Saturday, December 13, 2014

When Santa Implemented SMS (Streamlined Mission Service)

It is the time of year when Santa is getting ready to deliver gifts all over the world. He has one day to cover millions of square miles, and there is no room for mistakes. Over the years there has been some minor crashes on the rooftops, but nothing seriously that would stop deliveries. Most of these crash and stop events were caused by poor sleigh maintenance, lack of flight training for Santa, or poor approach by the lead reindeer. With the increasing competition of cyber-toys, he had also noticed less in demands for old-fashion toys. Santa had realized that he needed to make some changes to stay in business as the lead in toy-delivery, and implemented SMS last year.

It was not a simple decision to implement SMS. The concept of SMS was simple, but it became a huge task to identify root-causes of services malfunctions.

Prior to SMS Santa used a lantern to look for root-causes.
 The beginning of SMS started many years ago when Santa suggested to Mrs. Claus that he should fire everyone who did a mistake, including the reindeer. If he got rid of the “bad apples”, everything would be fine with no issues. Santa set a goal to hire only elves and reindeer that could not do mistakes. Due to public opinion, he had to keep Rudolph the Captain Reindeer on without questioning his performance.  He was convinced that if he hired elves and reindeer that did not do mistakes he would exceed all customer service expectations. Santa tried this approach for several years, but kept loosing elves and reindeer since it seems like everyone did mistakes.

Now, being defeated and humble he went to Mrs. Clause for advice of what to do. Mrs. Claus, who was an SMS expert from managing daily risks for centuries, forced him to implement SMS and to conduct QAP (Quotes About Performance) of past delivery services. Santa objected strongly since he did not understand why he had to implement a paper-trail system, when he had delivered for centuries without any issues until these last few years. Santa blamed the cyber-toys competition as a distraction to elves and reindeer.

However, Mrs. Claus asked a question that made Santa reconsider SMS: ”If you could only pick one person in the whole world to make toys and deliver, who would it be?”
Santa was thinking for a long time until the answer came to him. He happily ran over to Mrs. Claus, believing he had solved the issue to run an operation without SMS and shouted out: “There is only one person in the world that can do this job, and that’s me. If I was to hire only one person, I would hire myself.” 

During the dark long winter nights Santa looks forward Christmas to deliver gifts and happiness.
“There you have it”, said Mrs. Claus, “SMS is to hire only yourself for who you are and what you can do.” Mrs. Claus continued, "Now, go out and fire everyone else so you can get the job done."

“Well”, said Santa, “if I only hire myself, I cannot get the job done and SMS is not doing me any good at all if it is to only hire one person. I cannot make the sleigh fly, I do not have the strength to pull a full sleigh and I cannot operate all the equipment to make toys. The only thing I can do is to be the pilot of the flying sleigh.”

“That is all true”, said Mrs. Claus, “but since you cannot do the job alone, and for you to hire thousands of elves to do the job and provide excellence in service to boys and girls around the world, you have to implement SMS.”

“What do you mean by that?” asked Santa.

“It’s simple,” said Mrs. Claus, “Since you would only hire yourself, you have to make a system in the organization that reflect yourself. You just have to set up a system with policies, objectives and goals to let everyone know what you are looking for. When that is done you establish roles and responsibilities for elves and reindeer and set up processes, or steps, to follow for successful deliveries. After all, you are the leader in control.”

“Yes”, replied Santa, “but I always was the leader and nothing has changed.”

“One thing has changed”, said Mrs. Claus, “from now on, with the SMS implemented, you have to be accountable, and expect accountability from all elves and reindeer. The only way they can be accountable, is for you first to establish a non-punitive policy, where everyone can report issues to you without fear of being fired.”

“Oh…,” said Santa, tonally confused about what Mrs. Claus had just explained.

Mrs. Claus continued, “SMS is for you to take accountability as the AE (Accountable Elf) and set the stage for excellence in service by addressing human and organizational factors in training and performance. Over time everyone will work just like you do, with accountability, and this is as close as you can ever get to hire yourself.” 

Santa went out to hire positive people and train them for excellence in customer service.
Santa finally got the picture. He established an SMS and went out to hire positive elves and reindeer who he trained to do the job better than he could ever have done. The first year of SMS was a bit rough, since not everyone understood the concept. However, this year looks better, as Santa and everyone else is trained up. Santa has practiced his GPS (Gable Plan Slopes) approaches and the reindeer are cared for to be in top-shape for the Christmas run.

Santa was also conducting a QAP of the SMS program, and discovered that the North Pole might not be the best place to operate. With the sea-ice moving, the GPS approaches do not always line up the gable-roof or chimney simulation. Other issues SMS helped to point out, is that the cost by operating at the North Pole is extremely higher than if he operated closer to the market. Still, wanting a place that is remote, quiet and peaceful, with opportunities for practicing GPS approaches, he conducted several risk analysis of places with mountains, runways, available rooftops, chimneys, abandoned sites and cold weather in the winter. The place he found was Butte, MT. Since Santa is invisible during the rest of the year, except for Christmas, there would be no impact for local residents or industry. Santa would be able to train for his approaches from the tall mountains and land in the valley, and the elves would be able to work shift-work during the toy-building season and enjoy their free time with social activities. Santa sat back in his old rocking chair and grinned. He finally could rest for a bit and let his SMS do the job. 


Sunday, November 30, 2014

Identifying Hazards To Aviation Safety

The lowest level of safety in a safety regulated airline industry is to maintain regulatory requirements, which is a safety management system including a quality assurance program. In a safety environment the regulations establishes safety objectives for operational management and control.

A safety management system includes a process for identifying hazards to aviation safety and for evaluating and managing the associated risks. There are several methods to identify hazards.

One often applied method is the "shotgun" approach with an objective to report any hazard discovered. This approach may be combined with an encouragement whoever submits the most gets a prize. With this very broad and undefined definition to report a hazard  own experience becomes a determining factor if a situation or item is a hazard to justify a report. Some scenarios are therefore not identified as a hazard while others justify everything unusual as a hazard.

A hazard are to some to be parked next to a runway, while others see it as a mitigated event.
Another approach is for the organization to established a criteria for hazards to be found, and expect that each person identifies this criteria when reporting a hazard. With this approach the organization has established what to be on lookout for and instill alertness for these items. Some hazardous situations may therefore not be identified, since the task was to find hazards that fit an established criteria.

A third option in hazard identification is to establish a time-frame when to identify hazards. This could be between 8-9 AM, or 3-4 PM or any other times during the day. With this approach the task assigned is time oriented, and hazards outside of these set hours may not be identified and reported.

The regulatory requirement is to establish and includes a process for identifying hazards to aviation safety, one scenario of hazard identification is as good as the other. All hazard scenarios give the organization an opportunity to identify hazards, and managing associated risks. Since a hazard is a latent incident, and unknown until discovered, there is no right or wrong method to discover hazards, only right or wrong methods to apply corrective actions. 

The success to hazard management is to find the door where the key belong.
Hazard identification is not only valuable to mitigate the hazard itself, but also to assess organizational effectiveness. The "shotgun" approach could be applied in evaluation of organizational hazard identification training, if discovered that hazards reported were extremely high or extremely low. An established criteria approach to hazards could be applied to find out how well the organization conform to required processes. While the hazard-time approach could be applied to identify any change in level of task awareness during working hours. Applications of hazard reporting becomes indefinite when thinking outside the box identifying hazards to aviation. 

Sunday, November 16, 2014

The Goals Of SMS Management Review

An objective of a Safety Management System (SMS) is to include a Management Review, where the system is evaluated for effectiveness and if the systems are adequate to organizational needs and will continue to meet organizational needs over time.

Goals established for a Management Review are activities to be completed for a successful outcome of objectives. Effective goal activities are processes with defined roles of who does it, how it is done and when it's done.

Goal is a vehicle travelling to destination named Objective.
 Supporting goals for the Management Review are periodic, planned reviews and review for cause. A review for cause goal is the activity to take place when there are major changes in the organization that affects SMS or operations. These major activities could be due to senior management changes or activities requiring new non-established processes to operate.
Other goals for a Management Review objective are to review audits, verify that employees understand roles and responsibilities, verify achievement results of other objectives, review of results from investigation and analysis, effectiveness of internal and external feedback, determine the status of corrective actions completed and other with progress reports, follow-up from previous Management Review reports, goals of changes that could affect SMS, review recommendations for improvements and sharing of best practices across organization. All these goals are tools established for management to understand if their SMS is functioning as intended.

Objective is a destination for the Goal to stay on track.
In addition to operational goals, there are administrative goals. These goals are procedures and responsibilities for conducting audits of policies and procedures, and audits of SMS maintenance requirements.

A final goal is for Management Review to evaluate the effectiveness of corrective actions resulting from previous Management Reviews. This all boils down to the simple concept to Plan, Do, Check and Act. SMS is simple in concept, but comprehensive in assigning weight to each process 


Friday, November 7, 2014

Civil Aviation Daily Occurrence Reporting System (CADORS)

The Civil Aviation Daily Occurrence Reporting System (CADORS) reports daily airport or airline occurrences. Any operators could assume these reports of their operation to be annoying facts  and nothing else but to tell the world of what problems they have to fix. There some truth to this since these reports are publicly available and for anyone to view. However, there is also another side to these reports that are extremely valuable to any operator. This information is the discovery of potential unknown operational processes or lack of tools. It is a misconception that people will do what they were told in all situations. It is not that anyone intend to go outside the process, but because minor changes to processes are widely accepted the process deviates over time.

Over time these multiple small changes becomes the norm of what is organizational acceptable. With undocumented changes to a process, the next tolerance change does not take into account deviation from original process, but rather change from current process. Information reported in CADORS could give some clues to what out-of-tolerances an organization accepts.  

Regulatory violations could go unnoticeable until it reaching an unacceptable level.
In the above chart there is an incline in regulatory violations. It could be that this trend is not monitored and unnoticeable.  At some point the trend gets managers attention and mitigation is implemented.  It could be that a process, or how things are done, over time deviated widely from the standard operating procedures. Minor changes were operationally accepted, which sometimes is called "slacking off", when it actually is organizational acceptable process deviations.
In  an SMS world information from CADORS gives invaluable information of operational status. An airport bird occurrence graph could over a few years look like the graph below, with more occurrences in August than any other months. An assumption is that this happens due to more birds in the area during the migratory bird seasons.

An airport may apply different bird strategies applicable to seasonal processes.
An occurrence could be seasonal or organizational.
It takes some initiative and time on the part of both airport-operator and air-operator to investigate and analyze information of reports and then apply to their operations information given in the CADORS. That there are more bird-strikes in August / September does not necessarily imply process deviation in how things are done, but it rather could imply that there are no effective tools available for in-flight bird detections, or tools to move migratory birds from the approach paths.

Analyzing occurrences reports could detect process deviations or ineffective operational tools. 


Wednesday, October 22, 2014

Roles And Responsibilities In An SMS World

Roles are often associated with movies. A role where the sheriff is a newcomer to town and becomes a hero with overwhelming local support, the deputy is friends with all, the law-breaking are robbing banks and everyone else are law-abiding bystanders. These are all roles that are played to impress an audience.

In an SMS world everyone has a role to play to make the system effective, attractive, sustainable and supported by the public. A specific role in SMS is often associated with a specific SMS responsibility. A CEO of a corporation,  or an small-business owner, may have identical responsibilities in other similar structured organizations. 

Being unsure of the role is ineffective performance.
An SMS-world could have an objective of: 
Roles and responsibilities of personnel assigned duties under the safety management system. This objective identifies who, or what positions, are assigned these roles and associated responsibilities. An objective is accomplished by successfully completing tasks towards multiple goals.

Several goals, or task-oriented activities, to reach attain the objective cold be: 
Document roles and responsibilities; demonstrate control over available resources; person managing safety fulfills required job functions; safety authorities and accountability are communicated; and that personnel understand their authorities and accountability in regards to all decision and actions.

A dress code defines a role and acceptable performance level.
When people are asked what they are, many respond with what their profession is. This could be an accountant, a pilot, a doctor, a construction worker, a teacher or any other description of the job they do. The response is a description of what role they play at work. In day today living multiple roles may be taken on and played for an audience. 
With roles, responsibilities, objectives and goals, an organization has established a foundation to build an SMS world where each member is a role-player. These roles in an SMS world are played as any other roles that are taken on, and must be performed to acceptable standards for desired results.

Roles are not only found in the movies, but in everyday activities. It is not only the role-performance of a single sheriff, or manager that determines financial success, but the role-performance of all players. 


Friday, October 10, 2014

Non Punitive Reporting Policy

The intent of a non-punitive reporting policy is to improve job-performance and organizational effectiveness. A non-punitive reporting policy is either established as a “feel good – do the right thing” policy, or as a regulatory requirement, or as a policy for operational effectiveness. A non-punitive reporting policy is an organizational statement, and commitment, that a person reporting does not have to fear repercussion, threats or punitive actions from management or from their peer group when reporting a hazard, incident or accident. 

If a policy is to be considered only when the lake floods the runway, then any action cannot proceed until the runway is flooded.  

A non-punitive policy could include a statement under what conditions punitive disciplinary actions would be considered. Some of these conditions could be illegal activity, negligence or willful misconduct. By introducing this statement, illegal activity becomes the line drawn for punitive-action and not as representation of job-performance evaluation. Options for an organization are then either to view an incident as an illegal activity and proceed accordingly, or as non-illegal without applying job-performance related actions. In this environment the safety culture could become that anything goes as long as it is not done with intent.

When making the non-punitive policy an objective, the policy is a positive attraction to evaluate job performance. An objective example could be to have a policy for the internal reporting of hazards, incidents or accidents, and include conditions under which immunity from disciplinary action is granted. To reach this objective multiple goals are required, and these goals could be anything that would ensure the objective of a non-punitive job-performance environment. Goals are commitments given by both the organization and employees to strive for quality performance to reach these goals.  

Conditions under which immunity from disciplinary action is granted freedom from surprise. 
The significance difference between “conditions considered” or “immunity granted”, is that the application of “conditions considered” does not allow for job-performance adjustments unless it has reached the bar of what the conditions state, while the level of “immunity granted” is granted freedom from surprise and allows for job-performance adjustments at appropriate level and time. 


Wednesday, September 24, 2014

The Vital Few Or Trivial Many

The vital few or trivial many is the bumper-car process and found in a non-structured environment where priorities becomes to work on the "trivial many" rather than the "vital few", or the 80/20 rule. 

In a Safety Management System (SMS) an enterprise establishes Policies, Objectives, Goals and Parameters. A Safety Policy in aviation is an assurance to the flying public that the air operator maintains regulatory compliance and does not compromise aviation safety. A Safety Policy is a commitment that every time the public go flying, they can expect a safe and uneventful flight.

Bumper-cars is a messy process, but in control as expectations to the objectives. 
Regulations are performance based, or in other words, established objectives. The first step in a regulatory based environment is to ensure regulatory compliance by establishing the regulations as objectives. Everything else is incidental to the operation.

One regulatory objective is to have procedures for reporting hazards, incidents and accidents. Derived from this objective are goals, which establishes that there are communication processes in place that permit the SMS to function effectively. With processes defined, parameters are established as numerical values in order to determine by Statistical Process Control (SPC) if the processes are in control and results are acceptable.

Over time a process may become unnoticeable obsolete until point of no return.
An SMS system includes other regulatory objective such as performance goals and a means of measuring attainment of those goals. Goals are guidance of how to reach objectives and the means to reach these goals are processes with established parameters. Numeric parameters are applied  to analyze if processes are in control. However, a process in control could be just as ineffective as an out-of-control process. Random discovery of hazards could show a process in control, but it is not as effective as active hazard discovery. To pilots this is known as "scanning". A pilot may be looking outside through the windshield, but hazards may not be discovered unless there is an active scanning process of the horizon.  

Compliance with regulations is to conform to the objectives as defined by regulations; it's to establish goals of what is expected to be achieved; it's to set numerical parameters and to complete the circle with SPC to ensure in-control processes.
The key to success is to be removed from the trivial bumper-car processes to focus on the vital few objectives.


Friday, September 12, 2014

Process Matters

Changes are often difficult to accept and to put in effort to make it work. When new things are introduced there are often skepticism and opposition. At times these arguments make conflicts within an organization. It might be tempting not to make changes just to keep peace in the valley. Personnel who don't like changes make their own changes by making hurtles to stop the new process. That's in itself is a change and an ineffective process. 

Process Matters – Get the material first and then build.
The process matters to everyone, for or against. It matters to the ones who want a change in the process and it matters to those who opposes. If processes didn't matter there would be no need to plan, do act and check. Processes are how we do things. Most of us have a process of how to get dressed in the morning. Some of the steps may not be in the same order each day, while there are other steps that must conform to a required process. Socks must come on before the shoes.

When changes become personal issue, the changes are no longer operational process changes, but process protection of independent comfort. The fear of change is the fear of loosing a stable and comfortable position. A comfortable position may not be productive or produce a profit, but at least it is comfortable. 

Process Matters – Get the tracks first then move the freight.
In an organization with flexible processes personnel adapt easier to changes. These are not variable processes, just flexible, and allowing resilience. Knowledge of how to improve a process is at the level of competence. Inputs for process changes (which is a process in itself) have better rate of success if all levels of competence in an organization is included. When including suggestions and addressing objections during the planning phase changes do not become strange competition to comfort, but just changes to the processes.

Processes matters to all.  It matters to those who say it doesn't (or they wouldn't have objected) and it matters to those who embrace process changes. 


Wednesday, August 27, 2014

Training, Training, Training and Training

Training is a big chunk of aviation safety and a tool to ensure personnel are qualified to perform their duties. With ongoing training it could look like nobody is never fully trained. If someone is fully qualified and trained, then more training shouldn't be required. Training is therefore often looked at as being required for someone with lack of knowledge, qualifications and failure to perform. It couldn't be farther from the truth than that.

It's a misconception that training only has one function of learning, and that this function is to become qualified. Human culture associates training with learning, where learning begins in preschool, graduates to kindergarten, then elementary, and finally to high school. Each step is required as a level of learning to qualify for the next level. These are building blocks of learning moving from unknown to known. It's to instil knowledge in someone who didn't have that knowledge.

A training environment is the fruit of acquired knowledge, while learning is the bar of acceptance. 

Training has several other functions and cannot only be associated with learning, or lack of knowledge. Functions of training are associated with Human Performance, which again have multiple subsections. Some of these subsections are Human Behavior, Organizational Performance, Human Factors, Medical Performance, Aviation Performance, Optimal Operational Design, Interaction Modeling and more.

When applying the fact that training is associated with Human Performance, ongoing training becomes a tool to capture process deviations from performance parameters. Deviations from performance parameters are not lack of knowledge, but a process deviation to reach a common goal. Most standardized processes are arbitrarily chosen based on bias opinion of the person who established the process in the first place. This doesn't make the process wrong, bad, incorrect or dangerous, it's just the fact that someone established the process based on their experience and personal view of what to them made sense. From these processes, rules are derived to establish the lowest bar acceptable in aviation safety. As an example of a new rule is the Sterile Cockpit rule. This rule was implemented due to one notable accident which caused a crash just short of the runway conducting an instrument approach in dense fog. Training becomes a process to apply standardized procedures, capture deviations and excel in performance above the bar.   

The key to success is not in what was learned, but in the training of applied processes.
Training is not required due to lack of knowledge, but it is required to evaluate performance level against the bar, instil process control, correct process as applicable and assess Human Performance level at or above the bar. Training is to excel to levels that are above the trial and error method level.  


Thursday, August 14, 2014

Holes In The Cheese And Bad Apples Are Causing Accidents

It's neither true that when holes in the cheese lines up accidents happens, nor is it true that bad apples cause accidents. And if the facts were that every major accident is proceed by a few minor accidents and several incidents, there would be no management of safety. Safety would then be managed like a bag of marbles being dropped to spread in random patterns. 

A ridged process runs over variables instead of managing.
The holes in the cheese lines up because of a decision to slice the cheese in a certain way. If the objective was to slice the cheese in a way that the holes would not line up, a thorough analysis and risk assessment prior to slicing would be required. Holes lined  up in the cheese don't cause accidents. It is the outcome of how things are done during day to day of normal operations that are causing these events. When managing safety, daily routines and practices must be analyzed and then proceed to slice the task to manage the holes in the processes.

Bad apples don't cause accidents. Imagine a box of apples, open it and there are one or two bad apples on top. These apples were bad because they were not given proper treatment prior to be placed in the box. A week later, when opening the box again, there are several more bad apples that are discarded, and this goes on until the box is empty. When all bad apples are gone the goal is reached: To have no more bad apples.

People perform their job to the bar of a bad apple to what degree they are allowed to experience proper treatment. By keeping apples at the proper moisture and temperature, they remain good apples. Personnel that are trained property excel in their job to levels well above the bad apple bar. If they are not trained to perform and understand the processes their performance level rapidly decreases to a level of bad apples where they feel accountable to operate. 

When going down the slide for the first time hazards are carefully analyzed. On the next ride they are integrated in the process.
When marbles are dropped they spread in a random pattern. The location where each marble stops are determined by laws of physics; where each marble is in the group at the time of release; how each marble interact at point of impact; and the condition of the surface of impact. If this exact condition could be replicated the marbles would stop at exact same point every time. The reason they are spreading out differently is that the conditions cannot be reproduced. In theory the same result should be achieved, but due to special variables it is impossible to manage to get same result.

Reactions to these unknown and special variables must be applied at the time and location of where each variable occurs.  The key to manage safety is to reduce special variable and take more proactive than reactive measures.

There are no reasons to accept that accidents are inevitable just because a magic number of incidents are reached. Managing safety is to discover and learn about as many as possible of variables and then integrate these variables as a part of normal operation. 


Friday, August 1, 2014

Accidents and Incidents Are Time Converging Events

On a clear blue sky day one airplane left on a westbound trip, while another departed  on a southbound adventure, both bound to be on time for an unknown converging mid-air path. If the data of these two flights had been communicated, applied corrective actions would have separated their paths.

Mathematical equitation are applied every day to avoid conflicts when air traffic controllers (ATC) requests pilots to change speed or heading. These changes were not planned, but due to one or more variations new calculations predicted current paths to be converging in time.

A once perfect project may over time reveal its flaws. 
Unexpected variations, or special variations,  are hidden flaws hidden in layers of safety guards. Accidents happens when flaws are revealed in an unpredictable sequence and causing time crossing paths.

People are the strength of all safety processes with a unique ability above and beyond any automation in resilience, and the understanding of communicated data. Collected data of special variations are accumulate knowledge. This knowledge makes you wiser, not just older. How insignificant the data might seem at the time, it's an asset to improve safety.  

Special variations may be obscured by the view.
Communication is a key factor to manage safety. Tools and technology for effective communication to avoid time converging events may not be available at all locations, or in all types of airspace. The time to "time of no return" becomes relatively short when pilots first  have to establish visual contact.

Special variation management is to discover the unpredictable sequence at which these variations are revealed. 


Wednesday, July 16, 2014

Operational or Optimal Decision Making

Decisions are in concept either based on personal experience or on process data, as Operational or Optimal decisions. Operational decisions are based on heuristic data of outcome, while Optimal decisions are based on variations and performance measurements.

In addition to human factors variations, there are multiple other variations affecting safety of flying. Some of these are short runways, high altitude, unpredictable weather, difficult terrain or combinations of all, and including adding human performance variations.

If just getting there was the point, nothing has to change. 
On the Global playing field it is accepted that one major accident will happen within certain flight hours. However, it is impossible to determine and pin-point future location and time. Operational decisions maintains that the outcome of past flights did not cause an accident, and therefore identifies that the immediate next flight will not involve an accident. If an accident was  expected, the decisions leading up to the accident would not have been made in the first place.  

A perfect accident free record is not necessarily guarantee of an accident free future, or that the operation is managing safety. What heuristic data is telling us, is that operational parameters for a safe flight were greater than the optimal performance parameters of the aircraft. This can simply be illustrated with the process of a pilot's first solo flight. The aircraft is built to perform to far more restrictive parameters than the parameters for a pilot's first flight. Applied operational outcome data does not hold water in today's new generation of SMS, QA and SPC. A landing is only as perfect as the process behind the approach.

The old windsock displays results, but does not give upwind data.
Optimal decisions are based on aircraft performance parameters and takes into account performance parameters of approach speed, approach slope, approach stability, threshold crossing speed, touchdown speed, touchdown distance and rollout distance.  When runways, altitude, weather and terrain are in favor of aircraft performance capability, it is not necessary that the aircraft meets critical performance parameters for a safe landing.

A decisions based solely on heuristic data does in itself allow for optimal performance parameters to be ignored. 


Thursday, July 3, 2014

When The Cat's Away The Mice Will Play

In any operation it could become a task to ensure the job is done correctly when the boss is away. In a professional organization it becomes critical to ensure that everyone performs their tasks to an expected level of standard. A combination of organizational expected safety performance and accountability becomes the safety outcome of the processes.

No matter how the job is done, it leaves tracks for some else to follow.
Some people work well independently, while others needs the boss to assign activities and may not perform to expected standards when the boss is not around. One could say that the only way to have the boss around at any time, is to make everyone the boss of their own responsibilities. Defining documented roles in the process is  supervision, and expectations are job-management, with accountability the authority for an employee to be the boss of their personal responsibilities. These methods simplifies complexity and establishes accountability  of roles and responsibility at organizational levels where they belong.

A glider pilot's responsibility is acceptance of accountability within their work environment. 

As with any type of jobs, performance measurements is conducted by regular testing and sampling of process outcome. If the outcome meets the bar life is good. If it doesn't, then it's back to the drawing board, find the root cause, fix the root cause and do it all over again. It is simpler and more economical to do it right the first time. A process where there is not enough time to do the job right, but enough time to do it twice is a root cause of system failure. 

Applying roles, responsibilities and accountability at appropriate levels of an enterprise and conduct SPC and QA of these processes is preferable to being dependant on fixing root causes. No need to keep the cat around when housework is done. 


Thursday, June 19, 2014

When Paperwork In Order Becomes More Important Than The Process

It's an easy trap to be trapped in that having the paperwork in order becomes more important than the process itself.

When the paperwork gets an A++ rating it is assumed that the output of the process makes operations safer. This assumption is totally wrong if safety is solely based on how colorful the documents are and how well spoken the speakers are.

Perfect craftsmanship it gave in since the paperwork and planning placed the building in the wrong environment.
At the opposite end of the paperwork, it is a trap to assume that the output of a process is a threat to safety if the paperwork is a failure. This assumption is wrong if lack of safety is solely based on incomplete documents are and lack of public speaking ability.

Everyone are impressed or discouraged by the first impression (the first 7 seconds) and let  bias emotions rule the outcome. It takes a genius to put bias emotions aside and evaluate fairly, or it takes the tools of SMS and SPC to achieve the same result. 

If the outcome wasn't as expected, maybe bias and emotion prevented fair evaluation.
Paperwork sets the stage for process to follow, and the actions sets the stage for output of process. The paperwork is the memorybank, and where the outcome is the last link of the chain of multiple, and often memory tasked inputs. 

To achieve high quality safety, first class documents must be accompanied by quality assurance of memorized tasks performed. Assuming that the documents conform to regulatory requirements; the weight to put on what people write and say is a ratio of the lack of delivery to expected level of safety. In other words, if weighing words equal to high quality safety level the priority task becomes to achieve in document development and public speaking.