Friday, March 28, 2014

The Killer Bee

Since the European bees did not perform well in the tropical climate of Brazil a plan was introduced to breed European honey bees with African honey bees. The goal was to create a bee which was gentle, highly productive and successful in the tropics. However, there was a system failure in the process which caused the creation of a Killer Bee.

The Killer Bee was genetic alteration by good intent of creating a super bee.
After major airline accidents Corrective Action Plans (CAP) were implemented to satisfy the flying public that flying would be safe again. Some of these improvements were Pilots Flight and Duty Time limitations, Traffic Collision Avoidance System (TCAS), Crew Resource Management (CRM), Flight Deck Bolted Doors, and several other changes to the airline industry. 

In preparation of the implementation of a CAP  multiple risk analysis scenarios may be conducted to establish the effectiveness of the hazard mitigation. In addition to a risk analysis of the new process, other risk analyses should be conducted of  residual risks.  

Residual risks are hazards generated due to implementation of a new process. If residual risk analyses are not conducted, unexpected hazards may not be discovered until there is an incident. 

A residual risk of flight time limitations could be rushed decisions by pilots due to time constraint, or bolted doors causing hazards to be transferred from passengers to crew and other areas of flight operations. 

Since residual risks are not identified by incidents they are more complex to mitigate. Further, personal experience and opinions also plays more of a significant role in mitigation than mitigation of identified hazards. 

Throughout a process, Statistical Process Control (SPC) is applied to monitor and control the process. Monitoring and controlling a process ensures with a higher degree of certainty that the process operates at its full potential.

SPC ranges from complex mathematical formulas to simple practical tests.
Human behavior is what makes a difference in a process. This goes from the person who is applying controls, to the person who is inputting for automated operations. Just as there was a “hole in the fence” in the process of genetic alteration of bees to create a super-bee, there could be unidentified hazards in the processes of improving aviation safety. 

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Thursday, March 13, 2014

SMS and QA Is Processes Management

A Safety Management System (SMS) and Quality Assurance (QA) are systems that are valuable to manage processes in any organization. That it is called a safety system does not preclude it from being applied as an operational tool in organizations that are not regularly and directly exposed to catastrophic property damages or fatal accidents.

A Safety Management System is to manage processes where risks are involved. This could be financial risks, customer service risks, cyber-communication risks, employee retention risks, lawsuit risks, and any other risks affecting the operation of an enterprise.

Let's for a moment take SMS and QA into the Land Registry systems. Simplified, the survey monuments establishes the perimeters of a parcel. From the early days of surveys in North America, properties were surveyed into sections, quarter sections and in urban areas into 5 acres lots. Further subdivisions of these 5 acres lots were established by metes and bounds descriptions.

A 5 acre lot is approximately 521ft by 425ft. When a 5 acre lot "A" was subdivided into two separate parcels the metes and bounds would read for parcel 1; Owner "X" is the owner of the most northerly 313 feet of lot A, and for parcel 2, Owner "Y" is the owner of lot A, except for the most northerly 313 feet. By the metes and bound, and without any survey monuments the property had been subdivided between two different property owners.

An organization with an SMS in place is required to have processes in place to evaluate the level of risk and the tolerable level of risk the organization is willing to accept. A possible risk in a land title system is that the title description could be outside of the established boundaries by the survey monuments. Since the monuments establishes the boundaries, the title must ensure conformance with these monuments. A tolerable risk level would be zero tolerance to title discrepancies of monument locations. When there is a discrepancy the organization needs to implement a Corrective Action Plan (CAP). In addition, an organization must have processes for evaluating the effectiveness of the corrective actions.
Over the years of manually describing metes and bounds parcels, and applying a 20 foot chain for measurements, this process caused several, and beyond tolerable level of non-conforming titles. A CAP would therefore implemented to apply new electronic technology and assign each parcel with an unique parcel number. After CAP implementation, each parcel with a unique parcel number would be sampled in a QA system to find out how effective this new process was, and if it was within a tolerable level of risk to property owners.

By applying Statistical Process Control (SPC) the result showed that the new process was out of control for old parcels, but in control for new surveyed parcels. When going back to the above example of a 5 acre parcel being subdivided into two parcels, this new system had eliminated parcel 2, owned by owner "Y" in lot "A".

Both  SMS and QA systems are practical systems for any organization where risks are involved and where established processes are required for systems to work properly.


When an out of control process is identified, a CAP is developed, tested, implemented and assessed for effectiveness.

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