Friday, December 13, 2013

Santa, Rudolph And SMS

Over the years Santa Claus has successfully delivered Christmas gifts all over the world and without major incidents. Every year Rudolph the reindeer takes the lead and ensures kids gets their present. It is an amazing result.

Of all places on earth, Santa Clause lives at the North Pole. A deserted place where no one else lives but Santa, his helpers and the reindeers. At the North Pole he gets just the minimum training in roof and chimney approaches, since there are no other homes at that place. Even though not known, he informally assists the Easter Bunny in an attempt to stay airborne-proficient for next Christmas delivery.

So far, Santa hasn't had any major incidents. He got stuck in a chimney now and then and the reindeers stumbled as they landed on the rooftops. But the gifts were still delivered before days end, year in and year out. 

The deliveries did not always go as planned.
However, with the increasingly Cyber competition Santa needed to find a niche to maintain his position as the Christmas favorite.

Since Rudolph is the leader of the reindeers, Santa gave him a task to implement as system to ensure more effective deliveries and less stumbling on the roofs.

Santa named the system "Streamlined Mission Service" or SMS. Santa had come to realize that many of those little mishaps delayed his deliveries and upset kids around the world when he came late. He needed a way of knowing where he lacked proficiency so he could target his knowledge and practice. Santa's delivery policy was "Zero tolerance to delayed deliveries"

Over the last year of making toys, Santa also came up with a policy that Rudolph could not blame the other reindeers when incidents happened. Santa named this the "No bucking antlers" policy. Santa demanded that Rudolph addressed the training, the organization and his own leadership methods after each incident. On top of it all, he expected reindeer-accountability and gave them roles and responsibilities, with Santa himself as the AE (Accountable Elf).

Rudolph accepted his responsibility and implement SMS. He also documented the plan and submitted to the AE a plan for toys deliveries. After AE approved the plan, he gave Rudolph the Monopoly Money as an ER finance resource (Elf & Reindeer) in preparation of training and Christmas delivery trip.

When the time come for delivery, the plan, training and accountability had given Santa and his team an edge to the cyber-gift deliveries overflowing the world, where he delivered every present on time to all the kids in the world, and without as much as one single incident. Santa saved so much Monopoly Money by implementing SMS and maintaining his position as the leader of world gift deliveries that he secured a delivery contract for the next 100 years. 

With the contract secured, Santa is flying for another 100 years.
Yes, Santa and his helpers is an imaginary fantasy story where they are living in a perfect world.

Safety is much more than imaginary and fantasy stories.
Safety is to apply a Safety Management System as a tool to improve in an Imperfect World.

Merry Christmas and enjoy the Holidays!


Parameters As Statistical Profit-makers In SMS

SMS is defining parameters in operation. An Enterprise has processes in place for performance parameters that are linked to the organization’s goals and objectives, which again are linked to the safety policy. SMS is the tasks of manage applications within established parameters.

Parameters of zero airspeed are no RPM and equalized MP. Add another of oil temperature to improve reliability of statistics.

As a simplified example let's look at the parameters of an unsafe landing gear indication, where the corrective action plan of the "unsafe landing gear" checklist is applied.
This checklist is a parameter as an integrated part of other performance parameters required during its flight. However, it is different in that it is a non-desired outcome parameter and only addressed in a non-desired state of flight.

Assuming that parameter, goal and objective are as follows;
Parameter – Unsafe landing gear indication checklist.
Goal – Execution of appropriate checklist within endurance available.
Objective – Apply corrective action for a safe landing.

In the hierarchy of Safety Policy, the Objective is at a higher level than the Goal and at the operational level is the Parameter. With an unsafe landing gear light, the objective is to apply corrective actions for a safe landing. The goal is to apply appropriate checklist completed within endurance available. After completion of the checklist, the flight crew applies decision of further action based on their findings and in coordination with other flight parameters. 

From here on in; operational application of parameters determine the outcome.
A change in procedure to establish shorter usable lifetime for light-indicator may give statistical advantages of a reduction in non-desired outcome of flights and establish profit targets by risk management.  


Moneyball In SMS

Moneyball is a movie based on a baseball team where players for the team are picked based on their on-base percentage.  By getting players with a higher average of on-base percentages, the team manager executes a plan to build a competitive team at a lower cost and eliminate the subjective and often flawed process of picking high-impact team members. This approach brought a baseball team to the playoffs with only a salary budget of about 33% of the highest salary team.  Statistical Process Control (SPC) and SMS are profit makers when applied to desired operational results. When applying SPC to Aviation Safety, an Enterprise has established measurable parameters. 

Identified parameters set the stage for greater profit margin. However, precise application is what makes the difference. 
Moneyball in SMS is to know what an Enterprise's values are and what the undesired outcomes are. In the Moneyball movie the value is to win games and the undesired outcome is to play high salary players. This process is an uphill battle since it is not a conventional approach and it is a battle to receive cooperation from other managers. 

A Safety Policy should be written for application of measurable results. An Enterprise's Safety Policy that is measurable would state something like this: "Our Enterprise operates with zero tolerance to compromise aviation safety".  Every aspect of operation is then measurable against "zero tolerance".

The next step is for the Enterprise to establish measurable objectives. A measurable objective could be:" The objective of zero tolerance is to increase profit margin by 1.5% ". When a measurable objective is established, the Enterprise establishes measurable goals. A measurable goal could be:”The profit margin is increased by reducing hazard costs”.

After a goal is established, the parameters are established. A parameter is a variable given a specific measurable factor that sets the conditions of its operation, and could be: ”The condition of assessing hazard cost is limited to a dollar value of $ 1 per 1 second spent in processing hazard reports received, time spent on preliminary risk assessment and time spent processing into hazard registry”.

When the cost parameter is set at $ 1 per 1 second spent, the cost of hazard becomes a cost of the identified hazard. In other words, the hazard is assigned a cost-account and it doesn't matter to whom, or to what level in the Enterprise the task is assigned. 

A goal gives directions of action. However, arriving at the goal is what makes it measurable. 
An Enterprise applying SPC strategy to their SMS has direct and measurable links from Parameter – to Goal – to Objective – to Policy. 
The parameter is $ 1, the goal is to increase the value of $ 1, the objective is to apply the increased value of 1 to the profit margin, and the increased profit margin is based on a safety policy with ”zero tolerance to compromise aviation safety”. SPC is the tool to ensure SMS processes are in control. 


QA Of SMS Simplified

There is no simplified Quality Assurance of a Safety Management System. What is simplified is to select and accept simplified steps by adding multiple designs; or multiple triangles, without attempting to cover it all with one huge boulder.

Planning, organizing, action and control of each step is to simplify the QA of SMS. Without planning, the road leads to nowhere. Without organizing, the pieces don't fit. Without action, nothing is happening. Moreover, without control you don't know if you took the right turn at the fork in the road.

The Certificate is the top triangle of Quality Assurance. Everything else are the triangles of QA.

When applying building steps of triangles, one can visualize the imbalance if adding or removing triangles. Take away or add one, then other triangles are not connected.  

Let's look at an Airport QA of SMS since an airport is where a flight begins and ends. Building the triangles of all activities under the Certificate are QA of Safety Management System; Emergency Planning; Wildlife Planning; and Regulations and Standards. At the end of the day, the Certificate to protect from non-compliance becomes the top triangle.

All aspects of operations include Quality Assurance Test along the way to ensure control of processes. With the inclusion of a QA Test at each level, the Accountable Executive has a degree of confidence that the Enterprise is capable of maintaining compliance to regulatory requirements on an on-going basis.

Quality Assurance is to ensure that defined work gives desired result without an unexpected surprise. Out of 3 – one forgot QA.
Quality Assurance of SMS complex and requires planning, timing and defining of results. However, simplified QA of SMS is defining control steps and placing the triangles. 


When Hazard Reports Becomes Unimportant

When a hazard report is received the contributor is issued a confirmation of report received. Following an acknowledgement to contributor, the hazard is either entered in a hazard register for trending and then submitted to appropriate manager for further investigation and analysis, or just entered into the hazard register for trending.  Some hazards are investigated with a timeline for CAPs, while other hazards are closed after entry in the hazard register.

After submitting a hazard report, the contributor may receive a confirmation receipt with the following statement:  "Hazard report received, no investigation required".

The contributor of this hazard may have gone through a lengthy process and effort to accurately identify, describe and submit this report. A reply of "no investigation required" could imply to the contributor that this hazard was not important to the Enterprise. Next time that same hazard is identified there may be a temptation not to submit.

Hazard reports not received is not a statement of fact that that there are less hazards. It is just a statement of fact that hazard reports are not received. 

When hazard reports are not submitted, the snag goes unknown.
Bird hazard is a prime example of hazard report not received. Based on bird strike data, birds are struck about 92% of the time. This is an indication that bird sightings are not reported, but rather reported when struck, or avoided by rejected takeoff, overshoot or by an abrupt manoeuvre.
Bird sightings have become an unimportant hazard when not reported until becoming an incident. 

The process of reporting bird activity appears not to be in control.
In SMS hazard reports is the lifeline and the "heart" of pumping life into the system. Investigation and analysis are the "lungs" of extracting valuable safety information; and QA is the "brain" to process information, document results and implement actions.

When hazard reports become unimportant, the system becomes in a state of information starvation. The key to success is to make every hazard report important to the contributor. 


Airplanes Are Hitting The Birds Most Of The Times

Over a three-year period, airplanes in one region were on average striking birds at a rate of 92.7 %.  For every 100 landing or take-offs almost 93 of the birds were struck at or near an airport. The other seven birds either were avoided by pilot actions as an abrupt movement or rejected takeoff. The key to manage is to reduce bird activity near airports.

Birds is a hazard to aviation safety. The goal is to avoid as many as possible, but travelling at high speed it is not often enough distance available to avoid one or a flock of birds. Often a bird is not observed until after it has been hit.

Technology today does not have an effective means of "live time" tracking birds. There are records of migratory bird routes and nesting places. From these historical records, it is possible to assess past bird activity and predict time and location of future activity. Simply said, it is known that the birds travel north in the spring and south in the fall. This knowledge is then applied when planning bird-hazard mitigation. 

This chart is showing how many birds were struck, based on how many birds were in the area. 
The bird strikes numbers may be declining, but when 55 birds were struck, there were 60 birds in the vicinity, and when 84 were struck, there were 90 at or near the airport.

Birds may be such an overwhelming issue that it is tempting to take the "there is nothing we can do about the birds" approach to the hazard. However, if nothing can be done, why are birds an issue? Whenever there is an issue that compromises aviation safety, something can and must be done about it.

Birds are just like teenagers. They like to be where there is food, action and friends.  Airports take on their share of mitigation with a Wildlife Management Plan. An airport is the first defence in reducing bird activities, and therefore reducing strikes. A Wildlife Plan is bird mitigation or in other words; "does something about it". Airports take on bird-research, act on removing food sources, reducing gathering places and keeping birds away. 

If a hazard is not known is not the same as not being a hazard. (By the way, did you find the dog in picture?)  
Progress is being made in bird-science with DNA bird-analyzes and Wildlife Management Plans. In the past 100 years of aviation trial and error methods of safety management has already moved into the next generation of safety; which is a planned Safety Management System where processes are implemented to mitigate known hazards. 


When Regulations Are Performance Based, Make Safety Your Business.

When regulations are performance based they don't prescriptive describe what is required, but communicates what conforms to regulatory compliance. It might be tempting for an enterprise management to believe that actions are not required since regulation doesn't state what prescriptive action to take. If applying this approach the result might not be what conforms to regulatory compliance. 

Displacing the threshold 2000ft on a 4500ft runway might be what it takes to conform to regulatory compliance. 
Aviation safety has to be managed in a Safety Management System with a Quality Assurance Program where facts are analyzed. Whenever there are temptations to transfer responsibility and accountability from an enterprise to the regulations, that's when it is time to find out what went wrong with the processes.  

One regulation may say that airport operators are required to give notice of any known obstructions penetrating the protected Obstacle Limitation Surfaces. This could be cranes, trees or other objects being too high for the airport zoning.
An enterprise without a process to detect obstacles may believe that the obstructions were not known to them and therefore not required to give notice. This approach is an attempt to remove operational accountability and control from the operator and to transfer this  responsibility to the regulations. 

If an enterprise attempts to transfer responsibility to the regulations, what prevent pilots from taking the the same approach?
The proper CAP is to accept accountability and find opportunities to discover obstructions in the flight path. An enterprise needs to establish processes where obstructions that are "not known" to them becomes known.

Aviation safety is not to passively assume third parties to be accountable. Aviation safety is to actively seek out hazards, analyze and implement Corrective Action Plans.

When an obstacle violates an Obstacle Limitation Surfaces at an airport, someone accepted and allowed this violation to happen. This acceptance could be as simple as "it's not my problem" or "too much paperwork". When arriving at this fork in the road read the signs and chose a path  to aviation safety. 


We Just Fired The Accountable Executive...

An owner or family member may be appointed as the Accountable Executive (AE) and never change. Or, in a large organization the AE may be at the mercy of the Board of Directors or the Mayor and be fired for any reason at any time.  

An AE is the person in the enterprise who gets to``draw the line``. An AE draws  the line of the Safety Policy, Non-Punitive Reporting Policy, Human Resources, Financial Resources and the timeline for reports submitted to AE.

At first glance some may find it to be a trivial event that a person who is not involved in the day to day operation is being fired on the spot. However, since the AE is the organizational authority  on drawing the line, an enterprise may end up in a a state of disorder due to absence of nonrecognition of authority. 

An AE may not be involved in the daily operation as they decide where to draw the line. 
An un-schedule and emotionally driven firing of an AE is different than a planned and organized change. With a scheduled removal of an AE there is a continuous line of authority to ensure an enterprise is conforming to regulatory compliance.

After firing of an AE without a replacement the SMS Management Review may struggle to establish accountability to regulatory conformance and to document an SMS with continuing adequacy and effectiveness.
Further, an internal Quality Assurance Program may establish organizational regularly non-compliance with their audits of processes, inspections and training of all personnel.

Just a short deviation from the drawn line may cause major events. 
An enterprise without an AE is applying the wrong tool in the toolbox.


A Plan For The Corrective Action Plans (CAP) And Processes

A fix is for the malfunction, while a repair considers malfunction in addition to the malfunction.  

An Enterprise without a Plan for the Corrective Action Plans (CAP) is being lost in a Maze of Corrective Options.  The Maze of Corrective Options is a place of traditions and familiar operations, and it is a "safe place" to make decisions. It's a maze because for each decision made there is a fork in the road without a direction sign.

CAPs are not just for making changes after surveillance findings of non-regulatory compliance, but also as internal corrections of processes that are giving non-desired outputs. There are generally speaking two types of CAPs. One is an immediate fix and the other is a long term repair. A fix considers the malfunction but not the cause, while a repair considers the problem in addition to the the process which lead to the malfunction.  

A fix is compatible to dumping a task on someone, while a repair is a delegation of organizational authority and responsibility to repair processes.  An Enterprise that has a clear commitments and directions of processes  when arriving the  fork in the road,  is avoiding the continuous dumping of  fixes  on whoever is most convenient available.  

A process repair must be tailored to the vehicle it is intended to serve. 
It might be tempting for an Enterprise to stay within the safety of an established process and fixing malfunctions.  By taking this approach  there is no one in the organization who accepts accountability and there is always  someone else who can be blamed when things go wrong.

There are times when a CAP repair may not be effective. However, an Enterprise with a Plan for the Corrective Action Plans (CAP) has a map of how to make it back to fork in the road where  they took the wrong turn. 


Best Practice (BP) And Customer Service

It has been said that Best Practice (BP) is to apply better practices of quality in customer service. In some way that is correct, since operating by meeting minimum regulatory requirement only is not intended to produce satisfactory customer service.

On that day when an enterprise was issued an aviation operating certificate, they were regulatory compliant. This was a static mode, where there had been no movements of aircraft or operation of the airport. Maintaining this status quo of regulatory compliance as it was at the issuance of an operation certificate is neither practical nor the intent of the certificate. 

Best Practice is to establish customer friendly processes.
An enterprise; when operating airplanes or airports must establish processes that is conforming to regulatory compliance. Establishing these operational processes is to go beyond what regulation requires. This is Best Practice; It's to establish processes above and beyond what the regulation requires and to maintain operational processes which are conforming to regulatory compliance. 

Is an airline required by regulations to employ baggage handlers and ground crews? However, as ground crews tasks are related to aircraft operations  they must be trained in operational procedures, and be qualified to advise the Captain.  A "thumbs up" when nose wheel is disconnected doesn't just say "have a safe trip". 

When going "where birds don't fly" processes are conforming to regulatory requirements. Flooded airport is regulatory compliant by NOTAM closed.
An airport may be regulatory compliant by issuing a NOTAM of airport closed and an airline may be regulatory compliant by grounding airplanes. However, by doing that, there is lack of customer service.

Best Practice (BP) is what an Enterprise does to ensure operational processes conform to regulatory compliance by developing and maintaining processes of regulatory requirements.


Training As Represented By A Circle

In some organizations training may be viewed as a redundant task since an employee performs with great results the same tasks day in and day out. Or, some organizations may compare training to a long path of a “never ending story”. However, training is neither redundant nor a long and never ending path; Training is Continuous Improvement and a Circle. 

Training is a tower of circles.
When a new person is starting in a job the Enterprise has an indoctrination training planned even if one does not exactly know a new employee’s competence level. Based on historical facts, one assumes that a new person is qualified to enter the Circle of Training at the position’s Level of Performance Criteria.

Training becomes the circles of a “Circle Cookie Cake”, where each circle represents an organizational competence, performance criteria and training-entry level. The wider circles represent levels where more people are working. At the top, the circle is small with only a few selected individuals. 

When there are Management changes an Enterprise is conducting a “for cause” Management Review and a review of change which could affect the established Safety Management System. Should there be a change of Accountable Executive, it’s the top ring of the “Circle Cookie Cake” where training is applied. 

When there is a change of an established operational process, it is one of the lower rings where training is applied. Training applies to each circle of Performance Criteria.

Each circle represents an Enterprise’s planned training for Competence, Effectiveness and Continuous Improvement. 

The circle is complete
When a person has completed the circle’s indoctrination training level of training, it becomes a simple task to add SMS&QA training; technical; recurrent; and training for Continuous Improvement.  


Bird Activity Trending At Airports

Fall is the migratory bird season and bird activities are causing airport operational challenges. Without an automated real-time bird activity tracking system, airport operators are relying on submitted bird sighting reports for trending.  Birds are on the runway, in the approach/departure, and anywhere else in the vicinity of the airport. If there is a river near by, the birds may follow the river both upstream and downstream. Birds are hazards.

There is currently no commonly used technological application for real-time bird activity threats. Airport operators are relying on their own SMS reports submitted by airport staff, pilots or controllers. The bird sighting process may be simplified by counting one bird or a flock of birds as one sighting.

An airport somewhere had 58 actual birdstrikes over a 3 year period. 60 % of the birdstrikes occurred in August and September. 

During this same 3 year period 60% of the birdstrikes happened on Saturday, Sunday and Monday.

From these two simple graphs, it can be assessed that over a 3 year period 60% of birdstrikes happened between August 1st and September 30th, and between Thursday morning and Monday Evening.

When the bird-sighting numbers are known an airport operator may apply addition bird-avoidance mitigation during these peak times of bird activities. In business practices there is a common approach to target customers. In SMS, the common approach is still to “target customers”, which is this case are birds. 

In Business: Target the customers and set course of action. In SMS: Target the “customers” and set course of action. 
Reducing bird-sightings should reduce bird-strikes. In other words; Hazards are mitigated and Incidents reduced. Targeting hazards and set course of action is “Zero Tolerance to Compromise Aviation Safety”


After Training, Everyone Is Ready To Go... Or Are They?

An SMS Enterprise has established policies, objectives and goals. One of the policies is for employees to report hazards, incidents and accidents.  In addition to policies, the Enterprise has an SMS training system in place for requirements of reporting hazards, incidents or accidents. After this training is done, there is a knowledge test distributed and everyone passes. Everyone is now ready to go... or are they?

It does not make it a fact that there are no hazards to report if no hazards are reported.  
How is it possible to know if all hazard required to be reported are reported? In a “just culture” everyone should feel confidence that reporting hazards are vital to safe operation and that management needs these hazards reported for trending of their hazard register.

When hazards have been mitigated it is expected that they do not reoccur. However, if hazards are not reported and mitigated, someone will be exposed to that hazard several times.  At some point this unattended hazard could become an incident.  

There are several methods to track the ratio of hazards submitted to latent hazards.  As a simplified example I picked the Heinrich pyramide. Herbert William Heinrich was born in 1886 and a safety pioneer from the 1930s.  

The longer time it takes for a hazard to be exposed, the longer time it takes for the hazard to become an incident. 
In his research he found that for every 300 hazard exposed, there are 29 minor injuries and 1 major injury. When applying this simple theory, for each block of 29 minor injures reported to the Enterprise, the hazard must have been exposed 300 times. This is a simple method to begin the tracking ratio of hazards. 


Size, Complexity And SMS

It has been said that size and complexity is not taken into consideration for an Enterprise required to conform to regulatory compliance. Often this implies that regulations are targeted to fit large organizations and does not accommodate smaller Enterprises.

Both small and large organizations must conform to regulatory requirements to be regulatory compliant. A small organization should apply less complex systems to meet these requirements than what is expected from a large organization. 

On a foggy morning, size and complexity might not be obvious.
The issue is not that expectations are the same for both large and small, but rather that the small Operators are adapting processes to identify how a large organization conforms to regulatory compliance. Small Operators do not have manpower to operate in the same manner as large Organizations.

An SMS Enterprise has a system in place for the capture of information of hazards, incidents and accidents. In a small organization this may be done by submitting paper records direct to the SMS Manager. This report is hand delivery directly by the contributor and noted in the records. In a large organization a paper form submitted may be required to be scanned into an electronic database, entered in a database and submitted to a pre-scan manager for assessment, entered to the Hazard Register and then to the SMS Manager who delegates investigation. After risks have been investigated the report may be submitted for Corrective Action Plan through a committee or safety group. When a form is electronically submitted, several administrative tasks may be automated and the contributor may receive an electronic receipt with a generated tracking number.   

Apply the right tool and don’t use a broken jar as filing cabinet.
In large organizations there are often several individual involved prior to the hazard is risk-assessed. Should a small Operator attempt to follow the same complexity as a large Operator, they may be taking on a much greater task than what the organization is designed to manage.
Both small and large must conform to Regulatory Requirements for Regulatory Compliance. This is achieved by managing processes differently to conform to documented SMS processes. Regulatory Compliance is not achieved by conforming to systems which are not designed for the Enterprise.  


Thursday, December 12, 2013

Get The Cards In Order

The Root Cause of a Process which does not produce the desired outcome is that the process took the wrong turn at the fork in the road. This fork in the road could be anywhere in the process from the very first step to the last input. If the process does not give the desired outcome, find the fork in the road.

A simple distraction of the process is a fork in the road.
 When a process is not documented the outcome may vary by subjective inputs. The process of the “pick the card” game has changed over time with various results, and where the outcome did not always produce the correct card each time.

Often this happens in organizations, where errors slowly develop and nobody notice and captures these variations.

When analyzing the card-game process it is possible to find the link between the cards. As a test of the process, the cards were laid out in one row of Spades, one of Diamonds, one of Hearts and one of Clubs. This established a baseline the Ace as number one the King number 13. 

By testing the process it is possible to make changes before getting to the Fork in the Road.
The first step is to pick the Ace in the first row as the card, then apply the process, and continue each time with the next card in the row, until the Spade of King was picked. This gives 13 sample testing rounds to evaluate the process. When documenting the layouts, it becomes a trend that the card in the 2nd  deal is in rows 4-5-6 or 7, which then will be card number 17-18-19 or 20 of the 3rd deal, or the 5th card in the row. When knowing the row, the correct card is picked.  

An Enterprise Training System of a process should be to train individuals to understand the process in addition to perform the process. By understanding the process it is possible to recognize, make correction and changes so that errors do not happen.

An Enterprise Testing System of a process should test the process by applying scenario to the intent of the process. When a new process is developed, it is often assumed that it will function as intended, and therefore testing is not required. However, when the Testing System is not implemented, a potential error may not be discovered until it has caused an incident.

An Enterprise Review System of a process should review for Statistical Process Control. When there is no Review System established the process is an assumption. When one assume, the facts are not captured. 


Corrective Action Plan – The Nut To Crack Is In The Cards

A Corrective Action Plan (CAP) in a Safety Management System (SMS) is to change a process which is not effective in producing an acceptable outcome or desired result. A CAP is a proposed layout of a new and improved process to ensure desired result is achieved.

It is not a simple process to find the correct process. A process should be based on Enterprise Policy, Objective, Goals and Parameters. Let’s take a moment and apply a proven process to a card game.
An Organization decided that applying a recreational activity during working hours could increase the production level.

The Organization has established recreational activities for all staff.
The objective of recreational activities is to achieve organizational continuous satisfaction in job performance.
The goal of continuous satisfaction is to be able complete assigned task right the first time.
The parameters established are for staff to chose recreational activity based on their own interest. 

Based on the general policy an operational system, or game rules, are established for the game itself. These game rules are Policy, Objective, Goal and Parameter.
The Policy of the card game: Apply a regular 52 card deck to play game.
The Objective: Find out what card another person is thinking of.
The Goal: To pick out the correct card each time.
Parameter: Deal 52 cards randomly in 4 rows.

There are Standard Operating Procedures to this process, but since they are simple, they are unwritten and learned during training. 

                        By following a proven process it is possible to do the job right the first time; over and over again.

In this example the cards are dealt as in image 1. The process requires that one person is asked to think of a card and then identify the row where the card is. This row-identification could be verbally with pre-set identified row numbers or pointing at the row without pointing over the cards, or touching any of the cards. The cards are then placed with the identified row as the 2nd row in the deck and cards are dealt into 4 rows and question to identify the row is asked again. The process is repeated one more time, including asking to identify the row. 

The card the person was thinking of is number 5 in that row and is 3 of diamonds.

By following a simple process, it is possible to pick out what card another person is thinking of, time after time.
However, there are factors which could affect the desired outcome. These factors are Human, Organizational and Environmental factors.
Human factor could be that the person thinking of a card becomes distracted and during the process forgot what card it was. Organizational factor could be how clear the process is written and how simple it is to understand and follow. If the process is ambiguous it is possible to apply personal interpretations and a change in the process occurs. The process in example above may not be clear for someone who has not been trained. Training is an Organizational factor. Environmental factor could be that this recreational activity is required to be performed outside where strong winds could disturb the process.

Applying these simple principles of a road-map with Policy, Objective, Goal and Parameter to SMS processes are fundamental to know what result and outcome to plan for.