What is the Goal of this Blog?

What is this Blog about? Dedicated to proven formulas and tools of Quality Assurance and Safety Management Systems. After over 30 years of facilitating Quality and Safety Seminars, I truly have become a fan of the system and have enjoyed the discussions and debates that have ensued. As a teacher, I have a this inborn desire to share information and I needed a forum. Thus, this blog. Please feel free to post comments, rebuttals or just your thoughts that would be shared by those of like mind!

TOPIC: Safety Through Control

A true event from the Civil Aviation Daily Occurrence Reporting System, (CADORS),  in Canada. 

Two separate companies flying between the same cities in Canada. Both companies compete to fly passengers from one city to the other with the slogan “We’ll have you home before dinner time.” One company, we shall call Dart Air, has two crews to fly this route. Dart air management pressures the crews to do all that they can to reduce the flying time. The management pressure on the crews appears to be working since the times from wheels up to wheels down has been steadily reducing. Dart air records the flight time in the run chart below:

The Incident.

On the last Friday, as illustrated on the run chart, one of the flights ran off the end of the runway. The CADOR revealed that there were no injuries but, the plane sustained moderate damage to the landing gear. An internal investigation was initiated by Dart air. Interviews of both pilot teams revealed that the two crews were engaged in a competition to see who could fly the route the fastest! The pressure from Dart air management fostered and encouraged the competition which ended in a near disaster. It was not until the overrun and near accident that revealed the unsafe condition that was present in this route. You might say, we have an excellent reactive process.

Dart air management was praising the job of the crews in reducing the flight time between cities. The run charts reveals a steady drop in flight times. It was obvious that the crews were coming up with ways to make the flight much more efficient. This trend continued until one of the flights ran off the runway. The CADOR report stated excess landing speed as a contributor to the incident. Upon analysis by the company’s own personnel, it was revealed that two crews had a competition with each other on who could reduce the flight time best.  Unfortunately after the fact, we applied control limits using the data produced by the run chart. 

By applying control limits to the run chart, we can see that the Monday before the incident occurred the chart went “out of control.”  If Dart air monitored the flight time with a control chart rather than a run chart, the chart would have alerted company management that something was “abnormal.” with the flight time. Yes, the abnormal situation would have been “before” the incident and thus could have prevented the plane from running off the end of the runway. 

Variation vs. Failures

The Dart air case is a perfect illustration of the power of “control.” When a company uses control tools such as control charts, we see management acting on “variation” rather than failures. There is also an added benefit to the company’s 

safety management system. When a process is monitored using statistical methods, then that process can be exempt from the audit program freeing up audit resources to audits other areas. The question arises; what if a process does not produce numerical outputs? Remember the key is “variation.”  Processes must be governed by procedures that define what is normal. Anybody can see if something is “abnormal” if and only if they know what normal is in the process. 

Some examples of “variation” or “abnormality” is a doors that doesn’t close as usual, an unusual oder in an area, a discoloration that is not normal, a crew member that is acting differently, an unusual reading of an instrument. It is important to note that these examples are not failures but simply “variations” from what is defined as normal. By acting on variation we prevent the incident or accident from occurring. It should be noted that no one can predict a truly catastrophic failure. But, by looking at historical data, truly catastrophic failures are rare. Most accidents occur as a result of processes that went “out of control.” 

All the Tools needed for a Great SMS Program in one little pocket guide

Introducing the new SMS Memory Jogger. Sol and I have co-authored this great little book. Some of the most important tools are the Risk Assessment tool along with the new Bowtie diagram for risk assessment. We have also included a Case Study using some of the tools in the MJII. I think the most effective and practical tool in the book is the "7 Step Safety Management Plan." This template, when used, meets the requirements for an SMS management process by ICAO, FAA, and Transport Canada. Of course, the traditional Fishbone diagram and other RCA tools are explained using Aviation SMS examples. 

Goal QPC is a GREAT partner in putting together this practical tool.