We are pleased to introduce you to consultant and trainer Sandi Claudell, today’s featured guest blogger. Sandi is CEO of MindSpring Coaching, and has been a valued Palisade Six Sigma Partner for quite some time. She is a Six Sigma Master Black Belt (Motorola), and is a Lean Master (Toyota Motors – Japan) among other notable achievements.
Part 1: The Platform Disaster
Much has been said about the disastrous BP oil spill in New Orleans. If we use the theory of probability and reliability then have too many different companies responsible for a very complex construction and operation added to the chance of failure.
There is probably a cultural issue at work where each entity wanted to give the other what they wanted to hear rather than the truth. (For historic and recent examples: NASA Challenger and recent Toyota Prius problems). When we lose sight of quality and reliability of parts, construction, maintenance, testing under ALL conditions rather than the obvious few, etc. then we run high risks of failure. When you build 100+ wells and avoided disasters . . . perhaps people fool themselves into thinking there never WILL be a disaster. They don’t look at a model that demonstrates the longer you go without such an event (given the input factors of how each element can and will fail) the closer you come to the event we all want to avoid.
They may or may not have used an integrated Systems Design . . . not simply an engineering system but the system on how individuals work together, communicate with each other, act as a conforming unit or a more self-directed autonomous unit looking for and generating solutions outside the box. A team that is innovative and willing to look at all the possibilities and create a breakthrough design that was / is more mistake proof.
If they had used DFSS (Design for Six Sigma) then their designs would be more robust taking into consideration all the necessary safety precautions for human life as well as immediate response to a potential failure. As part of DFSS we use a statistical tool call Design of Experiments (Strategy of Formulations, Central Composites, etc.) where we can try very complex interactions (factors) with minimal effort / cost and maximum statistical accuracy. DoE creates prediction equations that allow us to model and ask questions of what would happen under different conditions. More importantly we can look at many different quality metrics (responses, outcomes, etc.) with the same experimental trial. If we replicate the test then we can even forecast what elements cause variation (very hard to detect in highly complex systems without the use of statistics).
If they had used an FMEA (Failure Mode Effect Analysis . . . a tool used in Six Sigma) then they could have anticipated failures and put error proofing devices in place to detect and/or respond to potential faults BEFORE it is irreversible. If we add a Monte Carlo simulation to potential working conditions then the model forecasts probability plots and identifies key factors that will be critical to success or failure.
Perhaps they did indeed use a Monte Carlo using Crystal Ball. It is a good product but if they used Palisade’s @RISK and added some of the other tools provided by Palisade such as RISK Optimizer, Neural Tools, etc. then they could have analyzed the system in other dimensions besides a simple Monte Carlo, thus uncovering weaknesses BEFORE designing and/or building the platform and well.
Part 2: Capping the well head
In Lean there is a whole discipline called “Error Proofing Devices”. As part of the design effort we need to create first and foremost safety and other devices that prevent the error from occurring in the first place. If that line of defense fails then there should be devices built into the process designed to cap the well if your error proofing fails. If that line of defense fails then there should be a disaster response plan created and practiced and tested to ensure that the spill is repaired immediately.
Part 3: Treating the resulting spill
Again, Design of Experiments could test different materials, chemicals and methods to find the right combination to contain or otherwise manage the resulting oil spill. Trying one chemical only may be the age old definition of madness . . . trying the same thing over and over again expecting different results. Again, a robust design of experiments could aid in the process of finding a solution that is most effective and with multiple tests on the same samples ensure that is it the most safe for the environment and the population most directly in the path of the oil spill. These tests are ideally run years before such a spill however, doing something now is better than simply standing by and watching it happen.
Last but not least:
Management (Executives down to line managers) should have coaches. Coaches who can speak to the culture, the systems design, the tools and methods used in Lean Six Sigma and who can verify data analysis and help with the accurate interpretation of the data. These coaches should be independent . . . not a full time employee of the corporation as they are more likely to speak the truth and highlight risks as well as opportunities.
Now BP and all the other entities may have done some of what I mentioned above. But I would assume they must have left out one or more of the listed items or we wouldn’t be looking at the oil traveling into the wetlands around New Orleans right now. Hindsight is always brilliant but we can learn from our mistakes. We can create better cultures, systems, error proofing devices, Experimental Designs etc.
Sandi Claudell is CEO of MindSpring Coaching. She is a Master Black Belt in Six Sigma, a Lean Master and has worked as a consultant for many companies to initiate worldwide improvements. For more information or to contact Sandi please visit http://www.mindspringcoaching.com/.