Question 3 Do you think that Tyko can avoid the Six Sigma initiative suffering the same fate as the TQM initiative?
2. Should the Pareto diagram be used to reflect improvement priorities? In other words, was the group correct to put priority on avoiding absence through photocopying, and
The total time spent away from the desk is only one (but an important) factor in determining priorities for improvement. In terms of the importance–performance approach described in Chapter 18 of the main book, it is the ‘performance’ side of the equation. What must be introduced is the ‘importance’ perspective. So, telefax service takes staff away from the desk, but how much benefit does it give the customers? If it is a particularly important service in most of the customers’ eyes then it may be worth looking at some other reason for absence.
Furthermore, perhaps we need to include the issue of how easy it is to overcome the reason for absence. For example, providing extra stationery for guests, although it does not take the staff away for too long, may be solved very easily merely by providing access to stationery on the desk itself.
C H A P T E R 1 9
Failure prevention and recovery Teaching guide
Introduction
Most of the topics covered in this chapter are relatively easy to teach. Failure especially is a topic, that most students respond to. Usually the popular press is full of failures (real and also the ones made up in order to sell newspapers). Any of these can be used to prompt a discussion on why the failures occurred, how they could be recovered from and what the operation should learn from the failure. Maintenance is a slightly less dramatic subject but nonetheless can usually be put in such a way that it engages students’ interest. Those students with cars will understand the costs and benefits of regular maintenance, whereas those without cars will appreciate perhaps a more domestic analogy such as cleaning the apartment (not always, some students have never maintained their apartments or themselves and have yet to understand the consequences!).
Key teaching objectives
• To demonstrate that most failures are operation-related failures of some kind
• To identify different types of failure and different levels of seriousness of the consequence of failure
• To establish the idea of maintenance and especially to distinguish between the more reactive run to breakdown maintenance, the proactive preventive maintenance and the contingency approach of reliability centred maintenance
• To demonstrate the importance of failure recovery from both dramatic failures and more routine failures
Exercises/discussion points
• Exercise – Utilize the fact that newspapers continually refer to failures. Just go through any of the broadsheet papers and cut out examples of failure. Give a separate one to each group of students and ask them to analyze their failures in terms of why it happened, what the consequences were and what could be done to prevent it from occurring again.
• Teaching tip – If your institution has an off-air recording licence, it is easy to find plenty of examples of failure on television. Some of these might be catastrophic failures such as major accidents, others may be alleged service failures such as those dealt with on consumer programmes. Either way, showing a video clip as a prelude to a discussion can usually prompt some interesting learning opportunities.
Nigel Slack, Stuart Chambers & Robert Johnston, Operations Management, fifth edition, Instructor’s Manual
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© Nigel Slack, Stuart Chambers & Robert Johnston 2007
• Exercise – Residential courses try combining business with pleasure by showing a movie in the evening that demonstrates failure. The next day this can be used as a case study. An ideal example is the Apollo 13 movie staring Tom Hanks. It is a great example of failure and recovery from failure. All manner of lessons come out of this including the importance of improvization, the use of fail-safe devices, the concept of balancing risks, the role of creativity in failure problem solving and so on.
• Exercise – Two examples in the chapter work well as a class discussion or exercise. They represent the two types of failure. The Carlsberg product recall is a particularly serious quality problem. It is serious, but there are well established mechanisms in most businesses that are designed to deal with this type of problem. The example of the ‘rogue trader’ Nick Leeson is different. It is an example of deliberate or malicious ‘failure’. The lack of operations control at Barings Bank allowed his fraudulent activity to eventually sink the company. Although many financial service businesses have, for many years, had processes in place that should detect fraud of this type, for other sectors it is a new threat. Not just individuals attempting fraud, but hackers, single-issue extremists, terrorists and so on, all now fall into the ‘potential hazard' category. An exercise can be built on the identification of such risks and what is required to prevent, mitigate and recover from them.
• Exercise – Ask each group to identify a service one of them has recently experienced. Get them to chart the service and identify potential failure points. Also, ask them to explore how fail-safe or poke-yokes could be used to prevent failures in groups.
• Exercise – Set each group a separate poke-yoke exercise. For example, how to prevent accidentally phoning the emergency services if a mobile (cell) phone is left unlocked. Other examples of poke-yokes can be found at the web address,
http://csob.berry.edu/faculty/jgrout/pokayoke.shtml and the poke-yoke page of John Grout.
Case study teaching notes The Chernobyl failure
The case exercise consists of an introduction to the Chernobyl nuclear reactor and the events leading up to the accident. More specifically, it examines all the significant events that took place between 1.00 pm on the 25th April 1986 and 1.24 am on the 26th April 1986 when the explosion took place. Actions, and the lack of action, which contributed to the final disaster, are classified as either violations or failures. Finally, the case makes some general points about why the disaster happened.
This case exercise can be used at any point in a general operations management course or even in more general management courses. It is usually well received primarily because most people have heard of the accident and are interested in the details of why it occurred. Although a particularly dramatic failure, it is possible to draw out some more general issues that apply to less disastrous failures. More specifically, debate can be encouraged on the relative contributions of
• specified rules and procedures designed to ensure that failure does not occur;
• the skills necessary both to prevent failure and recover from it; and
• the intrinsic knowledge and learning that are required to minimize the chances of serious failure.
Some notes on the Chernobyl failure case
For those who are not familiar with the safety issues at stake, it is best to start the case by summarizing the nuclear 'threat'. The essential difference between a nuclear reactor and an atomic bomb is one of containment.
• In an atomic bomb the nuclear chain reaction, whereby each atom of uranium 235 yields two fresh neutrons, continues unabated.
• In a nuclear reactor the nuclear chain reaction is moderated by the insertion of graphite rods that soak up excess neutrons and allow the reaction to continue at a controlled pace. This liberates energy in the form of heat, which is transferred by heat exchangers and used to drive steam turbines as in fossil-fuelled power stations.
The operators at Chernobyl had so interfered with the control mechanisms of the reactor that the chain reaction 'ran away' and an atomic explosion ensued.
The case also distinguishes between 'violations' (V) and 'errors' (E) that occurred in the vital hours before the explosion. This is a useful distinction that can be used when examining any complex failure. A violation occurs when a rule or procedure exists but is ignored or not executed, as it should be. An error is when the mental or physical judgement of someone is not as it should be or expected to be. Serious failures in complex operations are usually the result of both violations and errors. An analogy for the distinction between these two elements of failure is that of a 'high wire' circus performer. Errors are mistakes in judgement which make it more likely that the performer will fall. Violations are failures to observe the necessary precautions such as wearing a harness or using a safety net.