Newman, J.S. and Wander, S.M. (2018), "Prelims", Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning, Emerald Publishing Limited, Leeds, pp. i-xiii.



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Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning

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Harnessing the Power of Failure: Using Storytelling and Systems Engineering to Enhance Organizational Learning




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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN: 978-1-78754-200-6 (Print)

ISBN: 978-1-78754-199-3 (Online)

ISBN: 978-1-78754-201-3 (Epub)


John Steven Newman

For my Mary, Scott, and Matt

Stephen M. Wander

To my beloved wife Sandy, “Until we meet again.”

And for my children, ShariLynn, TariLee, CJay


Acknowledgments ix
About the Authors xi
Prologue xiii
Part I Introduction and Overview 1
Overarching Goals 2
Layout and Flow 4
Part II System Failure Case Studies 7
Case Study Format 8
Quick-Look Guide 9
That Sinking Feeling 12
Lewis Spins Out of Control 19
Almost Perfect 27
Two Rods Don’t Make it Right 34
Supercritical 40
Submarine Down 47
Fire in the Cockpit 52
Derailed 59
Powerless 65
Fender Bender 72
Innovation Pushed Too Far Too Fast 79
No Left Turns 86
Forrestal in Flames 93
Tunnel of Terror 100
Death on the Steppes 107
Rocky Mountain Death Trap 113
Refinery Ablaze – 15 Dead 120
The Million Mile Rescue 125
Part III Recurrent Themes – Integrated Analysis 133
Introduction 133
Enterprise/Business Management Framework 136
Enterprise/Business Management: Observations 138
Engineering Framework 141
Engineering Framework: Observations 144
Another Way of Looking at the Data 145
Part IV Harnessing the Power… or Not 147
Introduction 149
Navy SSP – ‘Always Had It and Kept It’ 149
Navy SUBSAFE – ‘Learning from Early Failure’ 152
Petrobras – ‘Had It and Gave It Away’ 155
WMATA Metro System – ‘Lacked Initial Safety Culture but Recovering’ 155
Metro Renaissance – The Winds of Change 159
Summary 161
Part V Roadmap to Harnessing the Power 163
Introduction 163
Leadership that Leads 163
Developing Enterprise Success Factors 166
Understanding Enterprise Vulnerabilities 171
People and Culture 176
Control – Checks and Balances 181
Embracing the Gift of Failure 188
Part VI Applying the Power of Failure 191
Introduction 191
Organizations/Enterprises 192
Academia 195
Summary 199
Epilogue 201
Bibliography and References 203
Acronym List 221
Index 225


The System Failure Case Study (SFCS) concept evolved from the notion of “hind casting,” or learning from failure events - a method Dr. Newman encountered in class at George Washington University in the Fall of 1999 (Risk and Crisis Management). In early 2000, the first prototype system failure case studies were developed based on a series of Titan IV launch mishaps. While addressing other issues, including support to the Columbia Accident Investigation (2003), the authors together evolved the SFCS to incorporate an increasingly sharp systems engineering “lens.” In the post-Columbia accident era, with an increased emphasis on knowledge management and lessons learned activities, the SFCS format underwent further evolution and development. The National Aeronautical and Space Administration (NASA), Review and Assessment Division (RAD) began developing and widely disseminating SFCSs in the 2005 time frame, employing NASA’s first operational knowledge management system. We wish to salute our colleagues in the RAD and the Office of Safety and Mission Assurance (OSMA) who supported SFCS implementation, in particular, Mr. John Castellano, and Mr. Bryan O’Connor, NASA Chief Safety Officer. We would also like to recognize Bryan for his ‘thought leadership’ relevant to safety, mission assurance, and organizational accountability in high reliability organizations (HRO). In developing our roadmap to harnessing the power of failure we draw on HRO philosophy evolved from leaders in the aerospace community but also derived from the joint NASA/Navy Benchmarking Exchange (NNBE) (2000–2003). In particular, we acknowledge our Navy counterparts, Messers Al Ford, Jimmy Lawrence, and Storm Kauffman for their valuable insights related to safety and risk management within the Navy nuclear propulsion and SUBSAFE programs. Most recently, we have had the opportunity to gain deep insights into the Navy Strategic Systems Program high reliability assurance culture and focus on multilevel leadership and human element weakness. We thank Vice Admiral Terry Benedict and Mr. Steve Zavadil for their valued time and effort in meeting with us. Very special thanks is extended to Mr. Don Vecellio, a long-time and valued colleague, for his encouragement and thought-provoking ideas and advice concerning the overall form and structure of the book, and to Mr. Coleman Cunningham for his insights and experience related to undergraduate general business and strategic management curriculum at the Fisher College of Business, The Ohio State University. The authors also wish to acknowledge Dr. Michael Stankosky for his support in encouraging us to move forward with this project and providing us navigational assistance along the challenging road to publication. Finally, the authors are deeply indebted to Ms. Charlotte Maiorana, Mr. Nick Wolterman, and S. Rajachitra of Emerald Publishing for their unwavering faith, guidance, and patience offered during the development and evolution of the themes, ideas, and production of this work.

About the Authors

J. Steven Newman, D.Sc. John Steven Newman had a distinguished 32 year career in government, with the National Aeronautics and Space Administration (NASA) and the Federal Aviation Administration (FAA). His experience base spans the Concorde Supersonic Transport, the Titan IV launch vehicle, the Space Shuttle, the International Space Station, and NASA Space Shuttle / Nuclear Submarine Benchmarking Exchange Program. Dr. Newman served in diverse leadership roles spanning project management, flight test, safety, quality, risk management, environmental management, accident and failure analysis. After retiring from NASA in 2006 Dr. Newman has served as an aerospace consultant, educator, and fine arts student. Dr. Newman holds a Bachelor of Science in Electrical Engineering, a Master of Science in Environmental Engineering from Northwestern University, and a Doctor of Science in Systems Engineering from The George Washington University.

Stephen M. Wander, B.M.E., M.E.A. Steve Wander has over 45 years of engineering management, research and development experience with the National Aeronautics and Space Administration (NASA), Energy Research and Development Administration (ERDA)/Department of Energy (DOE), and the United States Air Force. Since retirement from NASA Mr. Wander has served as a senior consultant in the fields of engineering management, risk management and systems engineering. Mr. Wander has also served as a Professorial Lecturer at George Washington University in the School of Engineering and Applied Sciences teaching graduate courses in engineering management, decision-making and problem-solving and undergraduate courses in probability, statistics, and statistical inference methods. Mr. Wander holds a Bachelor of Mechanical Engineering degree from The Ohio State University, and a Master of Engineering Administration degree from George Washington University.


A quick navigational tip – The authors have attempted and intended that each part of this text stand on its own with respect to focus, structure, and informational content. Accordingly, it is not necessary nor required to read or review all the case studies presented in Part II before proceeding to other parts – ‘analysis,’ ‘organizational examples,’ ‘system engineering tools and techniques,’ or ‘teaching models and methods.’ It is, indeed, up to the needs and desires of the reader. So, feel free to pick and choose the cases of greatest interest – then move on through the rest of the book cycling-back at any point to explore additional cases.