Friday, January 24, 2020

Powers of Incremental Improvements

Powers of Incremental Improvements
By Catalina9

Instant gratification is a common obstacle to safety in aviation but is very different than short term corrective action. A short-term corrective action is an immediate action to correct a condition or hazard. While the short-term repairs or mitigates the hazard for continuous operations, it doesn’t correct the contributing events causing the hazard to be displayed.

Powers of Incremental Improvements turns the light on one bulb at a time    
Hazards are displayed as incidents, accidents or published in communication. Instant gratification is communicated in statements, findings or root cause analysis as a failure to initiate, perform or complete one specific task. Conclusive incident reports commonly state the root cause as a deliberate behavior failure to eliminate a task expected to be performed. Instant gratification root cause analyses communicate a gap in time, or a period when time ceased to exist, since a failure is an omission of a required action. When the omission of a task is replaced with a task that was not performed, there is a break in the process, or an unidentified time period. A process, and when a task in that process as a procedure, expectation or job performance requirement is not performed is a non-conforming safety management system process. In an SMS environment, a finding, or root cause stated as a failure to complete a task is directly linked to the accountable executive. In the pre-SMS days, without accountability, a failure root cause functioned well and kept senior management out the loop.

Instant gratification has evolved to eliminated system comprehension.

Instant gratification root cause analysis is therefore not new but has been around since the beginning of time. Establishing a root cause is a function of system comprehension. Human factors as its own system was overlooked or ignored for decades. It wasn’t until the ‘70s & 80’s that the SHELL model was developed, modified and introduced into the aviation human factors system. The SHELL model linked software, hardware, environment, liveware and liveware to be coherent for the human factors system to function. An addition to the environment of the model affecting human factors is to branch the environmental model into a natural environment (weather/climate) branch and engineered environment (cockpit layout / user friendly) branch.

Comprehension of the human factors system is the foundation for Powers of Incremental Improvements. For system comprehension there must be data available. This data is turned into information to be extracted by one of more of the five senses, sight, hearing, smell, taste and touch. Information is then turned into knowledge, which is turned into system comprehension. For the most of us, it took us about a year to learn to walk, two years to talk, three years to recollect, four years to plan and five years to write sentences. This process is all a part of the powers of incremental improvements, incremental learning or continuous safety improvements. Crash-courses and compressed data training are instant gratification training and are acceptable processes throughout the aviation industry. This does not imply that crash-courses and compressed data workshops are irrelevant or hazardous to aviation safety, but that these types of learning are only effective as review and reinforcement of acquired knowledge after a person has completed Powers of Incremental Improvements. When instant gratification training is applied in any other way, the objective has become specific to remove system comprehension.

Success is to change behavior to eliminate 15 minutes of daily unimportant tasks.

It only takes 15 minutes a day to become an expert in your field. Expecting that everyone wants a vacation, weekends and other holidays, 15 minutes a day equals 60 hours a year of learning. Remember, this is to learn one task only and not to learn the whole system. Airports in Canada must be compliant with TP312 to maintain certification and to provide services for scheduled airlines. There is about 200 sub-chapters with multiple standards in the TP312. When applying the Powers of Incremental Improvements, it takes five years to comprehend the standards, and system interactions of TP312. This same concept is also applicable to airline operations. It is beyond human factors capability to comprehend 18,000 hours of learning material in a 3-day crash-course. Instant gratification is not limited to the industry, but also extends to the regulator, who expect inspectors, both airlines and airports, to comprehend their oversight systems after attending one instant gratification course.

The Powers of Incremental Improvements is applied in a Daily Rundown of Project Solutions Leadership Motivation and necessary for compliance comprehension of Regulations and Standards. Daily Rundown, as a 15 minutes daily task, is to develop goal achievement plans is to improve regulatory compliance and safety performance measured as a function of your system comprehension.  



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