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.


Thursday, June 5, 2014

If It Ain't Broke, Don't Fix It

If the phrase "if it ain't broke, don't fix it" was true, the aviation industry would still be living in the stone ages inventing the wheel. Changes are necessary to improve processes. But without conducting analysis' of proposals, it is possible that the outcome is not as great as expected. In the days before SMS, it was still acceptable for accidents to generate great improvements to flight safety. Prior to an unexpected accident the operation appeared to functioned perfectly and wasn't fixed, since it wasn't broken. What was forgotten is that it's "what you don't know that is what will surprise you."  

Obstacles must be identified and navigated
In the farming industry, growing grain seems to be a simple process by placing the seeds in the ground, wait for rain for a great crop, or worry about hot and windy for a poor yield. If the crop regularly gave poor yield, the solution was to move to a more fertile ground. For centuries this method was accepted as not being broke, and therefore wasn't fixed.

One day a visionary from Iowa decided that  seeds should be made more reliable to produce higher yields in hostile soil. This was a new way of thinking since the way farming was done had worked since beginning of time. However, by his new forward looking thinking he could feed the world, where the world couldn't feed itself. He had fixed what wasn't broke and was awarded the Nobel Peace Prize.

Aviation industry in the past lived by this principle "if it ain't broke, don't fix it". It wasn't until the Safety Management System (SMS) was introduced that forward thinking became a tool for planning, tracking and analyze results. With SMS the principle changed to "if it ain't broke, don't break it." SMS became the tool to develop better processes and to maintain well functioning systems. SMS changed organizational thinking from a rush to judgement by changing out the crew whenever there were incidents, to either analyze and repair the process, or to develop, implement and maintain a new process. 

Looking behind you in the past life was perfect, but look the other way and  the unknown may surprise you
If the old way of replacing crew to improve safety was true; then how many crew changes are required for the process to become perfect? Or look at it from an everyday prospective; if the toast was served burned, how many burnt toasts must be served for it to be perfect? Or, is it possible that rather than adapt to burnt toast, the day would be brightened  by changing the way we make toast?