CASE STUDIES USING AN EPISTEMOLOGICALLY DERIVED SYSTEMS THINKING APPROACH IN A FAILURE PREVENTION CONSULTING PRACTICE

摘要

How much work is enough work? How do we know that we have "done diligence" when we are planning a protocol for a machinery failure prevention project? The responsible approach to such projects which are an outgrowth of a serious failure event or a series of events differs from that which are a result of an event with minimal consequences of repetition. In some cases, spending a few hours to review the situation with eyeballs and brain and examining the machinery and some historical documentation may provide sufficient epistemological confidence. This minimalistic approach still gives two ways to view the situation. If both eyeballs / brain and paper trail point to the same place or at least don't contradict each other, then we can take action and move on. However, if the failure has led, or if repeated might lead, to major consequences, we probably need to do more up front work, before taking action to "prevent recurrence." No single viewpoint can determine the optimum amount of detail for any given investigation. A business decision, based on which criteria will be examined and in how much detail, must be made. The business decision will be made in an effective manner when an evolving, non-linear, transparent, value hierarchy (valuarchy) is used to flexibly plan the work scope.