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or. In slide show mode: slides advance automatically, fade-in, fade-out. Enjoy!. REALITY CHECK: Each of these disasters involved a process flaw Systemkey ™ competitors’ failed to catch. If “their way” worked, we wouldn’t have:. Lehman, Sep 2008 $613B bankruptcy

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  1. or In slide show mode: slides advance automatically, fade-in, fade-out. Enjoy!

  2. REALITY CHECK:Each of these disasters involved a process flaw Systemkey™ competitors’ failed to catch.If “their way” worked, we wouldn’t have: Lehman, Sep 2008 $613B bankruptcy Residual Risk: financial deception/fraud AIG 2008-2009 $182.5B bailout Residual Risk: financial incompetence/deception/fraud BP Deepwater, Apr 2010 $40B cleanup+settlements Residual Risk: untested, unproven processes Costa Concordia Jan 2012 17 confirmed dead, 15 missing, $800MM vessel lost + ?? in settlements? Residual Risk: multiple process violations, lack of feedback (false negative) on switching off approved route monitor Enron, Dec 2001 $63.4B bankruptcy Residual Risk: financial deception/fraud MCI Worldcom, July 2002 $107B bankruptcy Residual Risk: financial deception/fraud Fannie Mae/Freddie Mac, Sep 2008 $291B takeover Residual Risk: financial incompetence/deception/fraud Chernobyl, Apr 1986 est. 985,000 event-driven, cancer-related deaths 1986-2004, cleanup est. $605MM to-date Residual Risk: failed communication, lack of training Piper Alpha North Sea, July 1988 167 died, $3.4B cleanup Residual Risk: violated design parameters, lack of full maint status sit-rep Mars Climate Orbiter, Sep 1999 $125MM loss of spacecraft Residual Risk: mix-up between English & metric units Three Mile Island, Mar 1979 $1B cleanup, $1MM fine each day didn't deliver power Residual Risk: confusing signage; faulty ergonomics Kansas City Hyatt, July 1981 114 died, 216 severely injured $140MM cleanup+settlements Residual Risk: poor communication, fail to validate new drawings Bhopal, Dec 1984 3,787 died, est. 3,900 injuries+birth defects $470MM settlement, remaining envir cleanup Residual Risk: malfeasance, safety systems turned off Tacoma Narrows Bridge, Nov 1940 $8MM cost to construct, lasted 4 months! Residual Risk: invalid scientific theories Thalidomide, 1957-1962 est. 1500 died/15,000 birth defects, $20MM trust fund Residual Risk: invalid scientific theories Tenerife, Mar 1977 583 died, $110MM settlements, loss of two planes Residual Risk: early take-off/lack of standard phraseology

  3. Questions? Thank you for your interest! Matthew E. Weilert Systems Thinking Institute LLC systhink@systemkey.net +1-866-288-0530 North America +1-847-227-3006 International

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