the logical thinking process
TRANSCRIPT
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Goal Systems International1
The Logical Thinking Process
A Systems ApproachTo
Complex Problem Solving
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Goal Systems International2
Who AM I? Goal Systems International (Senior Partner)
Author of several books
Bill Dettmer
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What we’re going to talk about…
A quick review of systems thinking and constraint managementprinciples (:05 minutes)
Questions and Answers about the June WebEx session( :10 min)
Introduction to the Logical Thinking Process (:40 min) How it fits in with systems thinking/constraint management The five logical tools
Q & A ( :05 minutes)
A couple of simple exercises ( :25 minutes) Evaporating Cloud (conflict resolution) Negative Branch (“law of unintended consequences”)
“Last chance” Q & A ( :05 minutes)
…over the next hour
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What is the Systems Approach?Based on THREE concepts…
Holistic thinking (No part of the system is “an island”)
The whole is not the sum of its parts Interactions—interdependencies—among components are as important,
or more important, than the performance of the components themselves The whole system can’t be managed effectively by suboptimizing
Avoiding Suboptimization Not all components are “created equal” Some may accept inefficiencies so that more critical components can
succeed
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Complex SystemsInteractions
Production
Sales
Admin./HR
Engineer-ing
ProjectMgt .Market-
ing
Legal
QC/QA
TechnicalSupport
Info .Tech.
PublicRelations
Purchas-ing
FINANCE/CONTROLLER
EndUsers
EconomicEnvironment
Government /RegulatoryAgencies
Social IssuesCompetitors
InternationalPoliticalSituation
Customers
Educational Systems
REAL systems can beVERY complicated…
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The Concept of System Constraints
Systems are analogous to CHAINSEvery chain has ONE weakest link
A part that limits what the whole chain can do
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Weakest Link…An Opportunity
If the weakest link (constraint) limits thesystem’s potential the most…
…then if it can be improved, it should also providethe best opportunity to MAXIMIZE
system performance
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Types of Constraints
RESOURCE
MATERIAL
MARKET
VENDOR /SUPPLIERVENDOR /SUPPLIER
FINANCIAL
KNOWLEDGE/COMPETENCE
POLICYTHIS factor is usually
behind obvious problemsin other areas
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The Five Focusing Stepsfor System Improvement
1. Identify the constraint2. Exploit the constraint3. Subordinate everything else4. Elevate the constraint5. Go back to step 1
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SYSTEMSYSTEM
OUTPUTSINPUTS
Feedback loop
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Questions…
…on what I’ve covered so far,or on anything that mentioned
in our June session?
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Impactsof
Decisions…
…can befar-reaching
FinancialOfficeProduction
Engineering
Marketing& Sales
HumanResources
“The chief cause of problemsis…solutions!”
—Sevareid’s Law
FinancialOffice
HumanResources Engineering
Production
Marketing& Sales
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Wurtzburg CorporationA notional example
Sales slightly declining for two years
Expenses up, profits down for three straight years
Long backlogs in production
Difficulties in retaining qualified production operators
Few customers All long term 18+ months to develop new ones
Two biggest customers (55% of revenue) leaving in six months
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What’s Wurtzburg’s Problem?
Could these diverse problems be connected?
If so, which one is the critical root cause of all theothers?
How would we goabout finding out?
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Policy Constraints
Underlie almost all other kinds
A conscious decision on how business will or will not bedone
Maybe discretionary or imposedWe decideThe law requires…
An unconscious acceptance of historical practices “This is the way we’ve always done it…” or “We don’t do things that way.”Thinking “inside the box”
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Wurtzburg Corporation
“We are a metal-stamping company.” Reason given for not investing in laser-cutting technology
“We can only satisfy customers (to our standards)within 100 miles.” Reason given for not extending target marketing area
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These are Wurtzburg’s self-imposed policies…
They were SYSTEM CONSTRAINTS.They were not immediately obvious,
and the company did not understand their full impact.
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How do we…
Identify and manage system constraints that are: Not physical (not visible)?
Not easily measurable?
Apply to more than just manufacturing systems?
Pervade the organization (complex interdependency)?
Analyze complex system interactions?
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The Logical Thinking Process
A set of FIVE logic trees
A set of EIGHT rules that govern logical connections
Provides the answers to the only three questionsmanagers ever need to know…WHAT to change?What to change TO?HOW to make the change happen?
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The Rules of Logic(Categories of Legitimate Reservation)
1. CLARITY2. ENTITY EXISTENCE3. CAUSALITY EXISTENCE4. CAUSE INSUFFICIENCY5. ADDITIONAL CAUSE6. CAUSE-EFFECT REVERSAL7. PREDICTED EFFECT EXISTENCE8. TAUTOLOGY (circular logic)
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The Logic Trees
Intermediate Objectives (IO) MapWhat SHOULD we be trying to accomplish?
Current Reality Tree (CRT)What’s happening that we don’t like?What are the critical root causes?
Evaporating Cloud (EC)What conflict inhibits problem solution?What do we do about it?
Future Reality Tree (FRT)How do we know the solution will work?
Prerequisite Trees (PRT)How do we implement solutions?
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Intermediate (IO) Objectives Map
Establishes:Overall system goalCritical Success Factors
(CSF)Necessary Conditions (NC)
Determines the standardof performance requiredof the system
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Current Reality Tree (CRT)Identifies measurable
deviations from the IO Map
Traces an unbroken chain ofcause-effect back to criticalroot causesUsually includes the system
constraint
Identifies the fewest factorsguaranteed to delivermaximum benefit to thesystem
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Evaporating Cloud (EC)
Change usually elicits“pushback” from someoneSomebody wants to leave the
status quo alone
Affords the possibility of a“win” for both sides
Helps develop a thirdalternative to satisfy therequirements of both sides “Injection”
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Future Reality Tree (FRT)
Ideas are NOTsolutionsWill they work?Will they cause more
problems than theysolve?
FRT logically projectsoutcomes of proposedideas before resourcesare committed
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Prerequisite Tree (PRT)
How to make changehappen successfully?What are the non-
negotiable componenttasks?
What obstacles must beovercome (and how)?
PRT creates a sequencedimplementation activitynetwork
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The“Big Picture”
The FRT shows howchanges unfold Automatically, like
dominoes falling
The PRTs provide thedetailed executionprocess Discrete action required
(Intermediate Objectives)
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The Source…(Publication date: August 28, 2007)
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Thinking Process Symbology
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Categories of Legitimate ReservationLet’s look at these in a little more detail…
1. Clarity2. Entity Existence3. Causality Existence4. Cause Insufficiency5. Additional Cause6. Cause-Effect Reversal7. Predicted Effect Existence8. Tautology (circular logic)
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Categories of Legitimate ReservationClarity, Entity Existence, Causality Existence
1. CLARITY – The completeunderstanding of what has been said.
2. ENTITY EXISTENCE – A valid,complete expression of a single idea.
3. CAUSALITY EXISTENCE – A direct,unavoidable causal connection
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The productionprocess is bad.
What does “bad” mean?
Water runs uphill.
Is this really true?
Examples
The driverfalls asleep.
The car’sengine stops.
If…
…then…
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Categories of Legitimate ReservationCause Insufficiency, Additional Cause
4. CAUSE INSUFFICIENCY – Two ormore contributing causes required
5. ADDITIONAL CAUSE – A separate,independent cause of the same effect
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Examples
If…
…then…
We haveignition.
We have a fire.
We havefuel. ?????
…and… (What’smissing?)
A tornadohits.
The house isdestroyed.
We have anearthquake.If…
…then…
If…
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Categories of Legitimate ReservationCause-Effect Reversal, Predicted Effect Existence
6. CAUSE-EFFECT REVERSAL – Thecause is really the effect, and vice-versa
7. PREDICTED EFFECT EXISTENCE –A separate, independent effectattributable to the same cause
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Examples
If…
…then…
I have pain in mylower right side.
I haveappendicitis.
Unemploymentrises.
The economyis in recession.
My housedoesn’t sell.
?
If…
…then… …then…
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Categories of Legitimate ReservationTautology
8. TAUTOLOGY (circular logic) – The existence of the effect is offeredas the rationale for the causal relationship
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Example
I sleep witha cross.
Vampires stay awayfrom me at night.
I wear garlicaround my neck.
If…
…then…
…and…
Q: “How do you know thegarlic and cross are thecauses?”
A: “You don’t see anyvampires, do you…?”
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The Five Logic TreesLet’s look at these in a little more detail…
Intermediate Objectives (IO) Map
Current Reality Tree (CRT)
Evaporating Cloud (EC)
Future Reality Tree (FRT)Negative Branch (NB)
Prerequisite Tree (PRT)
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Constructing the Logic TreesTime required…
Throwing manpower at it only helps up toa point Two are better and faster than one Three are slightly worse than oneMore than three slows the pace to “glacial”
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My observation is that whenever one person is foundadequate to the discharge of a duty by close applicationthereto, it is worse executed by two persons, and scarcelydone at all if three or more are employed therein.
—George Washington
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Intermediate Objectives (IO) MapReflects the ultimate desired system outcomes
Goal (as defined by the owners of the system)Critical Success Factors (3-5 key terminal outcomes)Necessary Conditions (key supporting intermediate results)
Time to construct: 30 – 90 minutesRemember George Washington’s admonition!
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Intermediate Objectives (IO) Map(Example)
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Goal
Critical SuccessFactors (CSF)
NecessaryConditions
(NC)
The ITCorporation
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Current Reality Tree (CRT)
A “snapshot” of reality—NOW!
Undesirable Effects (UDE) at the topSpecific, verifiable statement of deviation between CSF
(from IO Map) and what is happening NOW
Critical Root Causes (CRC) at the bottomUsually a policy or practice that motivates action within the
system
Continuous chain of cause and effect connecting theUDE with the CRC
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Current Reality Tree (CRT) CRT indicates sequence, not
time
The example shown here isvery simple
The CRT you have in yourhandout materials (theChallenger accident) required14 years to unfold
Time to construct: 2-4 hours ormore Complexity-dependent
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Evaporating Cloud (EC)
Used to resolve conflict or contention
Normally used when proposed change elicits “push-back”
Structures and displays opposing positions for easierresolution
Seeks a “win-win” third alternativeReferred to as an “injection”
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Evaporating Cloud (EC) Objective of the EC is
normally the system goal
Each Requirement isnormally a critical successfactor Conditions/outcomes of
specific actions
Each Prerequisite is theaction (or policy) perceivedto satisfy the Requirement
Time required to construct:15 -30 minutes
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Underlying principles of the Evaporating Cloud
Requirements are non-negotiable (“win-win”)“There is more than one way to skin a cat”
(GOAL of thesystem)
(Critical SuccessFactor #2)
(Critical SuccessFactor #1)
(Conflict)
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Evaporating Cloud (EC)The keys to conflict resolution…
Assumptions underlie each side of the conflictAssumptions are “hidden” (not obvious)One or more assumptions are invalid
Each side desires to see the conflict resolved
Solutions (“injections”) often require “outside-the-box”thinking
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Evaporating Cloud(EC)
The completed analysis
Invalid assumptionshighlighted by “”
Prerequisites P2replaced
Injections ensuresatisfaction of R1 andR2
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Future Reality Tree (FRT)A projection of what the future would look like if change
is introduced
A means of “paper” (logic) testing whether proposedchanges will actually deliver the desired resultsOpposite of the Undesirable EffectsSatisfaction of the Critical Success Factors (IO Map)
Safeguards against the unwarranted expenditure ofresources in a failed effort If you can’t prove it logically, “go back to the drawing board”
Time required: 2-3 hours (complexity-dependent)
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Future Reality Tree (FRT)Example
No FRT was constructed onthis law in 1986 FRTs didn’t exist then
What do you think the missingInjection might have been? “Enforcement” perhaps?
Do you think an FRT wascompleted for theComprehensive ImmigrationReform Act of 2007?
Your handout shows anexample of a more detailed,real-world FRT
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Was an“injection”missing…?
Was theDesiredEffect
realized?
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Negative Branch Reservation (NB)“The Law of Unintended Consequences”
Even when Injections are capable of producing theDesired Effect, they can lead to unanticipatedconsequencesSometimes new problems, often worse than the original one
Negative Branch: Part of the FRT process Identify and avoid the “Law of Unintended Consequences”
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Negative BranchReservation (NB)“The Law of Unintended
Consequences”
Sometimes thecure is worse than
the disease
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NegativeBranch
A Real-WorldExample…
that was NEVER done(but probably should
have been!)
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If… …and…
…then…
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Future Reality Tree and Negative Branch
The FRT is where strategy is developed and tested
The Negative Branch is a subset of the FRT that helpsprotect against the “law of unintended consequences”
The purpose of these two treesSolution mapping and testingNOT implementation
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Prerequisite Tree (PRT)
Articulates the component tasks in executing/ implementingan Injection from a Future Reality Tree
Differs from an IO Map In level of the system addressed
IO Map – High system (conceptual) levelPRT – operational (working) level
In level of detail IO Map – Terminal outcomes of major system activitiesPRT – short-term tasks and activities
Time required: 30 – 90 minutes Depending on availability of content knowledge
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Prerequisite Tree (PRT) Injection to be implemented
Obstacles to be overcome
Intermediate Objectives To support Injection
implementation To overcome obstacles
Extends downward to: The first component activity that
must be completed, or… The most basic thing you know
how to do, or… The first obstacle to be overcome,
whichever is lowest
Your handout shows an example ofa real PRT
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Questions…
…on what I’ve covered so far?
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Before we move on to a “hands-on” exercise…
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“Hands-on” Exercises
Evaporating Cloud (conflict resolution)
Negative Branch
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SAILING A LEAKING BOAT:ROW OR BAIL?
AN EXERCISE IN CONFLICT RESOLUTION
“Managing around here is like being in a boatwith leak in it… I know I should row or I won't
get anywhere, but if I stop bailing then I'mgoing to sink!"
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NEGATIVE BRANCH EXERCISE
Anticipating the“Law of Unintended Consequences”
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The Negative BranchAvoiding the “Law of Unintended Consequences”
ScenarioYou are the executive head of your national governmentYou are faced with the imminent threat of terrorist attackYour security establishment has requested a law to make their
duties more reliable and effective. Provisions include:Surveillance video throughout all public places in major citiesNational identification cards for every citizenArrest and holding of suspects for 21 days without formal chargeWarrantless wire-tapping (phones)Internet / e-mail screening or tracing without judicial warrantsIncreases in numbers of security forces
You have some troubling concerns about this requestedlaw.
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The Negative BranchAvoiding the “Law of Unintended Consequences”
Charter:Construct a Negative Branch leading logically
to the Undesirable Effects you foreseehappening if the law is enacted
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Interactive Nature of the TP Tools
You have a well-developed Negative Branch on the terrorism law Clearly, it implies some undesirable potential outcomes But clearly, too, it offers some significant potential benefits in improved
security
As a decision-maker, you are faced with a dilemma Support the passage of the law, orOppose the passage of the law
It would be irresponsible to reject one side or the other without aviable alternative
Effective resolution of your dilemma requires a “win-win” solution And the appropriate Thinking Process tool for that would be…?
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The Evaporating Cloud(applied to REALLY high-level policy issues!)
Is there ANY doubt in yourmind about whether ornot YOU could resolvethis dilemma in a “win-win” manner…
IF you had tools like theThinking Process?
IF you had access to thecontent knowledge anational-level decision-maker has?
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The Logical Thinking ProcessSummary
An analysis and problem-solving tool for complex systems
Based on the fact that policies rule the operation of systems And constraint what the system may do (performance)
Can be applied to ALL systems Large or small Political, cultural, or organizational Regardless of goal / mission
The most powerful complex-system analysis tool ever invented
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The Logical Thinking ProcessSummary
Use requires: Time investment to learn System knowledge (“bullets to put into the gun”)
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Without the assistance of a teacher many roads become open to a practitioner, some on the correct pathand some on the incorrect path. It is not for everyone to be without guidance—only a few, and they areexceptional, can make a journey to wisdom without a teacher.
You must have extraordinary passion, patience, and self-discipline to make a journey alone. The goalsmust be understood, and no diversion can be acknowledged or permitted if you are to attainenlightenment within the sphere of a chosen art.
This is a very difficult road to travel and not many are made for it. It is frustrating, confusing, verylonely, certainly frightening, and it will sometimes make you think you do not have much sanity left todeal with the everyday surroundings of your world. Also, there is no guarantee that you will attainperfection. It must all come from inside you without any preconceived notions on your part.
—Miaymoto Musashi (1643)(The Book of Five Rings)Translated by Stephen F. Kaufman, Hanshi 10th dan)
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61“Oh…so you didn’t use the Thinking Process either?”
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“Last Chance…”
Any questions?
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GoalGoalSystemsSystemsInternationalInternational
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“Constructing and CommunicatingCommon Sense”
Objective
Requirement #1
Requirement #2 Prerequisite #2
Prerequisite #1
ASSUMPTIONS:1.
2.
3.
4.
ASSUMPTIONS:5.
6.
7.
8.
“Row or Bail?”
INJECTION #
INJECTION #
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NEGATIVE BRANCH #1:“Anti-Terrorism Law”
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[UNDESIRABLE EFFECT]
NB-01 The threat ofcontinuing terrorist
attacks in our countryis imminent.
INJECTIONAnti-TerrorismLaw of 200x is
passed.
NB-02 The AT Law of200x contains a provisionto...
100 NASA leadershipmakes cost a prime
consideration in designand development.
101 The fiscalenvironment in
the early 1970s isaustere.
104 NASA awardscontracts to thelowest bidder
whenever possible.
102 Morton-Thiokol has deep
experience in TitanIII solid rocket
boosters (SRB).
103 The cost economyin the Morton-Thiokolproposal is based onscaling up the provenTitan III SRB design.
105 Morton-Thiokolsubmits a bid
promising very lowcost.
106 Morton-Thiokol’sproposal for the SRBs is
lowest in cost but nobetter than 4th-rated indesign, development,
and verification.
107 Space shuttle SRBdevelopment is awarded
to Morton-Thiokolthrough competitive bid.
108 Morton-Thiokol assumeslittle difficulty inup-scaling the
Titan III design.
109 Titan IISRBs use a
clevis-and-tangdesign to
connect rocketmotor segments.
110 Morton-Thiokoldesigns space shuttle
SRBs with a clevis-and-tang segment connection.
112 Morton-Thiokolincreases clevis-and-
tang tolerances to makeassembly easier.
111 The substantially increasedscale of the space shuttle
SRBs creates unanticipated fitproblems during assembly.
113 The wider space betweenclevis and tang increases the
probability of joint rotation underthe pressure of combustion.
(Critical Root Cause)
210p.2
202p.2
Current Reality Tree“The Challenger Disaster” p.1
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Current Reality Tree“The Challenger Disaster” p.2
100 NASAleadership makes
cost a primeconsideration in
design anddevelopment.
113 The wider space betweenclevis and tang increases the
probability of joint rotation underthe pressure of combustion.
(From p. 1 )
(From p. 1 )
200 The clevis-and-tangjoint is designed to besealed by two O-rings
(primary and secondary)protected from combustion
heat by zinc chromate putty.
201 Joint rotationcompromises the sealingcharacteristics of the O-
rings and putty.
202 The O-rings fail toprovide a consistent,
reliable joint seal at theaft field joint.
203 Joint rotation producesa pressure leak at the aft
field joint (where the clevisand tang connect).
204 Hydrostatic pressure testson the SRB casing in 1977
reveal pressure leaking at onlyhalf the pressure expected with
am ignited motor.205 Combustion leakage
at the aft field jointpresents a critical hazard
to flight operations.
206 Critical flight hazards(possible loss of life) are
unacceptable.
208 A fix for thepressure leakage
problem is required.
207 The only realistic fixoptions are shimming the
existing design orredesigning the SRB case.
209 Redesigningthe SRBs from
scratch isprohibitivelyexpensive.
210 Marshall Space FlightCenter (NASA) rejects a
redesign as too expensive.
211 Shimming theexisting joints is theselected solution.
212 In spite of shimming, heat erosion of aprimary O-ring is detected in a SRB after STS-5(first operational mission) in December 1982.
213 NASA and Morton-Thiokol know thatshimming has not corrected the pressure leakproblem at the O-ring in the SRB aft field joint.
214 Only thesecondary O-ring
remains tocontain internal
booster pressure.608p.6
302p.3
409p.4
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Current Reality Tree“The Challenger Disaster” p.3
214 Only the secondary O-ring remains to contain
internal booster pressure.
(From p. 2 )
300 The aft filed joint hadbeen originally classifiedas redundant because of
the two O-rings.
301 The secondary O-ringwas never intended to
absorb the full pressure ofcombustion (i.e., to substitute
for the primary O-ring).
302 The aft field joint, inreality, no longer has
any redundancy.
303 NASA isaware of thepersistentproblem.
304 Marshall SpaceFlight Center reclassifies
the aft field joint fromredundant to critical.
305 Critical meansloss of life or vehicleof the component(primary O-ring)
fails.
307 Reclassification of the aftfield joint is not communicated
throughout Morton-Thiokol.
306 NASA policy now requires theshuttle to be grounded if evidenceis subsequently detected indicating
primary O-ring failure.
308 Key propulsion engineers never findout that redundancy has been lost
(primary O-ring integrity now critical).
309 Nobody at Morton-Thiokol has theinformation needed to pose a rational
objection to further launches.
405p.4
510p.5
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Current Reality Tree“The Challenger Disaster” p.4
306 NASA policy nowrequires the shuttle to begrounded if evidence issubsequently detected
indicating primary O-ringfailure.
213 NASA and Morton-Thiokol know thatshimming has not
corrected the pressure leakproblem at the O-ring inthe SRB aft field joint.
(From p. 2 )
(From p. 3 )
400 NASA space shuttlemanager are under intense
pressure to improve thepublic image of the program.
403 NASA has a strong publicrelations motivation to avoid
suspending the program.
401 Subsequent space shuttleflights (1983) are successful inspite of gas pressure blowing
by the primary O-ring.
402 No serious consequencesof pressure leakage have yetbeen observed on previous
launches.
404 NASA shuttle managerscome to consider O-ringblow-by to be a normal(acceptable) condition.
405 NASA shuttle managers begin toroutinely waive SRB discrepancies
related to SRB O-ring blow-by.
406 Marshall Space Flight Center’sproblem assessment report on the
aft field joint reads: “Remedialaction required: NONE.”
407 NASA continues operationalspace shuttle launches from
1983 through 1985.
408 No further technicalactions will be taken tocorrect the aft field joint
problem.
409 The space shuttle and creware at substantially increased risk
during all launches after 1982[UNDESIRABLE EFFECT]
(Critical Root Cause)
508p.5
508p.5
508p.5
© Copyright Goal Systems International, 2007All rights reserved
Current Reality Tree“The Challenger Disaster” p.5
403 NASA has a strong publicrelations motivation to avoid
suspending the program.
404 NASA shuttlemanagers come to
consider O-ring blow-byto be a normal
(acceptable) condition.
408 No further technicalactions will be taken tocorrect the aft field joint
problem.
309 Nobody at Morton-Thiokol has theinformation needed to pose a rational
objection to further launches.
(From p. 4 )
(From p. 4 )
(From p. 4 )
(From p. 3 )
501 O-rings areknown to be stiffer atlower temperatures.
500 Stiff O-rings takelonger to seat properly
(if they do so at all).
502 Morton-Thiokol engineersnotice a correlation between
severity of hot gas blowing byO-rings and low air
temperatures at launch.
504 Morton-Thiokolengineers perceive danger in
low-temperature launches(less than 53o F).
503 Temperature at launchtime for the 51-L mission is
forecast to be 37o F.
505 Morton-Thiokolengineers oppose launching
on January 28, 1986.
506 A conference call (35participants) is convened to
discuss the O-ring andtemperature problem.
507 Morton-Thiokol engineersvigorously express their opposition
to launching on January 28.
508 NASA shuttlemanagers “shout down”
the opposition of Morton-Thiokol engineers.
509 Morton-Thiokol engineershave only their gut-feel to
substantiate their concerns.
510 Morton-Thiokol vice-presidents(participating on the conference
call) overrule their own engineers.
600p.6
© Copyright Goal Systems International, 2007All rights reserved
Current Reality Tree“The Challenger Disaster” p.6
510 Morton-Thiokol vice-presidents(participating on the conference
call) overrule their own engineers.
(From p. 5 )
600 NASA and Morton-Thiokol reachconsensus to go ahead with the launch
of STS-51-L on January 28, 1986.
601 Launch sequencecommences at 11:38am EST.
602 Challenger’s main engines (liquid-fueled) ignite and build to full thrust (7
seconds) before ignition of SRBs.
603 Challenger’s left and rightSRBs ignite seven seconds after
main engine ignition.
605 Combustionpressure builds
rapidly within theSRBs.
604 Challenger lifts off.
607 Cold air temperatures forthe previous 12+ hours stiffenthe primary O-ring in the aftfield joint on the right SRB.
606 The last chanceto save the crew and
vehicle is gone.[UNDESIRABLE EFFECT]
608 Aft field jointrotation occurson the SRBs.
609 Sealing of the aft field joint onthe right SRB fails along a
significant length of the O-ring.
610 Seven-tenths of a second afterSRB ignition, an exceptional amount ofhot exhaust gas blows by the primaryO-ring on the right SRB aft field joint.
611 The secondary O-ring cannotwithstand the heat of the blow-by.
612 The secondary O-ring is burned through.
613 Over the next 70 seconds, asubstantial amount of combustion gasleaks out of the right SRB aft field joint.
213 Shimming hasnot corrected the
pressure leakproblem at the O-ringin the SRB aft field
joint.
(From p. 2 )
704p.7
© Copyright Goal Systems International, 2007All rights reserved
Current Reality Tree“The Challenger Disaster” p.7
613 Over the next 70 seconds, asubstantial amount of combustion gasleaks out of the right SRB aft field joint.
(From p. 6 )
700 The SRBs arelocated on the
vehicle centerline.
701 The SRBs aredesigned to operate at
equal internal pressures.
702 Pressure inthe left SRB
remains normal.
705 Challenger experiences asignificant , rapidly increasingpressure differential between
the left and right SRBs.
703 The pressureleak in the right
SRB continues toworsen.
710 At 70 seconds intothe flight, the roll/yawexceed the autopilot’scapability to correct.
704 Any pressuredifferential between SRBs
causes and immediateasymmetric thrust condition.
707 Challenger experiencesa significant asymmetric
thrust condition.
706 Asymmetricthrust imposes
large roll and yawforces on theentire vehicle.
713 Forcibledetachment fails
the structure of themain fuel tank.
714 The main fuel tank is ruptured.715 Leakingliquid fuel is
ignited.
708 Challengerbegins to roll
and yaw.709 Challenger’s autopilotattempts to correct for theincreasing roll and yaw.
712 The right SRB tears the lowerattachment loose from the main fuel tank.
711 Asymmetric aerodynamic loadsat speeds in excess of Mach 1
exceed the structural strength of theSRB attachment hardware.
717 Challenger’s main fuel tankexplodes 72 seconds into the flight.
716 The crew has nomeans of escape.
718 The crew is killed.[UNDESIRABLE EFFECT]
719 The Challenger is destroyed.[UNDESIRABLE EFFECT]
© Copyright Goal Systems International, 2007All rights reserved
FUTURE REALITY TREE“Successful Project Management”
p.1
101 Project teammembers provide
estimates of task durationfor scheduling purposes.
102 Team members are notconcerned about management
reducing the amount of time allowedfor task completion in the future.
103 Team membershave no reason to inflatetask duration estimates
with safety time.
104 Management’s overallproject schedule is initially basedon average expected task times.
105 Management’s overallproject schedule is corrected forreasonable risk of uncertainty.
106 Management’s overall projectschedule is shorter than it would bewith safety time built into each task.
109 The final project scheduleis more realistic and flexiblethan it would otherwise be.
108 Uncertaintyimpacts the
duration of everytask, sometimes
significantly.
107 Teammembers are
willing to reportearly completion
of tasks.
112 Tasks sometimesfinish LATER than
expected.
111 Tasks sometimefinish EXACTLYwhen expected.
110 ManagementKNOWS when tasks
sometimes finishEARLIER than
expected.
115 Sometimes resourcesneeded for a subsequent task arestill working on preceding tasks.
114 Sometimes resources areavailable to start on subsequent
tasks early or on time.
INJECTION # 1Management DOES NOT holdproject teams accountable forcompleting assigned tasks on
scheduled dates.
INJECTION # 2Management implements
project staggering and buffermanagement as a global
priority scheme (Reduce “multi-tasking” whenever possible)
INJECTION # 3Management separatesmedian task time from
safety time.
INJECTION # 5Some safety time issafely eliminated.
INJECTION # 4Some safety time is
placed at key locationsin the activity network.
207p.2
208p.2
<OR>
113 Tasks sometimesshare resources.
210p.2
202p.2
206p.2
© Copyright Goal Systems International, 2007All rights reserved
FUTURE REALITY TREE“Successful Project Management”
p.2
109 The final projectschedule is more
realistic and flexiblethan it wouldotherwise be.
115 Sometimes resourcesneeded for a subsequent task arestill working on preceding tasks.
114 Sometimesresources are
available to starton subsequent
tasks early or ontime.
(From p. 1 )
(From p. 1 )
(From p. 1 )
201 Sometimes tasks onthe critical chain aredelayed in starting.
202 Sometimes NON-critical chain tasks are
delayed in starting.
204 The project bufferabsorbs delays in
individual tasks on thecritical chain.
205 Feeding buffersabsorb delays in
individual tasks NOT onthe critical chain.
INJECTION # 6Some conserved safetytime is aggregated in aproject buffer (just prior
to delivery).
INJECTION # 7Some conserved safety
time is distributed tofeeding buffers (just prior
to critical chainconvergence).
203 Variation (delays) inindividual tasks normallyaccumulates at the end
of the project.
206 Project deliverytimes don’t slip
behind schedule.207 Subsequent tasksstart at or before the
expected time.
209 “Crashing”isn’t required. 210 Performance need not
be sacrificed to preservepromised delivery dates.
211 Project costsdon’t escalate.
215 The projectis delivered at
the quoted price.
208 The organization isable to safely promise
earlier delivery.[DESIRED EFFECT]
214 The organizationdoesn’t absorb added
costs related toschedule slippage.[DESIRED EFFECT]
213 The deliverableperforms as promised.
[DESIRED EFFECT]
217 Customers are delighted.[DESIRED EFFECT]
212 The project isdelivered when
promised.[DESIRED EFFECT]
216 The organization makesmoney on the project.
[DESIRED EFFECT]
(For-profitcompanies
only)
© Copyright Goal Systems International, 2007All rights reserved
PREREQUISITE TREE“Wurtzburg Corporation”
INJECTION # 8A formal job training
program is established.
808 Develop trainingeffectivenessmeasurement
method.
807 Develop trainingschedules
(in-house or outside)
809 Determinerefresher
certificationfrequency
805 Determinebudget / cost
804 Developcurriculum and
levelsOBS-2
Don’t havequantifiableperformance
standards
OBS-1Don’t know all
our trainingneeds
OBS-3Don’t haveinstructors
801 Establishperformancestandards.
802 Determinetraining target
(needsassessment)
803 Identifyinstructor
candidates (bestin class)
OBS-4Insufficient
knowledge ofmeasures
development
806 Develop trainingeffectivenessmeasurement
method.
© Copyright Goal Systems International, 2007All rights reserved
Goal Systems International“Constructing and Communicating Common Sense”
111 Hurricane View Lane Port Angeles, Washington USA 1-360-565-8300www.goalsys.com [email protected]
1
PROFESSIONAL RÉSUMÉ
H. WILLIAM DETTMER. Senior Partner, Goal Systems International.
Author: The Logical Thinking Process: A Systems Approach to Complex Problem-Solving (ASQQuality Press, 2007); Strategic Navigation: A Systems Approach to Business Strategy (ASQ QualityPress, 2003); Brainpower Networking Using the Crawford Slip Method (Trafford Publishing, 2003);High Velocity Manufacturing: Optimizing Supply Chain Financial Performance (with EliSchragenheim), CRC St. Lucie Press, 2000; Breaking the Constraints to World-Class Performance(ASQ Quality Press, 1998; Goldratt’s Theory of Constraints (ASQ Quality Press, 1996); The Handbookfor Quality Management. Thomas Pyzdek. (Ch. 9, “Constraint Management,” by H.W. Dettmer).Tucson, AZ: Quality Publishing, 2000;.
Articles in Quality Progress magazine (April 1995, March 1999); APICS Performance Advantage,2001.
Proceedings of the APICS Constraints Management Symposium (1995 - 2001); Proceedings of theAPICS International Conference (2003).
Proceedings of the ASQ Quality Management Division Annual Conference (1997, 1998).
Experience: Consulting and training on established applications of constraint management tools inboth manufacturing and services with Fortune 500 and other companies. Developing new applicationsfor the constraint theory, principles, and tools, including preparation of legal cases for negotiatedsettlements or courtroom litigation, and the acquisition and turn-around of distressed businesses. Partialclient list includes United Health Group; Raytheon Missile Systems, U.S. Air Force SoftwareTechnology Center, U.S. Navy Sea Systems Command, Tellabs, Lucent Technologies (both in Europeand the US), Western Digital Corporation, NEC America, Kauffman Products, Inc., Kendall HealthcareProducts, Ericsson Cellular, Weyerhaeuser, Boeing, INESA and ICI/Inca Corporations (SouthAmerica), Orrcon Ltd. (Australia), and Qualiplus, S.A. (Brazil).
Foremost expert in the world in the logical thinking process developed by E.M. Goldratt. Deepexperience in logistics, project planning and execution, and contracting/ procurement. Directresponsibility for project management, logistics planning, government contracting, system design,financial management, productivity improvement, idea generation, team building, strategic planning,and customer-supplier relations.
Eight years teaching masters level courses in project management (University of Southern California);systems analysis and problem solving; systems integration; management control systems; managerialeconomics; human factors in systems; organizational behavior and development; decision analysis; andmanagement of research, development, test, and evaluation (RDT&E) for the University of SouthernCalifornia’s Institute of Safety and Systems Management. Three years delivering professional seminarsin constraint management for the American Society for Quality (ASQ).
Education: MS, University of Southern California; BA, Rutgers University
Professional Affiliations: Founding Board Member, TOC International Certification Organization (TOCICO); certified in the
thinking process, holistic strategy, and operations management American Society for Quality (ASQ) American Production and Inventory Control Society (APICS)
Goal Systems International“Constructing and Communicating Common Sense”
111 Hurricane View Lane Port Angeles, Washington USA 1-360-565-8300www.goalsys.com [email protected]
2
PUBLISHED BOOKS
ASQ QUALITY PRESS, 1996 ASQ QUALITY PRESS, 1998 CRC ST. LUCIE PRESS, 2000
(Ch. 9 only)QUALITY PUBLISHING, 2000 ASQ QUALITY PRESS, 2003 TRAFFORD PUBLISHING, 2003
ASQ QUALITY PRESS, 2007
Supply ChainFulfillment
atWarp Speed
AUERBACH PUBLISHING(coming in 2008)