Thursday, January 31, 2013

Continuous Quality Improvement, CQI

From classrooms to board rooms, on manufacturing floors and in medical centers, organizations around the world are using continuous quality improvement (CQI) as their strategy to bring about dramatic changes in their operations. Their purpose is to stay competitive in a world of instant communication and technological advancement. 
These organizations need to meet or exceed customer expectations while maintaining a cost-competitive position. CQI, a systematic, organization-wide approach for continually improving all processes that deliver quality products and services, is the strategy many organizations are adopting to meet today’s challenges and to prepare for those down the road. I mention this because all Management Systems need CQI. This includes Safety Management Systems. 

In pursuing CQI, stick to these four basic principles: 
1. Develop a strong customer focus. 
2. Continually improve all processes. 
3. Involve employees. 
4. Mobilize both data and team knowledge to improve decision making. 

1. Develop a strong customer focus 
Total customer focus includes the needs of both external and internal customers. External customers are the end users internal customers are your coworkers and other departments in the organization. 
2. Continually improve all processes 
Identify them. A process is a sequence of repeat-able steps that lead to some desired end or output: a typed document, a printed circuit board, a “home-cooked” meal, arrival at work, and so on. 

Improve them. Use the Plan, Do, Check, Act (PDCA) Cycle: PLAN what you want to accomplish over a period of time and what you might do, or need to do, to get there. DO what you planned on doing. Start on a small scale! 

CHECK the results of what you did to see if the objective was achieved. ACT on the information. If you were successful, standardize the plan; otherwise, continue in the cycle to plan for further improvement. 
3. Involve employees 
Encourage teams—train them—support them— use their work—celebrate their accomplishments! 

4. Mobilize both data and team knowledge to improve decision making. 
Use the tools to get the most out of your data and the knowledge of your team members. The best Tool resource is the Memory jogger II for Safety Management Systems available at

You will find it very hard to analyze and communicate without the proper tools to help you. Using these tools on a regular basis will result in Continuous Quality Improvement.....your thoughts. 

Tuesday, January 29, 2013

FAA vs. Transport Canada SMS Comparison Snapshot

For those of you that just want to know the basic difference and similarities between the Safety Management Systems first implemented by Transport Canada and just recently mandated by the Federal Aviation Administration in the United States. Both mandates require Certificate Holders' to gain and maintain "Control" of all their processes.

FAA                                                                                                        TRANSPORT CANADA

FAA                                                                                             TRANSPORT CANADA

4 Components                                                                            6 Components
12 Elements                                                                              17 Elements
17 Processes

Assessment through Expectations                                            Assessment through 
(Divided into 4 levels)                                                                Expectations for each 

If you look at the overviews of both systems, you will see that almost all the requirements are the same. Some of the most obvious difference are the following:

The FAA does not separate Emergency Preparedness and the FAA Component 3.0 is called Safety Assurance which essential is Quality Assurance. There are many other correlations that I will go into detail in future blogs. If you are a certificate holder in the United States or Canada it is clear that  you must gain control of your processes and institute a system of continuous improvement. A good beginning is training and practical examples of implementation. You can get that from A good tool to get is the Safety Management System Memory Jogger available at 

What are you thoughts......

Friday, January 25, 2013

The Bowtie for Risk Assessment

The Bowtie Risk Assessment Diagram is simply a pictorial visualization tool to assess complex risk events. The creation of the diagram begins with these steps:

  1. Identify the Risky Action.
  2. Identify the significant Top Event that could occur.
  3. Based on the Top Event, brainstorm the possible Causes and/or Threats.
  4. List possible barriers that would help prevent the cause from contributing to the Top Event.
  5. Based on the event, brainstorm the possible Consequences. 
  6. List possible Barriers that could mitigate the specific Consequence. 
7. Evaluate Threats and Consequences by suggesting barriers that may be added to both sides to mitigate or even eliminate the possibility of the Top Event or mitigate the specified Consequences.

Steps in Example:

  1. In the example, the routine action is refueling an aircraft.
  2. What could occur? In this case the Top Event hazard is the contamination of the fuel.
  3. Brainstorming events yield possible causes. These causes range from Wrong Fuel to Contaminated Storage Tank. 
  4. What could happen if the fuel was contaminated? Brainstorming revealed Results or Consequences. These range from Repair to Engine Shutdown which could lead to an accident.  
  5. Now list barriers that mitigate possible causes. In our example, wrong fuel used could be mitigated through training and color coded hoses. 
  6. Brainstorming of barriers to mitigate possible consequences show repairs could be mitigated by inspection. Engine shutdown could be caught before take off by an engine run-up that might reveal problems causes by contaminated fuel. 
  7. Brainstorm new barriers to mitigate the results of the event to lessen the impact. For example: addition of fuel cutoff valves may lessen the effect of contaminated fuel on the engines themselves and could prevent the spread of fire. 

NOTE: The Bowtie Diagram illustrated here is the basic tool. The diagram can be expanded to include “holes” in the barriers. These are referred to as “Escalation Factors.” Here is an example:

A hole identified in training is if the training is inadequate. This will make difficult for the worker to identify wrong fuel. Also, we have identified that color coded hoses will not work if there is no procedure on what the colors indicate. 

You can even add Barriers to the escalation factors. These barriers would mitigate the barrier hole.

In this example: the Inadequate training result can be mitigated by the use of a post course exam.  Your thoughts.........

Wednesday, January 23, 2013

SMS forces Profitability and Efficiency for your company

SMS and $$$$$$$
For those of you unfortunately blessed by taking our Quality Assurance Class,  you experienced our “F” exercise. Where we hand out a procedure that states, “Simply count the number of ‘F’s’ in the following paragraph.” We’ve done this exercise..well..over a thousand times over 20 years. The result is the same; some say 78 some say 39 and some say 0. Sol then takes the results and relates them to money..remember?

It is a fact!  If your processes are under control, then  you are able to predict, within a set range, the output. When you can predict the output to any process you now may PLAN. Planning gives you efficiency and ultimately  increases profitability. We have discussed in previous blogs what “control” means. Control means that all inputs to the processes are known. The people, machines, materials, environment and methods (procedure). If no “outside” forces influence the now have control. Remember, that control does not mean the output is good. It only means the output is normal (predictable). 

SMS requires a Quality Assurance System to perform audits on all processes. In order to perform audits on processes, the processes must be governed by standard operating procedures. Just the fact that we operate to procedures will see an improvement in efficiency. The SMS requires that Continuous Improvement be an important part of the system. In order to have Continuos Improvement we must have process analysis. Again, Analyzing processes will reveal areas of waste and help streamline processes. 

Finally SMS requires Corrective and Preventative Action. This Corrective action must have a Root Cause Analysis component which again will force companies to look at long term system fixes to prevent incidents from reoccurring. This will automatically make the system more efficient. For testimonial as to the effectiveness of using SMS for profit can be provided. We can easily show you how this can work for your company. Obviously there is much more on this topic. I will revisit in future blogs or you can wade it .........Your thoughts.....

Monday, January 21, 2013

Can Human Factors be Controlled?

Definition: Human Factors The science of understanding the properties of human What Affects the Output of People? 

Have you ever filled out a form on-line. A form that requires you to fill “mandatory” information or the form can not be submitted. If you forget or overlook an data entry that is mandatory, the form doesn’t submit and the information field usually is highlighted in red. This is an example of “Robust” design of the process that helps reduce human factors as it relates to the output. (Note: I will have more on Robust Design in a future blog.)

These are factors that affect people and their performance. 

(AP)  Half of all dieters who reached their goal weight through Weight Watchers were still   least 5 percent lighter after five years, according to a study released in 2009.

It may not sound like much, but obesity experts meeting in Prague were impressed. Nearly all dieters eventually return to their old weight, and maintaining a 5 percent loss is considered a health benefit.

The study is the most rigorous investigation yet of a commercial weight loss program. Experts say that although dieters would probably hope for better results, a 5 percent reduction is enough to reduce the risks of developing such diseases as diabetes, heart disease and cancer.

Experts said the study indicated the value of programs that are well-rounded, promote gradual weight loss and include a strong support system.

"Motivation is very important. Weight Watchers is part of behavioral management of a serious condition and they do it very very well," said Lefebvre, president of the International Diabetes Federation. "It has a place."

When polled most weight watcher members attribute a lot of their success to motivation they receive. The fact that each member must “weigh in” was cited as the greatest factor in sticking to the plan. Just this year WW has introduced their 360 degree system. This system not only focuses in on food , (materials) ,but, also spaces, (environment), routines (methods)...almost 3 of the inputs we profess as Demings 5 inputs. All WW needs is Machines and People. 

This research only supports the theory:.........
What gets measured gets done
Your thoughts..........

Friday, January 18, 2013

The Theory of the BLACK SWAN

What does the “Black Swan” have anything to do with Aviation, Control or SMS? It actually has everything to do with all three. “Fooled by Randomness” by Nassim Nicholas Taleb says that the London expression derives from the old world presumption that all swans must be white because all historical records of swans reported that they had white feathers. In that context, a black swan was impossible or at least nonexistent. Until Dutch explorer Willem de Blaming discovered one in western Australia in 1697. 

The term “Black Swan” was then used to describe the following:

  1. The disproportionate role of high-profile, hard-to-predict, and rare events that are beyond the realm of normal expectations in history, science, finance, and technology
  2. The non-computability of the probability of the consequential rare events using scientific methods (owing to the very nature of small probabilities)
  3. The psychological biases that make people individually and collectively blind to uncertainty and unaware of the massive role of the rare event in historical affairs

As we teach in our statistical process control courses, randomness always forms a pattern. We can not predict an “Out of Control” event. The recent tragic Sandy hook school shooting is considered a black swan event. 9/11 is considered a black swan event also. But, like in the vast majority of accidents or events, there is always a trail of “out-of-control” or abnormal behavior or incidents that are evident in the trail leading up to the event. Keep in mind that a black swan event seems impossible to the viewer of the event. However, to another viewer the event can be possible or even probable. 

Example: A cow enjoying the grass in a meadow would consider being slaughtered and eaten as a black swan event. But, to the butcher it is inevitable. A catastrophic airline crash caused by a battery explosion would be considered a black swan event. But, I am willing to bet that the battery company has evidence of an explosion possibility. The battery company should consider all possibilities. At least do a risk analysis on that possibility. 

We must look at all our processes, no matter if we feel that there is no way this will cause an accident or tragedy. Using the inputs to all processes, i.e. materials, methods, people, machines and environment, to analyze and at least risk rate these processes. 

So the comment, we never had a problem with batteries before does not absolve the process owner form looking at the possibility of problems occurring. I am betting that variation will be present before the accident or event takes place.  Your thoughts....

Wednesday, January 16, 2013

How to Regulate an SMS compliant company!

First, let’s understand the foundational objective of having a Safety Management System. It is clear that the regulators, i.e. FAA and Transport Canada, can not be everywhere and at times. SMS put the onus on the company to “Control Themselves.
Control means to have standard operating procedures, follow them, audit them to make sure they are being followed and then take data from the processes and analyze them to improve their systems. The result will not only be a safety company but, will also improve efficiency of the companies processes that will result in money savings. 

In the past, regulators typically have performed audits against the regulations. If the regulator is doing this, they might as well be on the companies payroll. Under SMS the company becomes “self healing” of it’s own regulatory contraventions. The company institutes in own Findings, Corrective Actions, Root cause analysis, and Follow-up. The regulator is now is a position to simply ASSESS that the self controlling system is effective. 

EXAMPLE: Under the old Audit system, the regulator would pull a sample of pilot training records. If they found a deficient record, i.e. missing dates, signatures...etc, the Inspector would write up the record for corrective action and ask for a CAP to prevent that from happening again. 

Under SMS, the regulator will pull a sample of pilot training records, if they found a deficient record, then they would ask the question, “Why did we find it, You should have found it if you have an SMS?” Assessment is much easier to accomplish and will communicate to the company that they are responsible for their own CONTROL!

Transport Canada has been the most successful at implementing their Assessment and Systems Approach Surveillance program. The FAA has not really grasped the idea of Assessment and still is conducting Audits that are labor intensive and does nothing to determine efficiency of the companies SYSTEM. Your thoughts....
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Monday, January 14, 2013

Check out the only Safety Management System APP in the world! Yes, put together by DTI available on Android and soon to be available on Iphone through iTunes and Apple App store. You can easily launch any information that would be pertinent to a Safety Management System.

One click will bring you to live workshops, the Genesis on-line SMS Suite, an random number generator and the new Memory Jogger SMS pocket guide with all the tools necessary to make an SMS system work! You can scan the app into any phone by going to the web page and clicking on the app. Then simply scan the bar code. We not teach continuous improvement we live it!

Sunday, January 13, 2013

Oh, one more thing!

Lt. Columbo is one of my favorite characters. He has an instinct and ability to question things that seem, well, Abnormal!. Just as our discussions of variation. If things always followed the same process we would be able to predict, within reasonable limits, the output. Columbo uses "Experiential Control" to do his deducing. I am going to have a full explanation of experiential control in some future blogs. (

Friday, January 11, 2013

A Discussion on RISK!

Yesterday I met with my friends at Transport Canada. It was social gathering but the topic of risk came up. Of course my opinion has always been that Risk Assessment is "voodoo." The basis for my opinion relates to my QA frame of reference. Results of an evaluation should be scientific. Risk seems to be 10% science, probability and Severity, and 90% opinion. I agree risk assessment is essential, that's why I included it my new book, Memory Jogger for SMS, but we need to make it more objective. I will discuss other tools that may accomplish the risk rating with a little more objectivity in a future post.  What are your thoughts?

Wednesday, January 9, 2013

Tremendous Tool

Checked out the Safety Management Plan section in the SMS Memory Jogger,(Qoal/QPC),. It is so simple to use. Any company can easily transform the template to meet their own system requirements.

Tuesday, January 8, 2013

Procedures are the basics of control

The control of a system is essential to assure the outputs of the system are predictable. The first step in gaining that control must be standard operating procedures. These procedure tell people How to do the process. Where there are no procedures, there can not be control since people will tend do what they think is right in their own mind!

Monday, January 7, 2013

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. 

Line-Item Audits

  Line-Item Audits By OffRoadPilots A irports and airlines are required to conduct a triennial audit of the entire quality assurance program...