“The road to hell is paved with good intentions.” That’s my favorite aphorism that sums up the reality of unintended consequences. Those ripple effects from our best efforts that we had no idea would happen. Of course, unlike the proverb, not all ripple effects are bad.
The term “happy accidents” captures those moments when something positive results from what would otherwise be considered a disaster. According to the Urban Dictionary that’s how we got Guinness and it might refer to the origins of some of our good friends and colleagues. But I digress.
I recall an up close and personal example of unintended consequences while running some Process Improvement workshops in 2008. It wasn’t as momentous as the development of Ireland’s most famous beverage but it got me thinking. Take yourself back to the fall of 2007. Apple’s iPod had been around since 2001 but the iPhone had just been released. I was staying at a Westin, one of the Starwood properties that cater to high-end business travellers along with some pampered vacationers.
When I got to my room I noticed they had replaced all the old “Alarm A/Alarm B” bedside clocks with large, sleek, stainless columns of technology that served as both alarm clock and musical docking station. Just looking at them I felt privileged, pampered and sophisticated. What could go wrong?
In terms of my own habits at the time (I had no iPhone – yet), I systematically requested a wake-up call. Wake-up calls hadn’t been automated yet and, not having received the wake-up call a few crucial times, I made it a practice to both request a wake-up call and set the bedside alarm clock.
I approached this attractive new gizmo and scanned it for some telltale “Alarm” buttons but quickly decided I was out of my league. I called the front desk to get some help, and they sent a lovely woman from Housekeeping to help me. We both gave it the college try to no avail so she called a few of her colleagues in to see if they could help. After a few more attempts we flagged down a gentleman from Maintenance – the guy with a belt full of keys and tools. He came in, took one look and said he’d be right back. He returned with one of those “Alarm A/Alarm B” relics from a supply room somewhere. Problem solved.
But, what about the other guests? Did they know how to work the mini R2D2?
But, what about the other guests? Did they know how to work the mini R2D2? Did they try and fail? Did they do what I did and engage the very willing Front Desk, Housekeeping and Maintenance for the better part of an hour? What else could have gone wrong? This is exactly the thinking behind the Failure Modes and Effects Analysis or FMEA.
NASA to the Rescue! Sort of…
You don’t have to be a rocket scientist to solve this problem, but we do get a great tool from Aerospace. The FMEA is great risk assessment tool. NASA didn’t have the luxury of using the “Trial and Error” to perfect the exploration of space – think about launching astronauts to test if they could make it back safely – so they used this tool to great effect.
An ounce of prevention is worth a pound of cure.
With all this talk of rocket scientists and words like “Modes” it sounds a bit formidable. But the FMEA is simply a tool that helps us not only ask, “What could go wrong?” but to answer that question. Once we’ve considered what might go wrong we employ another timeworn adage, “an ounce of prevention is worth a pound of cure.”
Let’s see how Starwood might have used the FMEA with their fancy new bedside gadgets. Here’s a “New Clock FMEA”:
Now we’ve got to add in some numbers– everybody likes numbers…
What about our ability to detect this failure? Would the hotel know about this problem before a guest came racing through the lobby, hair in disarray proclaiming, “I’m late!”?…
Since the worst the result is 1000, 900 is pretty a high score or “Risk Priority Number.” And that’s the beauty of the FMEA – you get a numeric assist in terms of prioritizing which “risks” to address first. This example is somewhat linear but you can imagine that any given change might have multiple “failure modes” or ways things could go wrong.
In this case, what might they have done? What could Starwood have done to mitigate the risk posed by technologically challenged guests? The FMEA provides for not just follow-up actions, but a way to recalculate the Risk Priority Number. As you can see below, the severity of a slumbering guest missing an appointment is still a “9” and there’s still no way to know if they’ve failed to set the clock properly. With instruction, the occurrence would go down and that’s enough to reduce the overall risk.
Shortly thereafter I read about another hotel chain that had tried installing a similarly upscale bedside clock and had quickly opted to replace them with earlier models. Starwood eventually followed suit as well. If I use another Lean Six Sigma tool, The 5 Whys, my guess would be that their main clientele were a little older and still not as comfortable with emerging technology. If teenagers had the cash to stay at the Westin they would probably have nailed it.
Unintended consequences on a larger scale have had profound effects throughout history.
Unintended consequences on a larger scale have had profound effects throughout history. Here’s a small sampling of happy accidents or well-intended disasters. See how many of these you’ve heard about and take a moment to reflect on your own processes:
This is hard to imagine, but worth considering, as we continue to battle drug trafficking. Basically, the enactment of the National Prohibition Act of 1919 led to a large underground network of back room distilleries, illicit supply chains and vast quantities of illegal alcohol all facilitated by increasingly organized crime syndicates. The immense profits enabled the expansion of criminal enterprises and precipitated such an increase in violence that President Roosevelt saw fit to repeal the act in 1933. But organized crime had already created deep lasting roots.
In 1915, due to the disaster of the Titanic, the government passed the federal Seaman’s Act, which required The Eastland, a Great Lakes passenger steamer, to retrofit its upper decks with a complete set of lifeboats. The additional weight of the lifeboats worsened the existing issue of the Eastland being too top heavy. When passengers congregated on the port side, the Eastland rolled over and sank 20 feet from the wharf on Southbank of the Chicago River – just 3 years after the wreck of the Titanic.
3. Reintroducing Wolves to Yellowstone Park Changed the Rivers
By 1995, the deer population, without predators, had grown to such an extent that they had wiped out most of the vegetation in the park. Efforts to control the deer had failed so they reintroduced a small number of wolves. Just the presence of the wolves changed the behavior of the deer – they steered clear of open valley’s and gorges which resulted in the immediate regrowth of vegetation – trees alone grew to five times their height in 3 years. This created a habitat for mice, rabbits and birds and profoundly improved the eco-system. But the biggest surprise was that the new vegetation reduced erosion, narrowed the banks and changed the path of the rivers. A small number of wolves managed to change the physical geography of Yellowstone Park! Check out this video:
You may not be involved in the building of a Great Lakes Steamer or considering introducing mammals to a particular habitat, but you can always use the FMEA to make sure your process improvements don’t go awry. It’s an excellent and supremely simple tool with an easy to use template.