Tuesday, January 27, 2015

When Common Sense Rolls Away

Imagine a car incident where the vehicle ends up through a picket fence and into a yard. The incident may have been caused due to another traffic swirling in the path, or because the black cat crossed in front. Incidents are results of being distracted by outside events, which causes a split-second of distraction from task and with no time to invent a recovery process. 

It is common sense to put out the fire, and common sense was applied.
When the events are heated, or literally on fire, unless there are established processes in place it becomes easy to do mistakes, since the processes now has to be invented at the time of reaction.

Assume for a moment that this incident happened on top of a hill and the vehicle caught on fire. Fire trucks arrive and firefighter are running towards the vehicle ready to put out the fire. Then, in a split second, the car begins rolling away and down the street. Still on fire, the fire fighters run behind trying to catch up. But with no luck, and the car crashes into another fence. 

After all the excitement is calmed down and the fire is extinguished,  the next step is to find out what happen, what caused it, what link in the process was lacking, and what is the root cause.

After an incident the event must be made right again. Not just to prevent further similar incidents, or not just as a "lesson learned", but to make it right for what just happened. What makes it right is to find the root cause and make the current event right again with accountability.  

A process in control paints a marvelous picture.
Since there was no process of action established between fire crew arrival and putting out the fire, everything else became common sense.   


Sunday, January 11, 2015

Blame The Weather Or Implement Superior Systems

Once upon a time there was a weather system called Windy-Weather System that caused airplane accidents. It was a strong system which could transform from strong winds, to heavy snow, rain, hail, fog or thunderstorms. 
One day a brand new, top of the line airplane left a sunny place to bring people home to their families. The airplane had state of the art systems capable of handling anything known to man. There was noting imaginable in the world that could make this airplane loose control or crash. The airplane took off, climbed to cruise altitude and was on it's way home. On the far horizon Windy-Weather System spotted the airplane and got upset that the airplane had entered the airspace controlled by weather.  Windy-Weather System transformed into a snowstorm and set course for the airplane. The airplane was fighting back, trying to stay on course and get through the snowstorm. However, after a while the airplane had to give in an crashed into the Snowy Mountains.  Everyone was fumbled. How could this happen with the state of the art airplane? This was after all the modern times of 1931.

Severe weather conditions may develop in the most beautiful setting.
Airplane improvements were made to manage weather systems. After this trial and error method, airplanes were certain to win the battles with systems developed by Windy-Weather System.

Some years later Windy-Weather System discovered another airplane intruder. This time the airplane made it as far as to the approach before Windy-Weather System caught up.  The  airplane fought back, but just short of the runway it was overcome by the fierce powers of a weather system and crashed. Again, everyone was fumbled. The airplane was equipped with state of the art technology, and it was after all the modern times of 1997. 

Again, improvements were made for airplanes to manage weather systems. All sorts of technology were invented and installed in airplanes. Airplanes around the world were again equipped with the latest state of the art technology to combat Windy-Weather System. However, after all these years of weather systems combating airplanes around the world, Windy-Weather System had not made one single change to weather systems patterns or how they developed. These systems kept on moving around the world in the same pattern, with same components, and in a way they had always done. 

The components of rain or snow has not changed over 100 years of flying.
One would assume that after all these years of airplanes combating weather and loosing the battles time after time that lessons were learned and improvements made to manage Windy-Weather System predicable movements.  With all the scientific knowledge how Windy-Weather System operates , when another state of the art airplane crashed due to a weather system, everyone were again fumbled. How could this happen?  After all, it was the modern times of 2014.
Over the last hundred years of flying aviation has not managed to conquer weather systems by developing and installing state of the art technology in airplanes. Time after time the weather has won and airplanes crashed.

One important component to manage weather systems was not understood until just recently. The world of aviation has come to realized that with each state of the art improvement, the most important factor of aviation safety was either blamed or ignored. What was considered the source of failure has now become the source to plan for success.

The changes of implementing systems are moving forward to manage the most unique, intelligent and resilient link to further improve safety. This link is human factors operating in a just-culture where intelligence is applied in a Safety Management System, or SMS.  


Saturday, January 3, 2015

New Year Resolutions

New Year was just around the corner and many of us made New Year resolutions. These resolutions are often trivial, but still not less important to us when made. At the end of the year we may review these resolutions from previous year and assess how we did. However, by the time first month is gone, most of us have forgotten all about what resolutions were made. By the end of the year most of have forgot that any resolutions were made, so we ignore it and move forward with more resolutions. This may go on for years with the end result that nothing is being accomplished. 

Looking back has no value unless it's carried forward

When an organization is operating without a system; including policies, objective, goals and parameters, management becomes trivial New Year resolutions.  At the end of the year we may review, but without documentation it becomes a simpler task to forget the past and move on with new intentions.

Blogs of 2014 are ongoing New Year resolutions with the following New Year Eve being the date of a virtual Management Review.  Blogs of 2014 included several principles of SMS, with some of these being reviewed below. 

  • An effective non-punitive policy, which is not a "get out of jail free" card or an organizational excuse to deliver inferior quality job performance.  A non-punitive policy represents accountability and excellence;  
  • A fully operational SMS, which is a conglomerate plan of components, policies, objectives, goals and parameters; 
  • A system for documentation, knowing that documents are is the chosen method to recall plans, policies, objectives, goals and parameters, and a tool to recall future plans;
  • Training,  for all to receive job performance training to further develop performance skills to become a specialist in one area, or a selective few areas and receive SMS training;
  • 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;
  • Apply SMS as a tool for an enterprise to manage the day to day operation, to plan for the future and to analyze processes applied in the past for further improvement of operational safety;
  • Applying risk assessment to obvious situations that are threats to aviation safety, but also remember that pleasant conversation at the dinner table could distract and cause a human mind to drift away from focusing on tasks. What takes place at the dinner table may be a contributing factor to the outcome of next flight;
  • SMS makes aviation safer and a Safety Management System is a positive addition to deliver quality service to the flying public. Airlines operating within an SMS system are far better off than someone without an operational control management system;
  • Ensure manuals are up to date and relevant since the shelves could be stacked with manuals of different kinds and collecting more dust than fingerprints. Common purposes of manuals are to serve as a memory bank;
  • Assess the operation for effectiveness without falling into the trap that having the paperwork in order becomes more important than the process itself;
  • Changes are necessary to improve safety and not let accidents lead the way for improvements. In the days before SMS, it was 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";
  • The job needs to be done with accountability and not just because the boss is expecting quality. 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;
  • Performance measurements are tools in a decision making process. 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;
  • It is not true that when holes in the "Swiss Cheese" lines up accidents happens. If this was the case, safety could then be managed like dropping a bag of marbles to spread in random patterns to manage the unknown. It is how the cheese is sliced to line up the holes, or to avoid the holes, that cause, or avoid accidents. When managing safety, daily routines and practices must be analyzed and then proceed to slice the task to manage the holes in the processes.    

Changing policies has no effect unless the process is changed

At the end of the year these new resolutions of policies, objective, goals and parameters are reviewed, malfunctioning processes are changed with corrective action plans, effectiveness of prior years are assessed and guidelines for upcoming year is established.
New Year resolutions have been in place for centuries, but it took a new system of SMS to make these proposals effective.