Saturday, June 16, 2018

When Human Factors Snaps

When Human Factors Snaps

Post by CatalinaNJB

Quality assurance is a vital part of production in the manufacturing industry. There are several data collection points during the processes with the end result that the product is reliable. Whatever the manufacturing is, products are tested over and over again to ensure the quality delivered equals quality promised. These tests could be NDT (Non Destructive Testing) tests, destructive tests, endurance tests, or any other tests that are applicable to establish a confidence level of quality above the bar, or above promised quality. If the quality level is below the bar, there are two available options; 1) lower expectations of the product or promises; 2) improve the quality to a desired and acceptable quality level. The simplest solution is to lower the expectations of the product, which some manufacturer decide to do when coming to a fork in the road. There is some truth to the saying that “you get what you pay for”. 

Quality assurance is decided at the fork in the road.
When a product is manufactured as a larger piece of a system, it is tested prior to entry onto the assembly line. It becomes obvious that not all products, or all 100% of a sample, can be tested for quality by destructive testing, since there then would not be any parts left to assemble. The quality of parts within a system where a destructive testing is required is therefore based on random sampling of these pieces and applied to the remaining sample. Turbine blades and vanes in a jet engine cannot all be tested for material stress. Random samples are tested to establish a confidence level of product warranty. Should the sample “fail”, and the test is performed according to standard, it’s not the failure of the sample itself, but the process that lead up to the finished sample. Service industries also perform sampling of services for quality assurance. A service industry may sample how personnel perform in customer service relations, and they may sample the product they are servicing. A gas station may find that one supplier of gas often deliver poor quality, or they may find that one vendor often delivers poor quality dairy products. When a customer is complaining about the product, they are actually complaining about the service delivered. A customer expects that a service provider (E.g. gas station or general store) have a quality assurance system in place to ensure that each product they service is delivered to expected quality. This type of quality control is more difficult than strictly product quality, since the service provider must have confidence in, not only the manufacturer, but also in the vendor. The service provider must establish a confidence level of a manufacturer and the vendor that is at or above the bar of what a customer expects, and do this for each product they sell. 

Both manufacturer quality assurance and service provider quality assurance can be tested and evaluated based on known data that affects products or services. Sampling of what the vendor delivers can be evaluated based on known data that affects products or services. Sampling of what the vendor delivers can be taken at each delivery. Yes, they would lose the sale of that one item, but by sampling they can apply this data in their quality assurance system. Some years ago, a small produce wholesaler conducted their product quality assurance by asking each employee to pack themselves a bag of randomly selected fruits and vegetables every weekend. This competitive edge of testing the product weekly blew the larger and established competitors away. Eventually this small organization purchased the well established large produce wholesale companies. Not only did this improve their edge of product quality, but it improved their edge in customer service by having live and current testimonies of their quality. It could be that the manufacturer delivered a good product, while the quality deteriorated while in the possession of the vendor. By sampling the vendor, the quality of the product itself cannot be sampled. However, this is often the only practical solution to collect samples for quality assurance. This solution points the blame at the vendor and may not address the actual root cause. This approach is often applied, since it’s a simple and a justifiable action, to blame the nearest source when the failure happened. In addition, this type of root cause assessment does not have any cost incurred and it doesn’t require any special skills, knowledge or training.

Data is collected to analyze why the selected process didn’t win.
An effective Safety Management System operates the same way as a manufacturing system and service system by collecting data for quality assurance. Except that the SMS collects data of human factors, or human errors for lack of better words, of how much pressure it takes for human factors to snap, break or to malfunction in job performance. Personnel may be required to perform conflicting tasks in job performance, work with incomplete systems and must have resilience to change or divert a process when things go wrong, as they sometimes will. When applying this concept to an airport or airline, the airport makes an effort to maintain safe customer service, while regulatory requirements may demand that the airport temporary closes. A pilot may be tasked with flying in hazardous weather conditions, while simultaneously being tasked with unacceptable ATC clearances due to the closed airport. The question becomes how many combine tasks does it take before the performance of human factors snaps.

Human factors system was the forgotten system until the concept of SMS was introduced. After an aircraft accident the blame was immediately assign to the pilot. The pilot became the root cause, and it was named pilot error. Simple, closed and no questions allowed to be asked. This was safety in the old days. Nobody had the right to argue with safety. When the safety-card was played, the discussion ended. SMS is different. In a healthy safety system, there are discussions about safety issues and the root cause does not paint a person into a corner. However, there are few options to test human factors and test a person for acceptable pressure level. The task is not as simple as in a manufacturing process. Often the acceptable pressure level is not identified until after an accident. Now it’s time to investigate the underlying systems, organizational processes, environmental factors, supervision and the human factors concept itself to establish a root cause that can be further discussed and mitigated. 

When human factors become the subject of testing for quality assurance there are different processes than testing for material quality or product quality. However, the principles remain the same, that testing is required to establish to what level of quality systems are performing. First, it becomes a factor to establish the expected performance level of human factors and second, establishing training programs to ensure that pilots always perform above the established expectation, or their breaking point of performance. Everybody has a breaking point at witch time they are not capable of performing expected tasks.  E.g. Air France 447: “…completely surprised by technical problems experienced at high altitude and engaged in increasingly de-structured actions until suffering the total loss of cognitive control of the situation.”-BEA Report

The point of no return back to safe operations is the point when human factors snaps. The beauty of an effective Safety Management System is not only to assess for accidents, but to lead personnel on a path where they will never fly beyond a point of no return. In other words, SMS is not just about preventing accidents, it’s to establish a confidence level of air service safety warranty. Remember, without an SMS there is a safety confidence level of zero. 

CatalinaNJB

Friday, June 1, 2018

There Is No SMS Without A Just Culture

There Is No SMS Without A Just Culture

Post by CatalinaNJB

A safety management system cannot exist without a just culture since a non-just culture in itself is an opposition to forward looking accountability. Not only does a non-just culture oppose forward looking accountability, but it also opposes the principles of continuous safety improvements. In a traditional safety culture, safety is a mandate established by senior management and demanded that all personnel strictly follow these mandates. Aviation accidents are still classified as a failure to comply with regulations, policies or procedures. The conclusions are often that If only those pilots had complied with regulations, policies and processes there would not be a single aviation accident anymore.  Well, we know that’s not true. In 1956 and the Grand Canyon disaster both Captains of both airlines were following regulations, policies and procedures and they ended up in a mid-air collision. On the other hand, if KLM 4805 had continued their first takeoff roll without a clearance, is there a possibility they could have cleared Pan Am 1736? There are times when following the rule could have avoided an accident, but there also are times when not following the rule prevents an accident. Regulatory requirement serves a different purpose, or role, than operational safety. A finding that following regulations, policies and processes would have prevented an accident is not a fact of the true root cause. A true root cause analysis identifies what was done rather what was not done.
Just culture is to line elements for comprehension and continuous safety improvements.

An enterprise may conduct a self analysis of their own just culture. There are several variations of valuable just culture assessments tools available for an enterprise to conduct evaluation. A just culture self-evaluation is more than tick the correct boxes. It is to find the true culture in the organization. With a fully operational safety management system an operator is expected to operate within a just culture. It becomes a failure to the SMS unless the culture is present. An operator could believe that they are operating within a just culture while there is no data to support their opinion.  A just culture is not the same as a non-punitive culture, but a culture that is just in the assessment of root causes. A non-punitive culture is in itself a hazard to aviation safety when it is not incorporated in a just culture. The four parameters of a just culture are trust, learning, accountability and information sharing. When the system of just culture is effective the outcome is comprehension of SMS and continuous safety improvements.

Visualizing a just culture is to line up six dices in a row where all dices are displaying equal numbers. SMS process implemented needs one process to generate trust, one process to instill learning, one process to accept accountability and one process to share information. When these four processes are established, the effectiveness is shown in the output of system comprehension and continuous safety improvements.

A great safety change today could be obsolete over time.
In a non-just culture there is only one dice; the pilot. When things go wrong the pilot is blamed. By improving the process, a second dice was added; the nav-aids. Eventually other processes are put in place and with the third dice; the air traffic controller. In this example of a just culture, these are the three first elements of the culture, where the pilot is trusted the authority, the nav-aids provide guidance and support, the third is to place accountability on ATC, in that ATC has the authority to maintain safe air to air and air to ground separation. The fourth element of a just culture is to share this information by reporting of hazards, incidents accidents and safety concerns. Sharing this information improve individual comprehension of the SMS systems and how implemented improvements equals continuous safety improvements.

A just culture is expected to eliminate accidents. Some might say that it’s not possible to eliminate all, but if one flight can be safe, what are the reason for the next flight not to be safe. In a true story the safety process did not include all four elements with a fatal outcome. A person had sat down in front of a fire-trucks door and dozed off. The fire department was called out, opened the doors and run over the person sitting there. The fire department process had placed the role of safety on the person at the door, without considerations of the other elements. This is also the old-way in aviation safety. There is only one safeguard and that is the pilot. This safeguard is placing unreasonable expectations on one person to be perfect in all tasks, to always be vigilant and to never let person or mind leave the post. The new way of SMS and just culture is to implement support systems for continuous safety improvements for the flying customers and aviation services.  

CatalinaNJB



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