CONTACTS 
0201 - Intel Corporation
020101 - Mr. Morris E. Jones; Director of Architecture

SUBJECTS
Risk Communication Main Factor of Management Success
Rework Cycle Due to Miscommunication
Difficult to Calculate, Difficult to Believe
Mistakes Avoided, Saves Money, Lawsuits
Not Enough Time to Succeed
Denial Managers Making Mistakes Reject Savings
Communication Biggest Risk of Mistakes
Traceability & Aligning Communications
Engineering Management Mistakes
Simple Error Doomed Mars Polar Orbiter

2612 -
2612 -    ..
2613 - Summary/Objective
2614 -
261401 - Follow up ref SDS 60 0000, ref SDS 51 0000.
261402 -
261403 - The front page headline in the San Francisco Chronicle today has an
261404 - article on....
261405 -
261406 -
261407 -             Simple Error Doomed Mars Polar Orbiter
261408 -
261409 -
261410 - ...causing $125M loss of a space craft, ref OF 8 0001, plus $100M more
261411 - in planning and management costs, because engineers submitted
261412 - information on guidance using pounds, and the computer at another
261413 - location was programmed to use grams for the metrics system.
261414 - ref OF 8 4028
261415 -
261416 -      [On 991008 contacted author of article. ref SDS 68 0001]
261418 -       ..
261419 -      [On 991207 President announces initiative to reduce medical
261420 -      mistakes;, ref SDS 69 0889; letter to Intel cites further
261421 -      problems in NASA's Mars program. ref SDS 70 2881]
261423 -       ..
261424 -      [On 000328 report on NASA problems cites continual bumbling from
261425 -      striving to implement TQM objective -- faster, better, cheaper.
261426 -      ref SDS 71 0001
261428 -       ..
261429 -      [On 000822 Intel trying improve management. ref SDS 73 019R
261431 -       ..
261432 -      [On 001011 Firstone Ford trying to improve management avoid
261433 -      product defects causing accidents, cost $450M. ref SDS 74 0001
261435 -  ..
261436 - NASA officials report Lockheed should have used metrics for units of
261437 - measurements, rather than US standards. ref OF 8 0450
261439 -  ..
261440 - However, the larger flaw was failure to add "metrics" to communication
261441 - which aligns information with original sources under ISO criteria
261442 - requiring traceability to original sources, reviewed on 950721.
261443 - ref SDS 8 1740  Here, guidance data did not align with submission
261444 - requirements, which is an engineering management failure.
261446 -  ..
261447 - As a result, Lockheed's communication lacked context, and so was clear
261448 - and concise, but not complete.  On 950412 executives worry that
261449 - project managers do not tell the truth, yet insist communication be
261450 - limited to 25 words or 30 seconds, i.e., cursory, due to limited time.
261451 - ref SDS 7 3920
261453 -  ..
261454 - On 970524 case study found small communication mistakes caused
261455 - Columbia Space Shuttle crash in 1986. ref SDS 18 7298
261457 -  ..
261458 - On 990524 proposed Communication Metrics to improve engineering
261459 - management with traceability to original sources. ref SDS 36 0876  On
261460 - 990525 this could not be used because engineers don't like to write.
261461 - ref SDS 37 0966   On 990817 managers need commitment before getting
261462 - support that makes it easier to align work with requirements.
261463 - ref SDS 58 6829  Reflects cultural forces that require change in
261464 - attitude to improve management, reported on 990527. ref SDS 38 1233
261466 -  ..
261467 - $125M is an expensive "attitude" problem at IBM, Turner, USACE,
261468 - SFIA... everywhere.  How and where to begin solving "attitude"???
261469 -
261470 -     [On 991006 "attitude" caused medical mistakes. ref SDS 65 3596]
261471 -
261472 -     [On 991007 cited Mars incident in letter to Dave at Intel on using
261473 -     Com Metrics for risk management because communication is the
261474 -     biggest risk in enterprise. ref SDS 66 0001]
261476 -      ..
261477 -     [On 991008 wrote to Millie's daughter Pam, about setting a good
261478 -     example to develop constructive "attitude" for her son, who is 4
261479 -     years old. ref SDS 67 4140]
261480 -
261481 -
261482 -
2615 -

SUBJECTS
Little Deviations Lead to Big Problems
Murphy's Law, Avoiding Mistakes Requires More than Luck
Risk Caused by Complexity which causes Uncertainty
Intelligence Competence Enhanced Knowledge Space Saves Time Money Acc
Align Communications to Maintain Shared Meaning from Meetings, Calls
Align Avoid Rework Mistakes Subjects Discover all Factors
Communication Biggest Risk Enterprise Too Many Problems Stock Market
Error Too Small to Notice by Observing Daily Operations
Email Likely Caused Crash on Mars
Error Too Small to Notice by Observing Daily Operations
Email Likely Caused Crash on Mars

5013 -
501401 -  ..
501402 - Intelligence Avoids Mistakes:  Analysis, Alignment, Feedback, Summary
501403 - Communication Metrics Supports Concurrent Discovery of Alignment
501404 - Risk Management Identifies Small Risks Before They Grow to Disaster
501405 -
501406 - The error was too small to notice by observing daily operations
501407 - following launch of the Mars space craft; but, it multiplied many fold
501408 - over the months of space travel, and this caused the catastrophic end.
501409 - ref OF 8 6958
501411 -  ..
501412 - This fits Aristotle's point cited in the NWO... paper. ref OF 10 6056
501414 -  ..
501415 - On 970524 case study found communication mistakes caused Columbia
501416 - Space Shuttle crash in 1986. ref SDS 18 7298
501417 -
501418 -      [On 010725 analogy train wrech because bolts out of spec, cannot
501419 -      see wheels wobbling. ref SDS 75 HF4L
501421 -  ..
501422 - Since information overload increases the risk of "meaning drift," only
501423 - proactive Risk Management can maintain alignment of communication, as
501424 - reviewed on 960518. ref SDS 11 3734
501425 -
501426 -      On 970524 case study linking thousands of communications over 10
501427 -      years showed Columbia Space shuttle disaster in 1986 caused by
501428 -      small problems that grew due to telephone game. ref SDS 18 7298
501430 -       ..
501431 -      On 940611 a case study of an oil tanker that sank at sea, shows
501432 -      how "expediting" to avoid paperwork relies on conversation that
501433 -      ignores good management practice to align communications,
501434 -      ref SDS 3 2066, specified by ISO criteria, reviewed on 950721.
501435 -      ref SDS 8 1740  Lack of alignment causes small mistakes that are
501436 -      overlooked and grow over time into big catastrophes that are
501437 -      attributed to Murphy's Law, explained in the NWO... paper.
501438 -      ref OF 10 9449
501440 -  ..
501441 - The letter on 990924, ref DIP 2 1680, cites this same cause of medical
501442 - mistakes. ref SDS 62 0001
501444 -       ..
501445 -      Units of Measure Incorrect Email Likely Caused Crash on Mars
501446 -      Email Likely Caused Crash on Mars Units of Measure Incorrect
501447 -
501448 -      NASA engineers overwhelmed by information density, reported by
501449 -      CBS News on 60 Minutes, see 980412, ref SDS 29 8956, likely fell
501450 -      behind and got fouled up trying to make up time, (see later
501451 -      example reported on 011006, ref SDS 76 O99K), as occurred on the
501452 -      Columbia Space Shuttle that crashed in 1986, reported 921021.
501453 -      ref SDS 2 4499  Trying to catch up by "expediting," the engineers
501454 -      used email to "collaborate," which omitted units of measure, as
501455 -      people often do in email, as explained in POIMS. ref OF 9 YF5L,
501456 -      causing failure and loss of a $125M space craft, reported today.
501457 -      ref SDS 0 0001
501459 -       ..
501460 -      This seems likely because, if Lockheed had given the wrong units
501461 -      of measure along with the figures, it likely would have been
501462 -      noticed by the NASA people in Pasadena based on the report that
501463 -      this group has used metrics for a long time. ref OF 1 0820
501464 -      Evidently cursory methods were used to expedite.  Email is a
501465 -      popular method to "expedite" where people assume common
501466 -      understandings and omit information, as occurred here.
501467 -
501468 -          [On 000505 email proposed as core of KM system. ref SDS 72
501469 -          4392
501470 - ..
501471 - Risks of conventional email are explained in the letter on
501472 - medical mistakes, ref DIP 2 1045
501473 - ..
501474 - The Chronicle reports today that Lockheed is checking their
501475 - contract with NASA to see if units of measure were specified.
501476 - ref OF 8 4148  This applies traceability to original sources, see
501477 - again ISO criteria, ref SDS 8 1740, also, called "alignment" to
501478 - explain the role of "intelligence" in POIMS. ref OF 9 0582  However,
501479 - it is after-the-fact.  Proactive Risk Management recognizes it is too
501480 - late to discover requirements after the ship has crashed on Mars, or
501481 - at sea, or on the operating table.
501483 -  ..
501484 - Risk Management needs Concurrent Discovery supported by SDS that adds
501485 - and maintains alignment to make communication effective, developed on
501486 - 960620. ref SDS 12 1101
501488 -  ..
501489 - On 951212 a study on Risk Management reviewed communication alignment
501490 - as the most difficult requirement to maintain. ref SDS 10 8870
501491 -      ..
501492 -      Lockheed's conduct reflects NWO... sequence of discovering
501493 -      correct alignment after disaster strikes. ref OF 10 0645
501495 -       ..
501496 -      On 990912 articles on medical mistakes say hospitals use Risk
501497 -      Management after costly accidents occur, to avoid liability,
501498 -      rather than use management to reduce risk of mistakes.
501499 -      ref SDS 60 0165
501501 -       ..
501502 -      On 990925 Intel chip set delayed again due to poor management,
501503 -      ref SDS 63 0001, reflecting report on 970603.
501505 -       ..
501506 -      On 960620 Concurrent Discovery was developed to enable review and
501507 -      alignment with the record before mistakes occur. ref SDS 12 1101
501508 -
501509 -
501510 -
501511 -
501512 -
501513 -
5016 -

SUBJECTS
Communication Biggest Risk in Enterprise, Dilemma
90% Managers Time Communication
Risk Management Complexity Mistakes Communication
Too Many Problems Stock Market Crashes Downsizing Information Overloa
Bumbling Information Overload Highway Compounds Impact of Mistakes Re
Communication Biggest Risk of Enterprise Paradigm Shift of Millennium
$125M Mars Program Failed NASA Needs Loss Avoidance Communication Met
Communication Metrics Avoid Bumbling Discover & Fixes Mistakes
Align Avoid Rework Mistakes Subjects Discover all Factors

6011 -
6012 - 2128
601301 -  ..
601302 - Communication Primary Cause of Mistakes, SDS Alignment Needed
601303 -
601304 - Called and discussed space craft loss of $125M, per above, ref SDS 0
601305 - 0001, and related communication issues, per above, ref SDS 0 3192,
601306 - with Morris.
601307 -
601308 - We recalled our meeting on 960721 where Morris advised that Lockheed
601309 - had communication difficulty on a project with Intel and Chips.
601310 - ref SDS 14 0896  Possibly the same people or processes caused the
601311 - space craft to crash on Mars, because a small deviation grew into a
601312 - major problem over time, causing the loss of $125M. ref SDS 0 0001  On
601313 - 950303 Morris felt SDS could help avoid communication problems that
601314 - Chips people encountered at a meeting in Paris. ref SDS 5 3333
601315 - ..
601316 - I mentioned similarities between loss due to mistakes by NASA
601317 - and Lockheed, and public reports on 990925 of Intel's problems
601318 - releasing the 820 chipset. ref SDS 63 0001  Previously, on 990226
601319 - Intel delayed release of the chipset to September. ref SDS 32 0001
601320 - Now that target has come and gone.
601322 -  ..
601323 - Morris advised this matter is very secrete.  He feels SDS can't help
601324 - because communication was not the cause of Intel's delayed release of
601325 - the 820 chipset.  He cited 30,000 or so email have been issued to
601326 - ensure effective communication on this problem.
601328 -  ..
601329 - We reviewed my letter on 990718 explaining email is cursory and
601330 - incomplete, ref SDS 48 5251   Morris reported on 980722 that people
601331 - read and write email during long meetings at Intel. ref SDS 30 0464
601332 - Meeting notes consist of Power Point slide presentations, ref SDS 30
601333 - 4826, rather than alignment of what is discussed with requirements,
601334 - objectives and history, as reported by Dave Vannier on 970603.
601335 - ref SDS 19 5803
601336 - ..
601337 - On 951212 a study on Risk Management found that "understanding"
601338 - and "problem handling" are integral to communication which is the
601339 - biggest risk factor that causes mistakes. ref SDS 10 4433  Alignment,
601340 - also called "traceability to original sources" is a key aspect of
601341 - "understanding." ref OF 10 4212  On 970910 executives reported not
601342 - having time to think, which reduces understanding. ref SDS 21 3479
601344 -  ..
601345 - On 950927 Dave Vannier reported that email is Intel's least effective
601346 - business system. ref SDS 9 4939   On 970603 Dave related the need to
601347 - maintain alignment of communications at Intel. ref SDS 19 5803
601349 -  ..
601350 - Morris and I recalled this evening our discussion on 980722 about the
601351 - practice of reading and answering email during meetings, ref SDS 30
601352 - 0464, which causes cursory analysis and understanding set out in a
601353 - letter on 990718. ref SDS 48 5251
601354 - ..
601355 - I asked if Morris has read the letter explaining the cause and
601356 - solution to management mistakes, based on articles published the past
601357 - month about the high cost of medical mistakes? ref DIP 2 0001  It was
601358 - linked in the letter, ref DIP 3 0899, sent yesterday. ref SDS 64 5974
601360 -  ..
601361 - Morris advised that he has not had time to read the letter, since our
601362 - call yesterday. ref SDS 64 5696
601364 -  ..
601365 - The letter uses the "Telephone game" to illustrate how dialog and
601366 - documents that are not aligned compound error, as in the Lockheed
601367 - space craft crash on Mars. ref SDS 0 3192  Email is worse than dialog
601368 - and documents, because it is a stream of conscious rendering that is
601369 - devoid of alignment by virtue of shear volume.  Email is a series of
601370 - momentary impressions, that distribute errors faster and wider than
601371 - ordinary guess and gossip. ref DIP 2 1045   When a memo or letter is
601372 - printed and signed there is some level of review between admin and
601373 - author.  This reflection does not occur in email.
601374 - ..
601375 - We reviewed examples from the Broadwater Dam project where
601376 - errors in communication were repeated and compounded over months and
601377 - years through endless meetings, calls, fax and email.  See case study
601378 - on 990316. ref SDS 34 3088
601380 -  ..
601381 - Morris said Intel has a lot of sophisticated and powerful business
601382 - metrics to monitor mistakes.
601384 -  ..
601385 - Intel does not have a system of metrics for communication, which is
601386 - the biggest cause of errors in human endeavors.
601388 -  ..
601389 - On 921021 a JPL executive reported at a Cal Tech seminar that the
601390 - Columbia Space Shuttle crashed in 1986 because JPL and NASA business
601391 - metrics, which are sophisticated and powerful were inadequate.
601392 - ref SDS 2 4499  On 921021 this was still a problem. ref SDS 2 4390  On
601393 - 960712 Dave Vannier reported at Asilomar that technology was making
601394 - the problem worse. ref SDS 13 1552
601395 - ..
601396 - On 940611 the Asilomar Conference reported communication
601397 - problems that caused the loss of an oil tanker at sea, costing $500M.
601398 - ref SDS 3 8473
601400 -  ..
601401 - On 970524 Morris reported having attended a Cal Tech seminar that
601402 - traced the "root cause" of the Columbia Space shuttle to communication
601403 - failure. ref SDS 18 4401  This cost $billions of dollars.
601405 -  ..
601406 - On 961218 the U.S. Army Corps of Engineers made a decision that likely
601407 - resulted in a loss of $6M, without realizing it, that was outside the
601408 - system of business metrics, because counsel and executives do use
601409 - these methods. ref SDS 15 5790
601411 -  ..
601412 - On 970405 a meeting at USACE illustrates how lack of alignment in
601413 - communication causes meetings to fail, despite a lot of email, as used
601414 - at Intel. ref SDS 17 0001
601415 - ..
601416 - On 990525 Morris reported that engineers and managers cannot use
601417 - Communication Metrics because they don't like to write, and are
601418 - anxious to perform engineering and management. ref SDS 37 0966  On
601419 - 990817 Morris reported that people need a commitment to diligence in
601420 - order for business systems to be effective. ref SDS 58 6829
601422 -  ..
601423 - On 990625 Fortune reported communication is biggest cause of failure
601424 - by CEOs, and that "psyche" prevents CEOs from writing copious notes,
601425 - ref SDS 41 4914, which Andy Grove says (reviewed on 980307) removes
601426 - ambiguity of mental maps that otherwise cause errors. ref SDS 27 3668
601428 -  ..
601429 - This record suggests that the design problem and consequent delay in
601430 - releasing the 820 chipset likely can be traced to communication that
601431 - was not aligned with requirements, because SDS is the only system that
601432 - aligns communication over time, and it is not used at Intel.
601433 - ..
601434 - The only challenge is overcoming denial, cited by Andy Grove as
601435 - the "inertia of success" reviewed on 980307. ref SDS 26 3740
601437 -  ..
601438 - As things stand, only the CEO has authority to generate intelligence
601439 - in an organization, as reviewed on 980307, ref SDS 27 8488, and most
601440 - of them don't want to do this work because of "psyche."
601441 -
601442 - $125M is a lot money for psyche.
601443 -
601444 -
601445 -
601446 -
601447 -
601448 -
6015 -