Sunday, February 22, 2015

Cycle Of A Process Is More Than Inputs And Outputs

The cycle of a process is more than to input data, turn this data inputs into actionable items and wait for results. A process itself might be simple, complex or beyond currently invented capabilities. It's an assumption that a process is only as good as the inputs, and if the input is trash, then trash becomes the output. At the other end of the spectrum it is assumed that good data produces desirable process results. If these assumptions are true accidents would happen consistently with incorrect inputs, and would never happen with correct inputs. The pilot of an airplane rolling down the runway for takeoff has already put in place inputs to the processes for a safe flight and to arrive safely at destination as planned.

In a process with no variables, the output of a process would be in a Standard Atmospheric Condition.
 As a very young person, I would place my glass of milk at the edge of the table for easy reach. This did not fit the process for good input. So, the glass was moved to the top of the plate where it could not fall to the floor, since I had become known to spill the milk and accidentally push the glass over. I had not yet grown up to the size of an adult who developed the processes and it became a challenge to reach the glass. When placed at the edge of the table I had control of the process and could reach it without applying other variables than to reach for it. As the glass was placed farther away  I was faced with variables of leaning forward, move a bit higher, at the same time as I reached for the glass. As often, the milk was spilled since these variables were not trained for, or accounted for by the process-developers.

It is true that input of a process is a contributing factor of outcome, but only becomes a fact when there are no variables. When variables are removed the process is only as good as the inputs. However, when variables are presents the process is only as good as the quality assurance of output control. 

Unless the variables of a process is accounted for, the process outcome is random.

One quality of human factors is resilience, or the ability to bounce back from an unexpected variable. Humans have the ability to react both with a proactive solution, or with a reactive solution. Human factors also have the ability to apply unconventional process adjustments to return back to desired outcome. It is when variables are not accounted for that perfectly good inputs to a process could produce catastrophic result. The cycle of a process does not stop with the output or result. The cycle ends when human factors take control of quality assurance of the output. Safety in processes is only as good as the human control of the output.


Sunday, February 8, 2015

Has Aviation Become Safer In Two Years?

Two years ago an aviation-blog about Safety Management System (SMS) as a tool beyond the "Trial and Error Method" was published. Is aviation safer today than two years ago? There are still senior managers and regulators who believe that the only way to manage safety is to make new restrictive safety rules to prohibit, or requirement of certain actions. After each accident news media reports that this must be a "lesson learned" and demands changes to improve safety. Over the last couple of years there has been a demand for better tracking of airplanes in remote areas, and news stories states that "this must never happen again". The trial and error method is still continuing, but is slowly developing into SMS.

SMS developed from an unplanned aviation event which could have been managed.
How many lessons learned are expected before the world turns to SMS to be regulatory mandated in all countries? SMS regulations are performance based where operational control, and how-things-are-done in an organization determine their level of safety. Regulatory requirements is only the level where the bar is set for regulatory compliance. This can simply be explained as the "expectations" to meet the minimum regulatory requirement for a Safety Management System.

When applying each expectation as a goal for SMS operational control an enterprise is completing the first step to establish how regulatory goals are met. Everything else above regulatory requirements are processes for continuous improvements, and how to ensure safety for every flight, every year, month, day, hour, minute and second.

Has aviation become safer in these last two years because of SMS? Yes it has. Initiatives and mandates are proposed and implemented to apply Safety Management System as the preferred operational control tool and moving away from the trial and error method. 
However, it has been recognized that safety is a process and does not happen on its own merit, but require planning, implementation, checks and balances, and action for continuous safety improvements. This is only achieved with accountability in a just-culture.