A Project Post-mortem

14 Mar

Installation of a new piece of equipment for a new product is never easy.  There is always something that goes wrong.  When creating a validation plan for the installation and subsequent testing of the equipment, you have to make sure all the possible failure modes are examined and challenged.  Sometimes, new things pop up that cannot be predicted.  This was the case when trying to validate a 1-gram desiccant pouch into our product.

The original product design used a 3-gram silica gel desiccant sachet in sealed bag for moisture control.  The project was to change to a 1 g desiccant for an annual savings of $400,000.  The 1 g desiccant would be from a new supplier and also require a different style cutter on the equipment.  The cutter assembly was contracted to an outside firm and the test samples were obtained.  After installation, we found that the new supplier did not keep as tight of a control on the straightness of the packets on the spool which caused the packets to jam in the drop chute.  We also discovered that they did not seal the seams in the same manner causing detection issues with our optics.  The 1 g packet was also significantly lighter than the 3 g causing a placement issue in the final bag.  The first two problems were easily rectified with a minor design change to the chute and an optic change.  The placement issue, however, is still troubling us today.

We have now set up another project team to deal with the placement issue but there are some things that we are learning that we missed when the new desiccant entered production.  The biggest takeaway is the interaction between the new, lighter desiccant and the coefficient of friction in the foil of the final bag.  Lower coefficient of friction combined with a lighter desiccant yields positional issues, something that was masked with the weight of the heavier desiccant.  Due to the lack of some initial planning, a second project is needed to deal with the unseen consequences of the first.  Unidentified issues will always be part of project management, but knowledgeable managers can locate answers to undefined issues and take educated guesses for others (Portny et al., 2008).

There was a failure in the initial project team.  Portny et al. (2008) mentions that you must define the roles of the project team members from the outset.  In this case, we never involved the foil SME in the implementation of the new desiccant as we never considered the correlation between foil and desiccant.  It is the project manager’s duty select the team members and to identify both the roles and responsibilities (Murphy, 1994).  By neglecting to include a SME on the foil left some potentially key information hidden until after the problem was realized.  It was my failure as project manager to not create more diverse and better represented project team.

Another failure point was that we did not perform a full failure modes and effects analysis (FMEA) from the outset, this relationship may have been discovered.  An FMEA is a step-by-step analysis of the process in an attempt to identify all potential causes of failures in a process and the consequences of their effects.

Failure modes and effects analysis also documents current knowledge and actions about the risks of failures, for use in continuous improvement. FMEA is used during design to prevent failures. Later it’s used for control, before and during ongoing operation of the process. Ideally, FMEA begins during the earliest conceptual stages of design and continues throughout the life of the product or service. (ASQ, n.d., n.p.)

Like the ADDIE process, an FMEA is a systematic approach to a problem.  If we had conducted a logical review of the potential problems, we might have caught the issue or, at a minimum, realized that we did not include the appropriate groups from the outset (Van Rekom, Achong, & Budrovich, n.d.).  Systematic tools like ADDIE and FMEA are excellent means of determining the true character of a problem in a methodical manner (Clark, 2011).


ASQ. (n.d.). Failure mode effects analysis (FMEA). Retrieved March 13, 2013 from http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html

Clark, D. (2011, September 26). ADDIE model.  Big dog & little dogs’ performance juxtaposition. [Blog Posting].  Retrieved from http://www.nwlink.com/~donclark/history_isd/addie.html#zen

Murphy, C. (1994). Utilizing project management techniques in the design of instructional materials. Performance & Instruction, 33(3), 9–11.

Portny, S. E., Mantel, S. J., Meredith, J. R., Shafer, S. M., Sutton, M. M., & Kramer, B. E. (2008). Project management: Planning, scheduling, and controlling projects. Hoboken, NJ: John Wiley & Sons, Inc.

Van Rekom, P., Achong, V., & Budrovich, V. (n.d.). Practitioner voices: Scope creep.  . Lecture presented for Laureate Education, Inc. Retrieved March 12, 2013 from https://class.waldenu.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2652514_1%26url%3D


7 Responses to “A Project Post-mortem”

  1. Laurie Morgan March 18, 2013 at 12:18 am #

    “Post-mortem is an end-to-end review of the project from its conception to its delivery (Pastore, 2003).” Use of the project “post-mortem” from the initial stage provides value to future projects.

    During the initial brainstorming of the statement of work and scope of work, collectively the stakeholders should identify needed resources.

    Clarifying the roles of needed subject matter expert would have given your team an advantage. In your case, I believe fully utilizing the expertise of your team would prove valuable. At times, you may not foresee need for additional experts. However, subject matter experts involved in the process should have communicated need for an SME specializing in foil.


    Pastore, M. (2003, May 7). Post-mortems key to successful future projects. Retrieve from http://www.cioupdate.com/reports/article.php/2202921/Post-Mortems-Key-to-Successful-Future-Projects.htm

  2. idt2me March 17, 2013 at 10:26 pm #


    Great post mortem. It is fascinating to hear from someone coming from outside of the teaching profession. I am wondering how large your team was to begin with. At what point do you feel the team would have been so large that it wouldn’t be functional anymore? Lastly, I am wondering if a cost saving were realized with this project.



    • Dave Levine March 18, 2013 at 9:04 am #

      The actual functional team (the people doing the work) was a moderate 8 people. Not too bad and not so overwhelming that it could not be managed. The team consisted of a technician, a programmer, a mechanical engineer (part time), a drafter (part time), a machinist (part time), a purchasing representative, a quality representative and myself. The purchasing rep was the true project manager but I acted as the PM for the implementation. We realized a material savings of about $400,000 anually. We produce about 30 million tests every year and each one gets a desiccant packet.

  3. Jeremy March 17, 2013 at 4:38 pm #

    I’m curious Dave, why didn’t the new supplier send a knowledgeable person to the shop and help with the diagnostics? I think you are absolutely right about conducting an FMEA structure prior to implementing the tool. You discussed SMEs and their purpose in the project. I think its also important to bring a SME from the supplier. Obviously not for the entire process, but I think they should be included in the SOW as they can provide additional information (Portny, Mnatel, Meredith, Shafer, Sutton, & Kramer, 2008). Is this possible, Dave?

    Portny, S. E., Mantel, S. J., Meredith, J. R., Shafer, S. M., Sutton, M. M., & Kramer, B. E. (2008). Project management: Planning, scheduling, and controlling projects. Hoboken, NJ: John Wiley & Sons, Inc.

    • Dave Levine March 18, 2013 at 9:09 am #

      It was not the vendor’s responsibility to get their desiccant to run on our equipment, that is our responsibility. They do not possess the knowledge of our bagging equipment. They provided assistence with the cutting and feeding portion, but not the actual bagging process. There were quality concerns that we brought up along the way that the vendor was able to assist with as well as some feeding issues at the front end of the equipment. The only SME that we could have involved from the outset would have been a representative from the bagger equipment vendor. He has been in house recently to help but really offered no cut and dried solution to our problem.

  4. Marta March 17, 2013 at 11:27 am #

    Hi David,

    A project manager has to constantly balance the competing demands of a project “scope, time, cost, quality, resources, and risk.” (PMBOK Guide, 2008, p.37). In this case, it seems that “cost” – the reduction of it, was the priority but the quality of the end product and/or the potential risk were not thoroughly analyzed. As you pointed out the right SMEs were not involved. This may not necessarily be your fault as a project manager. You may not have had (been allowed) adequate time to thoroughly research and identify the SMEs. Additionally, if the initial focus of the scope was cost, and you (and the team) fulfilled the scope, technically, the project is not a failure. The good thing is that you were able to identify the problem that has now led to another phase (fix) of the project. (Portny, Mantel, Meredith, Shafer, Sutton, & Kramer, 2008, p. 106) note that “project managers often learn by doing” and it seems that this project has been a great learning experience for you.

    Excellent post!


    PMBOK Guide (2008). A Guide to the Project Management Body of Knowledge (PMBOK® Guide). 4th ed. Newton Square, PA: Project Management Institute, Inc.

    Portny, S.E., Mantel, S. J., Meredith, J. R., Shafer, S. M., Sutton, M. M., & Kramer, B. E. (2008). (pp. 279-280). Project Management: Planning, scheduling, and controlling projects. Hoboken, NJ: John Wiley & Sons, Inc.

    • Dave Levine March 18, 2013 at 9:11 am #

      Yes, we fulfilled the scope by reducing cost but we did not succeed as the implementation into production is not complete. We needed to implement the new desiccant into the product without affecting quality which did not happen. We are still working on it and may have actually found a solution. I will keep everyone informed of the progress.

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