1.
Introduction
“The
Principles of Scientific Management” (TAYLOR, 1910) described the need for
management to develop and document the science and definition for each element
of an employee’s work to replace the old “rule-of-thumb” way of working. Taylor
firmly believed that it was up to management to determine the best way to do
efficient work with the use of “time and motion” and other process analysis
techniques.
Frank
Gilbreth created the first structured method for documenting the
flow of a process, which was presented to members of the
American Society of Mechanical Engineers (ASME) in 1921 as a
presentation titled “Process Charts - First Steps in Finding the One Best Way
to do Work” (GILBRETH, 1921). Gilbreth was a bricklayer who later turned into
an efficiency expert. He was consumed with the pursuit of improving the process
of bricklaying. His passion for process efficiency launched the birth of the
process mapping techniques that are used today. These process mapping tools
were later integrated into industrial engineering curricula. In 1947, ASME adopted a
set of symbols derived from Gilbreth's original work as the ASME Standard for
Process Mapping.
This
paper will show how that PPA is a continued evolution of the process mapping
techniques that Taylor and Gilbreth started. It incorporates Taylor’s
Principles through an expanded version of standard process mapping, while
assuring management involvement. Using PPA during business process analysis and
mapping events is an enlightening and often enjoyable experience for the
participants because it allows all of the issues in a manufacturing process and
the surrounding enterprise to be openly discussed and assessed. This effort should focus on blaming the
process and not the people in the process. When facilitated properly, all
inefficiencies, waste risks are identified using the additional 10 layers of
analysis in a process mapping exercise, which are added to a detailed process
map, one layer at a time.
The
author has been able to identify 54 organizational elements of risk assigned to
5 tiers of risky chain reactions to explain almost every human-made negative
outcomes or disaster in business. A wide array of unpublished business cases
with negative outcomes has been studied by the author as well as many other
highly publicized human-initiated disasters, of which a small sampling is
listed below:
·
The
Iroquois Theatre Fire Of 1903 (BRANDT, 2003)
·
Sinking of sank the Titanic in 1912 (MCCARTY, 2008)
·
Great
Chinese Famine (1958-1961) (DIKOTTER, 2010)
·
The USS Indianapolis Sinking in 1945 (THE USS
INDIANAPOLIS STORY, 1998)
·
Banqiao Reservoir Dam
failure, China, in 1975 (XINHAU,
2005)
·
NASA Space Shuttle Challenger disaster in 1986 (ROGERS,1986)
·
Alaska Airlines Flight 261 crash in 2000 (NTSB, 2002)
·
Petrobras 36 Oil Rig sinking in 2001 (WANDER, 2008)
·
NASA Space Shuttle Columbia disaster in 2003 (GEHMAN,
2003)
·
Deepwater Horizon Oil Spill in the Gulf of Mexico in
2006 (GRAHAM AND REILLY, 2012)
When
large clusters of 54 available Inefficiency and risk Icons are assigned to
specific process steps within a process map, this is a visual signal that
highlights the need for dramatic process re-engineering in specific areas. The
Inefficiency Icons represent organizational weaknesses that are part of 5 tiers
of destructive chain reactions, that should be addressed to remove business
risk, improve process efficiency and enhance customer satisfaction. The highly
visual efficiency assessment of processes using PPA with its 10 layers of
analysis allows the process analysis group to focus in on specific areas of the
process that are not working well and are in need of immediate improvements.
The
use of PPA will be demonstrated in this paper with the analysis of a simple
generic manufacturing process shown in Figure 1. Each of the 10 layers of
Pictorial Process Analysis will be added to assess this manufacturing process
and bring it to life and determine its true efficiency levels. PPA identifies
organizational barriers that are holding processes back from greatness.
The
manufacturing process shown in Figure 1 is a very general process map, which,
by itself, does not help us to assess its efficiency or opportunities for
improvement. Ten layers of process analysis will be added to this simple
process map to identify its true efficiency levels, which is necessary to
critique, analyze, then optimize this process.
Figure 1: The simple manufacturing process
used as a basis for analysis.
Source:
The Author)
|
2.
Research
Methodology
The
theories created, fine-tuned and applied in Pictorial Process Analysis has been
successfully applied by companies in many industries to assess and address the
internal barriers that hold them back from achieving process improvement
breakthroughs. PPA was the result of 9+ years of Qualitative Research using
inductive reasoning and the Grounded Theory Method (GTM) of research, usually
applied in social work research (OKTAY, 2012). The author used GTM under an
Applied Research agenda, with the goal of developing a practical an analytical
method for modern companies to reduce risk, optimize their business processes
and break their barriers to greatness. Three open-ended Applied Research &
GTM research-style "What's going on here" questions were asked at the
beginning of the research that led to the discovery of the 5 chain reactions
and their elements of risk:
·
What
are the common causes for business mediocrity, missed targets and disasters?
·
What
are the barriers that hold organizations back from greatness?
·
What
techniques could be created to identify the barriers to greatness and help to
transform ordinary business processes into extraordinary ones?
These
research questions were pointed at a select series of well documented serious
business disasters and at businesses during dozens of Lean Kaizen events that
the author facilitated. Many other business distress case studies were also
subjected to this style of research.
The
details of business distress and disaster case studies were investigated,
analyzed, coded for commonality of cause and further coded for theorized
interactions and tiered chain reactions. The final working theories of the
author's research identified five chain reaction waves that are capable of
destroying any organization of any size and mission. There are many elements of
risk inside each of these waves that have been identified that can be
highlighted with the author's inefficiency and risk cards during detailed
process mapping of individual business processes.
3.
The
Theory of Self-Destructive Chain Reactions
The
result of the above mentioned research is a theory that is applied in PPA. This
Theory states that most cases of organizational mediocrity, missed targets,
business failures and even serious disasters are initiated by self-destructive
and avoidable chain reactions that can be displayed and taught to professionals
with the help of a unique deck of cards. This all-too-common scenario of
escalating negative consequences is described below.
1.
A
series of Undisciplined Leadership Practices (16 Aces) can create…
2.
flaws
in the Work Environment (10 Kings), which can cause…
3.
serious
inefficiencies in Work Processes (21 Queens), which can cause…
4.
a
bad or failing Business Report Card (9 Jacks), which can cause…
5.
a
surprisingly faulty response to high risk situations (2 Jokers), for which the
final outcome can be disastrous.
The
54 elements of risk in the 5 chain reactions (The Aces, Kings, Queens, Jacks
and Jokers) are ever-present and can flair up at any time, without warning, if
they are not consciously and continually assessed and addressed. The author has
developed a USA Patent Pending Business Improvement Process that can be used to
assess and address these elements of risk in chain reactions and break these
barriers to greatness. PPA is very integral to that improvement process, which
can be applied to any business process within any service or manufacturing
company.
4.
The
10 Layers of Pictorial Process Analysis
A PPA
event to improve a specific process is best conducted with the use of a
cross-functional core team of process experts. Other process experts can be
brought in to aid in the analysis as needed.
The
10 layers of Analysis used during PPA are listed below with a short explanation
for each layer of analysis.
1. Identify
and add specific “Swim Lanes” to the process map to show each functional area, department
and customer that interacts with the manufacturing process.
2. Identify
all correction, redo, rework and repair loops on the process map, even if they
do not happen all the time. Show how many times these loops actually happen.
3. Identify
how long (Low to high range) each process step takes. If there are extended
waiting times, elevate the “Wait” step to an official process step so it can be
targeted for improvement.
4. Identify
and note what percent of VA (Value Added) activities are included in each
process step. If the VA% is less than 50%, note it as red. If the VA% is
greater than 50%, note it as green. Use innovation techniques to pursue 100%
VA. Focus on possibilities and solutions, not excuses.
5. Note
the estimated FTY (First Time Yield) of the process step and decision. In other
words, what is the percent of the time that this process step is done right the
first time?
6. Show
Red dotted boxes to depict redo, fix, rework or repair loops in the process
necessary to correct errors. Also note the number of times each redo loop
happens.
7. Note
if data is being collected for each process step that can be used for process
efficiency and performance analysis purposes.
8. Show
which of the 54 Inefficiency and risk Icons apply to this process and place
them next to the process steps on the process map when they are present. This
will highlight areas that need to be improved.
9. Add a Total Process Efficiency Scorecard noting the
ranges in efficiency from low end to high end, for the following criteria:
a.
Total Process Lead Time (How
long does the process take?)
b.
Adjusted VA Time for the
process (The time of the "true value" present in the process)
c.
Total % VA Time for the whole
process (The true process value in %)
d.
RTY (Rolled Throughput Yield)
for the whole process (The probability that
a product will make it through the process without any issues)
10. Add a concise executive
summary of the process analysis
findings that PPA identified.
·
Analysis
Layer #1: Adding Swim Lanes to align tasks to Departments
The
PPA team will identify and add specific “Swim Lanes”, shown in Figure 2, for
each functional area, department and customer that interacts with the
manufacturing process depicted in Figure 1. The purpose of this layer of
analysis is to understand the interactions within and between different
departments as well as interactions with customers. It might be discovered that certain
department hand-offs create more delays and errors or that customers are poorly
informed on information that is critical for them. This step will also help to
determine if one department is too overloaded and if too many tasks are being
done in series and not in parallel, which could slow down the process. 7 to 21
swim lanes will usually be required to represent manufacturing processes to
capture all of the actual department activities and interactions. After this
layer of analysis is completed for the current process, the team should
brainstorm what improved department and customer interactions should look like.
Complexity reduction should be a priority during this effort.
Joseph
M. Juran was a strong proponent of cross-functional process excellence as defined
in his "Juran Trilogy" (JURAN, 1988). Most processes cross different
functional and department lines. Juran stressed the need for cross-functional
excellence, which includes quality planning, quality control and quality
improvement in manufacturing processes. Management should not just let
processes randomly develop on their own but help to design and manage processes
to ensure an efficient, productive and competitive outcome.
|
Figure 2: Swim lanes added to the previous process
map. Source: The Author |
·
Analysis
Layer #2: Identify and add all Redo and Correction Loops
Add a
description of all correction, redo, rework and repair loops to the process
map, even if they do not happen all the time. Show what percent of the time
they actually happen. Do the same for any decision point (diamond symbol). The
purpose of this layer of analysis is to identify the amount of redo, rework and
repair loops that are present. This will help you to assess the impact of all
process decisions. Figure 3 shows what the manufacturing process looks like
after the swim lanes; decision points and redo loops have been added to the
process map. Whenever decision points are listed, note the percent of the time
for each of the optional outcomes of the decision, as shown in Figure 3. After
this layer of analysis is completed for the current process, the team should
brainstorm how to minimize or eliminate the redo loops for the new and improved
process.
Figure 3: Correction,
redo, rework and repair loops are added to the previous manufacturing process. (Source: The Author)
·
Analysis
Layer #3: Identify how long it takes for each Process Step
Add a
time note on the process map for the duration of each process step and decision
point. If there is variation in the time estimates, note the range of those
times on the process map, from the best time to the worst time. The purpose of
this layer of analysis is to identify the process steps that take too long so
that the PPA team can brainstorm opportunities for improvement at the end of this
analysis step. These new ideas will be implemented later when the new process
is developed. Figure 4 shows what the process map now looks like when the times
are added to the process steps. Unacceptable waiting periods are often
identified during this analysis. When excessive waiting periods are identified,
add them as an official process step. Do not just add those waiting times to
the process step before or after the waiting periods in an indiscriminate
manner.
Carrying
out time studies for manufacturing processes is an important analysis step,
which was identified as early as 1910 by Frederick Taylor and others. It is
also an important aspect of Value Stream Mapping as originally defined by
Shingeo Shingo (SHINGO, 1986) from Toyota and in later books from James Womack
(WOMACK, 1996) and others.
|
Figure 4: Notes are added to the
previous process map to show how long each
step in the process takes to complete. Source: The Author |
·
Analysis
Layer #4: Identify the Percent of Value added activities for each Process Step
Adam
Smith was a Scottish economist and moral philosopher. He published the book
“The Wealth of Nations” (SMITH, 1776), which argued that “productive labor”
adds to the wealth of an entire nation and its economy, while
"unproductive labor" does not. That drove the birth of the concepts
for VA and NVA. VA work can be best defined as those activities that an
external customer could fully appreciate as an activity that is fully worth the
expense and effort of doing it. NVA activities are those that an external
customer would not see any sense in doing and would deem as a "waste of
time and effort". All forms of waiting and other forms of NVA, no matter
how excusable they may seem, should be targeted for elimination. PPA teams are
chartered to drive process innovation, not to make excuses.
The
purpose of this layer of analysis is for the PPA team to estimate the percent
of VA that is present for each process step and decision. These estimates for
the percent of VA (Value Added) will be added to the process step as shown in
figure 5. If the VA% is less than 50%, note it as red. If the VA% is greater
than 50%, note it as green. The team must ask themselves 2 questions:
·
Does this process or decision
point add any true value to the final customer
(%VA external)?
·
How efficient is each of the
process steps (%VA internal)?
Efficiency
estimates for each process step will have to be made. An example estimate
follows.
·
Example #1: A certain
manufacturing process activity is only 50% internally
efficient but it is 100% important to the customer. In that case, the %VA would be 0.5 x 1 = 50% VA.
·
Example #2: A certain
manufacturing process activity is 95% internally efficient but it is totally
unimportant (0%) to the customer. In that case, the %VA would be 0.95 x 0 = 0%
VA.
The
percent of value that should be added for each process step will be calculated
as follows: The true efficiency of the internal activities (% internal VA/100)
multiplied by the perceived value of this process step in the eyes of the final
customer (% external VA/100). The results can range from 0% to 100%.
It
could be argued that quality checks are VA. In PPA, we argue, as Shingeo Shingo
(SHINGO, 1986) and others did from Toyota (OHNO, 1988), that quality should be
built into the product and manufacturing process and not inspected into the
product. If manufacturing processes were rigorously error-proofed (poke-yoke),
they would not need to be quality tested. Shingeo Shingo implemented this
concept at Toyota and made it part of the Toyota Production System (SHINGO,
1986). Highly efficient manufacturing processes prevent mistakes from happening
and do not rely on imperfect quality checks to sort out defective products.
Figure 5 shows how %VA information can be added to a PPA process map.
|
Figure 5: The
percent VA for each process step is added to the previous process map. Source: The Author |
·
Analysis
Layer #5: Identify the FTY for each Process Step
The
estimated FTY % (First Time Yield) should now be added for each of the process
steps and decisions. The team is now being asked here to estimate what is the
percent of the time that this process step is done right the first time. If
exact data is not available for this required performance metric, the team
should make a good estimate, which the team can agree on. The purpose of this
activity is to identify process steps that are not done right the first time,
which would require scrap, rework or customer complaints if the products or
services were sent to the customer, in error, before being corrected. After
adding this information to the process map, the team will scan the FTY notes
made on the process map and focus on the lowest FTY entries and brainstorm how
they might improve those situations in the new and improved process. These new
ideas will be implemented later when the new process is developed. See Figure 6
for how this information is added to the PPA process map.
Figure 6: A note is added to each
process step and decision to designate the FTY % for each process and
decision.
Source:
The Author
|
·
Analysis
Layer #6: Add Red Boxes around Redo Loops
The
purpose of this layer of analysis is to visually highlight the process steps
and decisions that are involved in redoing, repairing and correcting products
and services. Show red dotted boxes to depict redo, fix, rework or repair loops
in the process necessary to correct errors. Also note the average number of
times that each redo loop happens. The intent here is to identify how often
these redo loops happen so they can be minimized or eliminated in the new and
improved process. Figure 7 shows what this process map looks like when redo
loops are highlighted with the red boxes.
Figure 7: This shows what the process
map looks like when 2 redo loops are highlighted with dotted lines and added
to the previous process map.
Source:
The Author
|
·
Analysis
Layer #7: Identify where Data is being collected in the Process
Note
if data is being currently collected for any of the process steps that can be
used for process efficiency, trend analysis and performance assessment purposes
(See Figure 8). If process data is available, analyze it to learn more about
the process efficiency and performance levels over time and use that data to
calculate efficiency and performance levels for different customers and
products.
Figure
8: Data collection symbols are now added to show
if process data is being collected for the process steps.
Source:
The Author
|
·
Analysis
Layer #8: Adding Inefficiency Icons to represent the forms of Waste and
Inefficiency present in the Manufacturing Process
The
purpose of this layer of analysis is to "pictorially" depict the 54
barriers to greatness (54 cards from a unique deck of cards shown in figure 9)
and negative chain reactions (Aces, Kings, Queens, jacks and Jokers) that
threaten specific business processes.
Larry
Bossidy notes that “many people regard execution as detail work that’s beneath
the dignity of a business leader. That’s wrong. To the contrary, it’s a
leader’s most important job” (BOSSIDY, 2002). 13 of the 54 cards in PPA can
highlight undisciplined leadership attributes that need to be addressed.
Leadership aspects of an organization have a paramount impact on the efficiency
of their manufacturing processes. Other process assessment techniques avoid
this sensitive issue of Operations Management assessment; PPA does not.
Disasters are initiated by self-destructive and avoidable chain reactions. This
layer of analysis is intended to visualize those threats by pasting the
specific cards next to the process and decisions in the process map where those
risks exist. The 54 elements of risk are pictorially shown in Figure 9.
Some
of the best hands-on and iconic CEOs in the USA, like Jack Welch (GE) and Larry
Bossidy (Allied Signal/ Honeywell) have written about their management
philosophies and paths they followed that enabled their successes in business
leadership (WELCH, 2001), (BOSSIDY, 2002). Jack Welch, at the end of his
career, reflects in his book “Jack - Straight from the Gut” (WELCH, 2001) on
what made GE a great company. He does not boast much about the great products
they made but rather he states: “in the end, I believe we created the greatest
people factory in the world, a learning enterprise, with a boundary less
culture”. Jack Welch knows that if you create great people, great products will
follow, so he and GE addressed the root cause (people development), which in
turn will drive the creation of great products. Any effective process analysis
technique must be able to assess risky cultural issues; PPA does. Jack Welch
also states: “I stuck to some pretty basic ideas that worked for me, integrity
being the biggest one”. PPA also has a card (Ace #9) that can be used to flag
any integrity issues that can have a negative effect on a manufacturing
process.
Larry Bossidy’s book “Execution – the discipline of
getting things done” (BOSSIDY, 2002) talks a lot about the right and wrong
management behaviors and attitudes he observed later in his career. He saw
manufacturing facilities where “plants were run by accountants instead of
production people."
The
previously listed 54 barriers to greatness are fully capable of holding
organizations back from attaining high levels process efficiency. Figure 9
shows the cards available for use in PPA. For organizations with mature
business process management techniques in place, the Ace and King Inefficiency
Icons might not be required for the assessment of their organizations. These 54
risk factors also incorporate the philosophy of Deming’s 14 Key Principles
published in his book “Out of the Crisis” (DEMING, 1982), which are actions
required by management first, to signal that they are capable and seriously
engaged in the right activities to drive efficiency, stay in business and
protect investor interests and employee jobs. These culture-shift activities
must be driven by top management.
Frederick
Winslow Taylor (TAYLOR, 1911) also noted many strong opinions in his book “The
Principles of Scientific Management” where he notes that management should take
over all work for which they are better suited for than the workers, stating
that in the past almost all of the work and responsibility was thrown upon the
workers to struggle with. They usually did not have the proper level of
expertise or management authority and support to deal with the challenges they
were given.
|
Figure 9: The 54
forms of waste, inefficiency and risk. Source: The Author |
Figure
10 shows what the next level of a PPA process map could look like if all top to
bottom aspects of the enterprise were assessed and not only the direct
activities in which the production workers are active. The top row of
Inefficiency Icons above the process map shows inefficiencies in the operations
management. The second row of Inefficiency Icons assesses the weaknesses in the
work culture and the resulting organization’s overall mode of operation.
Figure 10: The PPA team now assigns the
efficiency risk factors that relate to this manufacturing process.
Source:
The Author
|
The
Inefficiency Icons shown inside the process map identify the forms of waste,
inefficiency and risk inside this process. The icons above the process map
highlight management and cultural issues to address. The purpose of this step
in PPA is to visually highlight all of the efficiency barriers and risk factors
that the PPA team must address in the new and improved process.
·
Analysis
Layer #9: The Total Process Efficiency Scorecard
A
total summarized Process Efficiency Scorecard (Figure 11) should be added at
the end of the process mapping analysis, which includes key calculated
efficiency performance metrics for the manufacturing process. This particular
PPA assessment was supplemented with 3 Inefficiency Icons, which best described
the manufacturing process under review. The RTY range shown here of 16 – 31% on
the scorecard in Figure 11, is the Rolled Throughput Yield. RTY is the result
of multiplying all FTY values against each other. RTY is best described as the
probability that a product or service will make it through this manufacturing
process without being scrapped, reworked or being defective in some way.
This
process scorecard is somewhat similar in nature with the Balanced Scorecard
(BSC), which was popularized in the 1990s by Bob Kaplan (KAPLAN, 1992) and
others.
|
Figure 11: The
Process Efficiency Scorecard and Inefficiency Icons that best describe the
whole process. Source: The Author |
·
Analysis
Layer #10: An Executive Summary of the process analysis findings
What
follows is an example of an executive summary typically used to wrap up the PPA
work.
There are various management and work environment inefficiencies that
handicap this process and hold it back from greatness. Actual process activity inefficiencies
include unsynchronized cycle times, low VA percentage process steps, low First
Time Yield (FTY) activities and low quality levels, which result in low
internal and external customer satisfaction levels. The organizational
fire-fighting efforts are ineffective and only address the symptoms and not the
true root causes. This leads to elevated employee stress levels, frustration
and high employee turnover.
Inefficient
Operations Management is the root cause here for the lack of performance stated
above. It is not the fault of the employees who work in an ineffectively
managed process. In the book “Good to Great” (COLLINS, 2001), Jim Collins
describes beneficial and reckless management styles that can greatly influence
the success or failure of entire companies. The next step for the PPA team
would be to create a new and improved process, which is not shown in this
paper. That new process map, supplemented with a detailed action plan list,
will have to demonstrate how the PPA team will eliminate the waste,
efficiencies and risk in the current process.
5.
creating
the new and improved process
At
the end of a PPA session, the process analysis team should be ready to
brainstorm ways to address all of the process weaknesses that have been
identified. After that brainstorming exercise, realistic process improvement
solutions should be identified for the proposed new and improved process. The
proposed new process should also be subjected to the same PPA layers of
analysis as the current process was exposed to. Noticeable improvements for all
of the layers of analysis should be achieved. If this is not the case, the team
brainstorming for improved solutions was not effective. PPA strives to achieve
"new and improved" processes, not just "new" processes.
After management has approved the improved solutions, the PPA team leader or an
experienced program manager should be tasked with rolling out all of the
organizational communications, process changes and training required to
transform the old process into the new and improved process. This could happen very
quickly or over a few weeks or months, depending on the complexity of the
changes required.
6.
Conclusion
PPA
can create high resolution XRAY pictures of business processes that can be used
to accurately assess process efficiency, health, competitiveness and their
ability to satisfy internal and external customers. When analyzed correctly
with a team of process experts, the current process should be able to achieve
vast improvements in cycle time, overall process lead time, error rates, scrap
rates, customer satisfaction, value added activities and rolled throughput
yield. Vast reductions in process complexity, risk and inefficiency should also
be attained. Process mapping can be very effective way to understand, document
and optimize business processes. PPA, with its 10 layers of analysis, can offer
much more process scrutiny and identify many more opportunities for improvement
than classic process mapping.
REFERENCES
BOSSIDY, LARRY (2002), Execution – The Discipline of Getting
Things Done, Crown Business / Random House, NY
BRANDT, NATT, (2003), Chicago
Death Trap: The Iroquois Theatre Fire Of
1903, Southern Illinois University
Press, Southern Illinois University Press, Chicago, Ill
BUNKER, FRANK, GILBRETH, LILLIAN MOLLER GILBRETH (1921) Process Charts. American Society of Mechanical
Engineers
COLLINS, JIM (2001), Good to Great, Harper Business, NY
DEMING, WILLIAM E. (1982), Out of the Crisis, Cambridge University
Press, Cambridge
DIKOTTER, FRANK,
(2010), Mao's Great Famine, Walker
Publishing Company, NY
GEHMAN, HAROLD, (2003),
Columbia Accident Investigation Board,
Washington, DC
GILBRETH, FRANK,
(1921), Process Charts, ASME, NY
GRAHAM, BOB AND REILLY, WILLIAM, (2012), Deep
Water - The Gulf Oil Disaster and the Future, Report to the President,
National Commission on the BP Deepwater Horizon Oil Spill and Offshore
Drilling, Washington, DC
JURAN, JOSEPH M.
(1988), Juran on Planning for Quality,
Free Press, New York, NY, USA
KAPLAN, ROBERT S. AND
NORTON, DAVID P. (1992), "The
Balanced Scorecard", Harvard
Business Review Jan – Feb, 1992
KESWANI, RAJKUMAR,
(1984), Wake up
people of Bhopal, you are on the edge of a volcano!, Hindi Jansatta daily, http://bhopal.net/an-entirely-avoidable-disaster/,
Bhopali, India
MCCARTY, JENNIFER (2008),
What Really Sank the Titanic,
Citadel Press, NY
NTSB - National
Transportation Safety Board, (2002), Loss of Control and Impact with Pacific Ocean Alaska Airlines Flight
261 McDonnell Douglas MD-83, Washington, DC
OHNO, TAIICHI (1988), Toyota Production System, Productivity
Press, Portland, Oregon
OKTAY, JULIANNE (2012), Grounded Theory, Oxford Press, NY
PATRISHKOFF, DAVID (2010), Training in PPA &
E3 Extreme Enterprise Efficiency:
http://leansixsigmaandbeyond.com/
PATRISHKOFF, DAVID (2012),
Pictorial Process Analysis (PPA),
Paper presented for the International Conference on Industrial Engineering and
Operations Management (ICIEOM’2012), Guimarães, Portugal
PATRISHKOFF, DAVID
(2013), Breaking the Barriers to
Greatness, Slideshare, http://www.slideshare.net/davidpatrishkoff/16-slide-pres-of-bt-war-games-for-slide-share
ROGERS,
WILLIAM, (1986), Presidential Commission on the Space Shuttle Challenger Accident, Washington, DC
SHINGO, SHINGEO (1986),
Zero quality control:
The Poka-yoke System, Productivity Press, Portland,
Oregon
SMITH, ADAM (1976), The Wealth of Nations, The Works and Correspondence of
Adam Smith, Scotland
TAYLOR, FREDERICK
WINSLOW (1911), The Principles of Scientific Management, Harper and Bros., New
York, NY
The USS Indianapolis Story, (1998), http://www.ussindianapolis.org/intro.htm
WANDER, STEVE, NASA Safety Center, (2008) System
Failure Case Studies - That Sinking Feeling (Petrobras 36 Oil Rig sinking),
volume 2, issue 8
WELCH, JACK (2001), Jack
- Straight from the Gut, Warner Books, NY
WOMACK, JAMES P.
(1996), Lean Thinking, Simon &
Schuster, NY
XINHAU CHINA
NEWS AGENCY, (2005), After 30 years, secrets, lessons of
China's worst dams burst accident surface, http://english.people.com.cn/200510/01/eng20051001_211892.html,
China