lessons from space shuttle disasters for avoiding it ... · lessons from space shuttle disasters...
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LessonsFromSpaceShuttleDisastersFor
AvoidingITProjectDisasters
JohnHelm
Executive Timeslice, LLCwww.ExecutiveTimeslice.com
Jhelm Associates, LLCwww.JHelmAssociates.com
http://jhelmassociates.com/resources.html?item=spaceProjCopyright(c)2013byJohnHelm.ThisworkismadeavailableunderthetermsoftheCreativeCommonsAttribution-ShareAlike 3.0Unsupportedlicense.
ApreviousversionofthistalkwaspresentedatAgile2013,Nashville,TN,5-9August2013
Motivation
Atleast45yearsofITProjectHell
• Significantimprovementsstubbornlyelusive– SoftwareEngineering:AReportonaconferencesponsoredbytheNATOScienceCommittee.Garmisch,Germany.07-11Oct1968.PeterNaur andBrianRandell,Eds.
• RiskAdjustedPerformanceshows– Junkbondsoftenbetterinvestments– See:“JunkBondsVersusITProjects”*
1*http://jhelmassociates.com/resources.html?item=junkProj
FourUserStories(3StoriesAndOneSmallEpic,really:^)
• AsanAgileProfessional,Iwantto1. ApplyfindingsfromDecisionSciencetomyworksoIcanbe
moreeffectiveo Note:PresentHolisticCriticalDecisionMakingFramework
2. Avoidadeathof10,000smellsbecausedyingthatwaysuckso Note:DoChallengercasestudyo Note:Setstageforthinkingtools
3. Learnaboutnewtoolstomakebetterexecutiondecisionsandhavebetterfact-basedconversationswithmystakeholderso Note:Introduceunpredictabilitymeasurementandthinkingtools
4. SeeAgilebedeployedmoresuccessfullyo Note:DoColumbiacasestudy
2
WhyThinkAboutThinking?
3
WhyThinkAboutThinking?
4
Themostdangerous
decisiontrapsaretheonesweareunawareof!
ArtandScienceofDecisionMakingIndividualDecisionMaking
5
Cognitiverulesofthumbusedsubconsciously
Subconscioustendencytothinkinacertainway
Mentalprocessesthatmake
thingsworse
ArtandScienceofDecisionMakingGroupDecisionMaking
6
ArtandScienceofDecisionMakingOrganizationalModulation
7
ArtandScienceofDecisionMakingHeuristics
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ArtandScienceofDecisionMakingCognitiveBiases
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ArtandScienceofDecisionMakingCognitiveBiases:ConfirmationBias
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Photo:BillCunningham,CapricornControl
TheTRUTHIsOutThere…
NoomiRapace,SwedishActress
AllSwedesAreBlond…
ArtandScienceofDecisionMakingCognitiveBiases:ConfirmationBias
• ConfirmationBiasisbuiltintous
• Quantitativestudiesarenoprotection
• Example:inferenceofacausalrelationshipfromcorrelateddata
Read:WhyMostPublishedResearchFindingsAreFalse
11
ByJohnIoannidishttp://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124
ArtandScienceofDecisionMakingCognitiveBiases:FramingandProspectTheory
12
Yoursurgeryhasan75%chancetosaveyourlife
HalfEmpty
HalfFull
Yoursurgeryhasa25%chanceitwillkillyou
FrameintermsofLOSS• Easiertomotivate• Choicesconstrainedtofamiliar
FrameintermsofOPPORTUNITY• Hardertomotivate• Moreflexibility&innovation
ArtandScienceofDecisionMakingHyperbolicDiscounting
13
• Preferenceforsmallpleasurestodaythataredetrimentaltoourfuture
– Skipfullcoveragetestingtoday,2dayoutagenextyear?
– $50todayv.$100tomorrow?– $50todayv.$1006months?– $50todayv.$1001year?
• Ourbrainsarewiredtorespondtofutureuncertaintybydiscountingthefuture– Coke&friestoday,bypasssurgeryin10yrs?– 500,000bypasssurgeries/year
– Only10%undotheirunhealthylifestyle
• Codingwhilebehindscheduleforrelease…– Cutandpastetoday,spaghetticodenextyear?
ArtandScienceofDecisionMakingHyperbolicDiscounting
14
• Discounting is the assessment of present value of a future gain– At 4% inflation, $100 in 10 years should be worth $67.55 today
• The 4% is called the discount rate; 0.6755 is the discount factor– According to the rational approach
Each period is discounted the same– Theresultisanexponentialdiscount
function
• ButpeopleDON’Tdiscounteachperiodthesame!– Thenearfutureisvaluedmuchmore
relativeto“far” future– Theresultingdiscountfunctionis
calledHYPERBOLIC(morecorrectly,it’squasi-hyperbolic)
ArtandScienceofDecisionMakingHyperbolicDiscounting
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• Discount function graphs are unhelpfully abstract• Whatmattersforpeopleisthe
anticipationofsatisfaction!• Moreinterestingisthetrade-off
betweenasmallrewardsoonvs.alargerrewardfartherinthefuture
Delaydependentpreferencereversal!
MatthewG.Miller,RayJ.Dawson,KieranB.Miller,MalcolmBradley(2008).NewInsightsintoITProjectFailure&HowtoAvoidIt.Presentedat22ndIPMAWorldCongress- Rome(Italy)November9-11,2008,inStream6.AsofMay2013,selfpublishedathttp://www.mgmiller.co.uk/files/paper.pdf
The measured success rate (10% allowances) compared to how the project managers perceived their projects
16
ArtandScienceofDecisionMakingOverconfidence/AttributionBias
41.84%
79.32%
ArtandScienceofDecisionMakingThinkingTraps
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ArtandScienceofDecisionMakingFunctionalFixedness
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The Candle ProblemKarl Dunker, 1945Sam Glucksberg, 1962
The task: – Fix a lit candle to the
wall such that no wax hits the table using only
– Book of matches– A box of thumbtacks– A candle (of course)
How long to do?– Box empty– Tacks in box– No Pressure– Under Pressure
ArtandScienceofDecisionMakingFunctionalFixedness
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• Financialincentives– Improvedperformanceofsimpledoingtask– HURT performanceofcreativethinkingtask
– Moreincentive➜ worsecreativethinkingresults
MeanTimeToSolvePuzzle
TacksOutofBox(Easy) TacksInsideBox(Hard)
Low PerformancePressure 4.99min 7.41min
HighPerformance Pressure 3.67min 11.08 min
ArtandScienceofDecisionMakingCognitiveDissonance
• Cognitivedissonance:– Unpleasantemotionsarisingfromsimultaneousmutuallyexclusivebeliefs
– Rationalizationsdevelopedtodefendbeliefwewishtohold• Aronsonmodel:RoleofEgoistoprotectidentity,whateverittakes
• Canmotivatemanyirrationaldecisionsandbehaviors– Denial– IllogicalRationalization(specialpleading)– EscalationofCommitment
20
ArtandScienceofDecisionMakingCognitiveDissonance
21
GreatFloodScheduledDec21,1954
ArtandScienceofDecisionMakingCognitiveDissonance
22
Believers,giveitallaway!YouwillbesavedbyUFO
GreatFloodScheduledDec21,1954
ArtandScienceofDecisionMakingCognitiveDissonance
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Believers:giveitallaway!YouwillbesavedbyaUFO
GreatFloodScheduledDec21,1954
4:45am“PressRelease”
“Thelittlegroup,sittingallnightlong,hadspreadsomuchlightthatGodhadsavedtheworldfromdestruction.”
Theinconsideratebuggersfailedtoshowup!!!
4:00amCataclysmDay
ArtandScienceofDecisionMakingGroupDecisionMaking
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ArtandScienceofDecisionMakingGroupDecisionMaking
• OftenmanyheadsAREmuchbetterthanone– Groupspoolandtapdiversetalents– Surfaceandcorrectimperfectindividualdecisions
• “WhoWantsToBeaMillionaire?” audiencecorrect91%
• BUT,often“ProcessLosses”trashthemagic
25
DesiredCondition ProcessLoss
Diversityofskills andviews Everybodylikemindedor samebackground
Decentralization/Delegation Centrally directeddecisionmaking
Aggregation Can’tintegrateindividualcontributions
Safety/Independence Mightgetfiredforideas orspeakingup
ArtandScienceofDecisionMakingGroupDecisionMaking
26
ArtandScienceofDecisionMakingOrganizationalModulation
• Twodimensionsoforganizationexamination– StructuralPerspective(e.g.NormalAccidentTheory)– BehavioralPerspective(Many)
• DecisionmakingissuescanarisefromBOTH– Structuralfeatures
• Clumsyorganizationalrelationships• Toomanytimezones….
– Behavioraltendencies• Corporateidentity• Culture• Values
27
GroupdecisionsDONOT occurinavacuum
ArtandScienceofDecisionMakingOrganizationalModulation
• Structuralpropertiesoforganizationsinclude– ComponentCoupling(LooseorTight)– InteractiveComplexity(LinearorNon-linear)
• Organizationalcontextshapesbehavior– Identity:whoweare
• Constrainsorbiasessolutionsets
– ValuesandCulture:unspoken“rules”everyonemustknow• Constrainsanddirectsbehavior
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ArtandScienceofDecisionMakingOrganizationalModulation
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ArtandScienceofDecisionMakingDecisionsandProjects
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ProjectManagementApproachResourceChoicesCommunicationProtocolsCompliance/Governance
ToolChoicesTechnologySelectionsArchitectureDeliveryPracticesCut&PasteorRefactor?
FourUserStories
• AsanAgileProfessional,Iwantto
2. Avoidadeathof10,000smellsbecausedyingthatwaysucks3. Learnnewtoolstomakebetterexecutiondecisionsandhave
betterfact-basedconversationswithmystakeholders4. SeeAgilebedeployedmoresuccessfully
31
DecisionsAndTheChallengerDisaster27YearsAgo
32
DecisionsAndTheChallengerDisasterThe"L-1Meeting"DecisionToLaunch
33
“Ifthedecisionmakershadknownallofthefacts,itishighlyunlikelythattheywouldhavedecidedtolaunch51-LonJan28,1986.”(Pg.82,RogersCommissionReport)
Strongevidencesuggestsmattersnotthissimple
TheRogersCommission:Communicationfailuresenabledflawedgroupdecision:
DecisionsAndTheChallengerDisasterProcessLossesintheL-1Meeting?
GroupthinkUnlikely
34
DesiredCondition ProcessLoss? Why?
Diversity ofviews No Variousinternal andexternalexperts
Decentralization No NASA staffandmany independentcontractors
Aggregation No Vigorousandopendebateofdifferingviews
Safety/Independence No Managersdidnot“pullrank”Decisionwas“rule-based”
DecisionsAndTheChallengerDisasterDidStress/FunctionalFixednessplayarole?
35
Discussionfocusedontwokeylaunches,circledinred
DecisionsAndTheChallengerDisasterDidStress/FunctionalFixednessplayarole?
36
• Dataofproblemsonly• Discussionfocusedon
– SRM-15– SRM-22
DecisionsAndTheChallengerDisasterDidStress/FunctionalFixednessplayarole?
• Dataall24Launches– Damagelaunchesinred
37
DecisionsAndTheChallengerDisasterNASA:StructuralConsiderations
• StructuralObservations– Complexmatrixorg(NASA-contractorecosystem)
• Geographicallydispersed
– Establishedhierarchicalbureaucracy
• Littleevidencethatstructurewasissue– Longandimpressivehistoryofsuperbexecution– Effectivemanagementofcomplexecosystemandsupplychain
– Impressivesafetyrecordfor“twomillionparts– allbuiltbythelowestbidderonagovernmentcontract”
38
DecisionsAndTheChallengerDisasterNASA'sOrganizationalIdentity,ValuesandCulture
39
Theycalledita
SHUTTLE
“Beginningwiththenextflight,theColumbiaanditssistershipswillbefullyoperational”– Reagan,after4th flight
“Itwillrevolutionizetransportationintonearspacebyroutinizingit”
– Nixon,1972
DecisionsAndTheChallengerDisasterNASA'sOrganizationalIdentity,ValuesandCulture
• PoliticsandFunding– WrongFrame➡ Structureandcultureofroutineoperations
• BehavioralObservations– Rigidrulesandprotocols(nolevelhopping)
• Poorinformationflow
– Obsessionwithscheduleanddeadlines– Starkdistinctionbetweenengineersandmanagers
• “Takeoffyourengineer'shatandputonyourmanager'shat”
– Penchantforextensivesupportingdata– Insufficientacknowledgementoftheunknowns
40
CriticalThinkingandDecisionMakingNormalizationofDeviance
• DianeVaughnstudiedNASA’sorganizationalcontextandhistory– ObservedO-Ringproblemswerenotnew
• Issuescroppedupovertheyears• Historyandcontextmust haveinfluencedthelaunchdecision
• Vaughnarguedthelaunchdecisionisbestunderstoodinhistoricalcontext– O-ringerosionunexpected– Happenedonce,nodisaster– O-ringerosionbegantooccurregularly– Rationalizedredundancywassufficient– Graduallytheunexpectedbecame,expected,thenaccepted
41
CriticalThinkingandDecisionMakingNormalizationofDeviance
Vaughnproposedaslowholisticprocessatwork1. Smalldeviationsfromstandardsornormsarerationalized,
oftenunder(perceived)coercivepressure2. Nothingbadhappens,supportingthecorrectnessofthe
rationalization3. Withrepetitionsthe“deviation”eventuallybecomesthe
newnorm
NORMALIZATIONOFDEVIANCE
Notincompetence,justhumanity!SeeAlso:PracticalDrift; read“FriendlyFire”,Snook
42
FourUserStories
• AsanAgileProfessional,Iwantto
3. Learnnewtoolstomakebetterexecutiondecisionsandhavebetterfact-basedconversationswithmystakeholders
4. SeeAgilebedeployedmoresuccessfully
43
QuantitativeUnpredictabilityManagement
AmIdoomedifIcan’tpronounceCynefin?
44
QuantitativeUnpredictabilityManagement
45
Deterministic
Nondeterministic
SystemtobeManaged
ApproximateModel
QuantitativeUnpredictabilityManagement
• NormalizationofDeviance➡ 10,000smells– Everyriskierbehavior– Increasinglypoorjudgment– Escalatingvulnerabilityto“BlackSwans”
• LikeO-ringleaks,canseethemdeveloping
• UseEstimationErrorDistributions• Lookforlongtails
46
QuantitativeUnpredictabilityManagement
• Youcan’tmanagewhatyoudon’tmeasure• Track
47
RelativeEstimationError= Est − ActualEst
DecisionsandProjectsMeasureUnpredictability
48
ALongTail• Gaussiandatashouldhave1
or2cases(0.35%)• Actuallyhave40cases(8.6%)
DecisionsandProjectsMeasureUnpredictability
Uses:SensemakingwithCynefin
49
Youarehere!ALongTail
• Gaussiandatashouldhave1or2cases(0.35%)
• Actuallyhave40cases(8.6%)
DecisionsandProjectsMeasureUnpredictability
Longtailsdeprivesystemsofconsistent predictabilityWaterfallrequiresLOTSpredictability
50
-400 -300 -200 -100 0 100 0
20
40
60
80
100
120
Relative Estimation Error [%]
Estimation Accuracy “Distribution”
Not es: 465 User Stories; Single Scrum Team; 39 sprin ts in 2 yrs
DecisionsandProjectsMeasureUnpredictability
Uses1. SensemakingwithCynefin2. Conversationswithbusiness3. Seeing
– Deteriorationincodebase/system– Effectofchanges
51
DecisionsandProjectsSourceofMuri andMura?
• BlackSwanunderestimation– CreatesMuri andMura– Underminestrustbuilding
• Escalatingstressandfatiguedefinenegativefeedback
52
DecisionsandProjectsProtectiveToolsAndTechniques• BiasGuards
– Becomeawareandunderstandbiasesexist
• Trytolearnyours– SWOT-styledecisionanalysis– Managestress
• GroupEffectiveness– Understandandapplyframing
• Leadersmustframeespeciallycarefully• Usemultipleframes
– Monitorgroupdynamicsforprocesslosses• Watchforgroupthink• Stimulateconstructivedebate(scenarios/pre-postmortems)
– Includedecisionreviewsinretrospectives
– Fixmembershipproblemspromptly!
53
DecisionsandProjectsProtectiveToolsAndTechniques
• NormalizationofDeviance
UseTHEFORCE
• CognitiveDissonance– EngageaTruthsayer– Focuson(attachidentityto)process,notoutcome– Keepwrittenrecords– Usehonestmetrics
• UnderstandtheCultureCode– Seetheorganizationthatis– Ifactions≠words,ignorewords
54
DecisionsandProjectsDecisionAccounting/ChecksandBalances
• Setupchecksandbalances– Don'tonlyselfassess
• Inviteanoutsideauditor
• Useseparategroupsto– Approveprojects– Monitororcancelprojects
55
FourUserStories
• AsanAgileProfessional,Iwantto
4. SeeAgilebedeployedmoresuccessfully
56
Take-Aways andOpportunitiesTheColumbiaDisaster
57
• Observations– NASAnever interviewedVaughn– Evidenceof
• Confirmationbias• Processlossesindebrismeetings
• TheColumbiadisasterinvestigationboard:TheFoamDidIt,ButTheOrganizationLetItHappen
• NASA– FailedtolearnfromtheChallengerexperience– Failedtomeaningfullychangeitsbehavior
58
Take-Aways andOpportunitiesTheColumbiaDisaster
Take-Aways andOpportunitiesBewaretheHypecycle!
• ProjectManagementremainsunsatisfactory– Stubbornlysosince1968NATOConference
• Agileishelping!
• Havewe“CrossedtheChasm”?
• Withincreasingadoptioncomesincreasingrisk
• Failedadoptiondamages“thebrand”
• Embracecriticalthinkingandcriticaldecisioning
59
Take-Aways andOpportunitiesLet'sUseGandhi'sFormula
“Bethechangeyouwishtoseeintheworld”Gandhi
Letthatchangebeenrichedbycriticaldecisionmaking
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Let'sGetStarted
61
• WhySmartPeopleMakeBigMoneyMistakesandHowtoCorrectThem,Belsky andGilovich
• PredictablyIrrational,DanAriely
• FriendlyFire:TheAccidentalShootdownofU.S.BlackHawksoverNorthernIraq,ScottSnook
Let'sGetStarted• MistakesWereMade(ButNotbyMe),Tavris andAronson
• SnakesinSuits:WhenPsychopathsGotoWork,Babiak andHare
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• TheWisdomofPsychopaths:WhatSaints,Spies,andSerialKillersCanTeachUsAboutSuccess,Dutton
Namaste
QuestionsandDiscussion
63
AppendixandExtrasThiokolRecordofO-RingErosionandBlowby
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AppendixandExtrasThiokolRecordofO-RingErosionandBlowby
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AppendixandExtrasBoxplotRangesOverTheGaussianDistribution
66
ENDOFDECK
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