Management and Metrics Professionals
2. Linkedin Lean Six Sigma for Service Companies
Registration: To register for this webinar, please click here!
Six Sigma at General Electric
General Electric enjoys the distinction of having the highest market capitalization of any public company in the world – $321 billion. Former CEO, Jack Welch attributes much of this success to the company’s Six Sigma program. Since 1995, GE has reaped more than $14 billion in cost reductions alone from their investment in Six Sigma. Here are a couple of GE success stories:
- By changing test & repair processes, a Six Sigma Team improved on-time delivery, increased productivity and saved $4 million dollars for GE Appliances.
- At a GE Plastics plant, a Six Sigma Team reduced lead time for matching colors of resins by 85% a distinct and real competitive advantage in the fast-paced global market for plastics.
What exactly is Six Sigma?
In laymen’s terms, Six Sigma performance is achieving perfection in the manufacturing of products and delivery of services. The mathematical symbol σ (sigma) is a Greek letter that represents variation. A sigma value, or standard deviation, indicates how well a process is performing. A process is performing at a 6σ level if it achieves 3.4 errors out of every million opportunities (3.4 EPMO). This level of performance, in manufacturing and in service outcomes, implies the process is 99.9997 effective or “process perfect”. What does that mean to every day working professionals? It means:
- 10,800,000 mishandled healthcare claims would not be mishandled.
- 18,900 US Savings bonds lost monthly would not be lost.
- 54,000 checks lost nightly by a single large bank would not be lost.
- 4,050 incorrect telephone bills sent out monthly by a modest sized telecommunications company would not be sent out.
- 540,000 erroneous call details recorded daily by a regional telecom company would not be recorded.
- 270,000,000 erroneous credit card transactions recorded each year would not be recorded.
With numbers like these, it’s easy to see that the modern world of business demands extremely high levels of error free performance. Six Sigma rose in response to this realization.
Products and services with deficiencies create customer dissatisfaction. They are also costly to a company because mistakes must be identified and corrected, and the customer must be appeased. What is more, the original work is wasted. In the world of Six Sigma these costs are referred to as the cost of poor quality (COPQ). For most companies, costs associated with wasted effort and corrected work is between 20 and 40 percent of total operating expenses. These costs can be found in all operational and administrative areas. All these costs can be trimmed when quality is improved by reducing deficiencies. Here are just a few examples:
- By cutting defects in work out processes by 96%, GE Capital was able to offer borrowers quicker solutions while reducing claims payments by $8 million.
- Prudential Financial estimates that Bank of America will save nearly $1.2 billion, by reducing deficiencies, in its first year of deploying Six Sigma.
- In its first year of limited deployment of Six Sigma, Phelps Dodge saved over $80 million.
These are many reasons why investing in Six Sigma programs is increasingly considered a mission-critical business strategy, even among mid-sized and smaller firms.
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