Culture can Kill: 3 Train Wrecks, One Connection!

Culture can Kill: 3 Train Wrecks, one connection

An observation in Human Factors by Dennis Taboada.

Lac-Megantic Quebec train crash and explosion

Lac-Megantic, Quebec July 6th; A Montreal Maine and Atlantic Railway freight train carrying tank cars full of fuel rolled into the town an exploded killing over 50 people. 

Suspected Cause: Brakes not properly applied.

High speed train crash in Spain

Galicia Northwestern Spain  July 24: a high speed passenger train traveling more than 90 mph derails on curve killing 79 people.

Suspected Cause: Driver on his cell phone

Switzerland head-on collision of two passenger trains

Granges-pres-Marnand Switzerland July 29: At least 35 people were injured, five of them seriously, in a head-on collision of two trains in western Switzerland late Monday

Suspected Cause: Newspapers splashed photos of the wreckage across their front pages, claiming that the early departure of one of the trains may be to blame.

When investigating the root cause of an accident it is proper to look at all possible contributors defined by the Deming inputs: People, Environment, Machines, Materials, and Methods. Of course, these accidents are recent so I must be careful in my opinion as other information may surface. There is a common theme that initially arises as we look at these three separate rail incidents. It must be the fault of a person. The Spain train driver has admitted to being on the phone. The Quebec driver admitted to not applying all the brakes as required by procedure. The Swiss crash had a driver leaving a station early. 

Where are the procedures? Without even knowing, I can assure you that the driver of a high speed train should not be on his cell phone during a high speed turn. Oh yeah, he was going more than twice the allowable speed. I am sure there is a procedure for leaving and returning to a station and we know all brakes should be applied to a stopped train. 

I have seen this type of  human factor before. Yes, it is possible for someone to error but, I am willing to bet that these companies have a “Culture” of sloppy operations. This is common when you have “seasoned” workers who know their job very well. They become lax and begin to cut corners. This is where upper management of the company comes it to communicate the importance of Safety Policy and Procedures. Where management is serious about Safety, the workers take it seriously as well. I am sure after these disasters, procedures will change, training will take place, new policy and procedures will be written. All after the fact. Another example of “Reactive” Safety. We know that management can effectively gain "control" of culture. First through hiring practice, standard operating procedures, training, and support. It is interesting to note that in all three stories the train companies have a "good" safety record. As Dr. Deming says, "The past is no indication of the future.." Safety is a "continuous improvement" process. 

Your thoughts......

NOTE: "Control" is a topic of discussion at the up coming "Tools of SMS and QA" symposium held at the Coronado Resort Hotel on Disney World property. Please go to:

http://www.dtiatlanta.com/Symposium2013.html for more information. 

Size, Complexity and SMS.

Here is a post from one of our regular contributors, birdseye59604. You may comment on this post below. 

It has been said that size and complexity is not taken into consideration for an Enterprise required to conform to regulatory compliance. Often this implies that regulations are targeted to fit large organizations and does not accommodate smaller Enterprises. 

Both small and large organizations must conform to regulatory requirements to be regulatory compliant. A small organization should apply less complex systems to meet these requirements than what is expected from a large organization. 

On a foggy morning, size and complexity might not be obvious.

The issue is not that expectations are the same for both large and small, but rather that the small Operators are adapting processes to identify how a large organization conforms to regulatory compliance. Small Operators do not have manpower to operate in the same manner as large Organizations. 

A Safety Management System, SMS, Enterprise has a system in place for the capture of information of hazards, incidents and accidents. In a small organization this may be done by submitting paper records direct to the SMS Manager. This report is hand delivery directly by the contributor and noted in the records. In a large organization a paper form submitted may be required to be scanned into an electronic database, entered in a database and submitted to a pre-scan manager for assessment, entered to the Hazard Register and then to the SMS Manager who delegates investigation. After risks have been investigated the report may be submitted for Corrective Action Plan through a committee or safety group. When a form is electronically submitted, several administrative tasks may be automated and the contributor may receive an electronic receipt with a generated tracking number.   

Apply the right tool and don't use a broken jar as filing cabinet. 

In large organizations there are often several individual involved prior to the hazard is risk-assessed. Should a small Operator attempt to follow the same complexity as a large Operator, they may be taking on a much greater task than what the organization is designed to manage. 

Both small and large must conform to Regulatory Requirements for Regulatory Compliance. This is achieved by managing processes differently to conform to documented SMS processes. Regulatory Compliance is not achieved by conforming to systems which are not designed for the Enterprise.    

Your thoughts.......

BirdsEye59604 

Saint Louis Study Finds Opinions Vary on Benefits of SMS | Aviation International News

Saint Louis Study Finds Opinions Vary on Benefits of SMS | Aviation International News

Get the Cards in Order

Get the Cards in Order

The Root Cause of a Process which does not produce the desired outcome is that the process took the wrong turn at the fork in the road. This fork in the road could be anywhere in the process from the very first step to the last input. If the process does not give the desired outcome, find the fork in the road. 

A simple distraction of the process is a fork in the road

When a process is not documented the outcome may vary by subjective inputs. The process of the “pick the card” game has changed over time with various results, and where the outcome did not always produce the correct card each time. 

Often this happens in organizations, where errors slowly develop and nobody notice and captures these variations. 

When analyzing the card-game process it is possible to find the link between the cards. As a test of the process, the cards were laid out in one row of Spades, one of Diamonds, one of Hearts and one of Clubs. This established a baseline the Ace as number one the King number 13

By testing the process it is possible to make changes before getting to the Fork in the Road

The first step is to pick the Ace in the first row as the card, then apply the process, and continue each time with the next card in the row, until the Spade of King was picked. This gives 13 sample testing rounds to evaluate the process. When documenting the layouts, it becomes a trend that the card in the 2^nd  deal is in rows 4-5-6 or 7, which then will be card number 17-18-19 or 20 of the 3^rd deal, or the 5^th card in the row. When knowing the row, the correct card is picked.  

An Enterprise Training System of a process should be to train individuals to understand the process in addition to perform the process. By understanding the process it is possible to recognize, make correction and changes so that errors do not happen. 

An Enterprise Testing System of a process should test the process by applying scenario to the intent of the process. When a new process is developed, it is often assumed that it will function as intended, and therefore testing is not required. However, when the Testing System is not implemented, a potential error may not be discovered until it has caused an incident. 

An Enterprise Review System of a process should review for Statistical Process Control. When there is no Review System established the process is an assumption. When one assume, the facts are not captured. 

   

BirdsEye59604

Lessons in the Leaning of the Tower

Lessons in the Leaning of the Tower

What's leaning..me or the Tower?

I just got back from my 30th anniversary cruise of the Mediterranean. One of the most fascinating places we visited was Pisa Italy. As an Quality engineer, I was very interested in the story behind the tower and why it is leaning. In learning, I discovered several parallels to creating a Safety Management Quality Assurance System. Here are the facts:

The Foundation:

First, the land. The location for the Church of Pisa, and the bell tower, was chosen because of the significance of the ground. The location was a cemetery. The land turned out to be marshy. In fact, the Greek word for marshy is Pisa.  

The Tower from the West side

The foundation of any system must be based on a corporate policy that is agreed to by all in the company and has the support of the CEO and upper management. Policy is what we are going to do. Once we all agree on what we are going to do, then we begin to build upon that foundation as to how we will accomplish our goals and objective. The leaning tower’s foundation was not able to support the objective...but, they when ahead a began building on a faulty marshy foundation. 

“Construction of the tower occurred in three stages across 344 years. Work on the ground floor of the white marble campanile began on August 14, 1173, during a period of military success and prosperity. This ground floor is a blind arcade articulated by engaged columns with classical Corinthian capitals.

The tower began to sink after construction had progressed to the second floor in 1178. This was due to a mere three-metre foundation, set in weak, unstable subsoil, a design that was flawed from the beginning.” Wikipedia 

Columns expanded to compensate causing
the tower to be "banana" shaped.

Building on a Flawed Foundation:

In 1272 construction resumed under Giovanni di Simone, architect of the Camposanto. In an effort to compensate for the tilt, the engineers built upper floors with one side taller than the other. Because of this, the tower is actually curved. Construction was halted again in 1284, when the Pisans were defeated by the Genoans in the Battle of Meloria.

Trying to fix a flawed system only made the curve of the tower worse. One of the key decision management must make is this. If a system, process or program has problems, do we continue and try to fix the flaws or should we scrap the project and start new. The  Tower is a tribute to poor engineering decisions over and over. 

Recently in 2002, the best structural support was accomplished with the combination of Sub-terrain excavation of the north side and the additional of foundation counter weights. The tower is open to tourists but, still leans as do all the structures in the Pisa square. 

Prospective of the Tower

Your Management System must be based on Policy that reflects your actual commitment to Safety and your customers. This is the foundation. Then you must plan how you are going to build on this policy. Procedures must be made to standardize the operations within the enterprise. These procedures must be followed, analyzed and continuously improved. Then each member of the team must take “ownership” of their processes. It is ironic that in the 12th century where sculptors, artists and artisans signed all their work.....the Leaning Tower has no person that claims responsibility for its construction. “The Tower of Pisa was commissioned by the city of Pisa. We're not completely sure about the real identity of the architect. Originally, Guglielmo and Bonanno Pisano were credited with the design.” wiki answers

Your thoughts........

NOTE: For the greatest lessons in implementing an SMS/QA System, you need to take a vacation to DisneyWorld Sept 29-Oct 2 2012. The Tools of SMS/QA Symposium has 2 top speakers, 3 QA/SMS Workshops, Free Airport transportation, DisneyWorld park discounts, Free Disney catered Breakfast each day, Coronado Resort Hotel on DisneyWorld Property, free Disney park transport and discounts. 
Goto: http://www.dtiatlanta.com/Symposium2013.html

Train Crash: Criminal or Culture?

Train Crash: Criminal or Culture?

Tank car remains after the horrific crash and fire at Lac-Megnatic

The head of the U.S. railway company whose oil train crashed into the Quebec town has blamed the engineer for failing to set the brakes properly. A fire on the train just hours before the crash is also being investigated. Oh it’s the engineer’s fault. That’s the result of the Root Cause Analysis..really. No, obviously this company has a systematic problem. It could be culture, organizational, practices....etc. 

"Under Transport Canada’s Railway SMS Regulations, in force since 2001, all federally regulated railway companies must implement and maintain an SMS. While railways may create an SMS that best suits their organization, needs and operations, it must include documented systems and procedures, which give both Transport Canada and the railways a consistent basis for monitoring safety performance. Railways must also report to Transport Canada on their safety performance, safety goals, and new safety efforts - every year." Transport Canada.ca SMS for Rail.

SMS requires companies to have Standard Operating Procedures in all aspects of their operations. Most companies have procedures but, most do not follow them. It is important to realize the merely having procedures is not enough. Performing routine operation often evolve into "short cut" without an SOP to compare to. This practice is the beginning of a culture problem. 

CEO of Rail World Inc. Edward Burkhardt

"It's very questionable whether the hand brakes were properly applied on this train," said Edward Burkhardt, chief executive officer of Rail World Inc., owner of Montreal, Maine & Atlantic Railway Ltd. "As a matter of fact, I'll say they weren't, otherwise we wouldn't have had this incident."

Burkhardt paid his first visit to Lac-Megantic, four days after an unmanned, 72-car oil train rolled from an overnight parking spot into the town, where it jumped the tracks, incinerated about 30 buildings and killed at least 20 people. Burkhardt laid the blame for the crash on his own engineer for failing to properly apply hand brakes on the rail cars when they were parked in nearby Nantes. He said his company's inspection indicated the brakes were applied on the locomotives, but not on the rail cars. Burkhardt told reporters today that the train's engineer told the company he had applied 11 hand brakes. Procedures require that all handbrakes be applied. 

Fire plumb from the burning tank cars.

"We think he applied some hand brakes, the question is, did he apply enough of them?" Burkhardt said. "He's told us that he applied 11 hand brakes and our general feeling now is that that is not true. Initially we took him at his word."

While leaving locomotives running overnight with no one aboard is standard practice, Montreal Maine won't do so again, Burkhardt said in the interview. "We're going to tighten up our procedures," he said. "I expect there will be a push to tighten up regulation as well. I support that.

"Tightening up regulations? What about the Safety Management System regulation? The SMS already requires procedures be reviewed and analyzed for continuous improvement. 

Asked how he would react if criminal charges are laid, "if that's the case, let the chips fall where they may," he said. "I can't draw the line between carelessness and criminal negligence." Montreal Maine's US accident rates exceed the average for commercial railroads operating in the country for at least the past decade, according to data compiled by the Federal Railroad Administration. 

Just from the reaction of the President of Rail World Inc. It is clear, the SMS is not working in this company. Equally disturbing is the fact Transport Canada Rail should have objective evidence of the break down in the SMS for this company. Unfortunately this tragic accident is additional evidence of the cost of not having a Safety Management System. Your thoughts....

Ref: http://www.thenational.ae/news/world/americas/rail-chief-says-engineer-did-not-set-brakes-properly-before-canada-rail-crash#ixzz2Yqm5NPNw

SFO Crash: Human Factors or Swiss Cheese?

Two days ago an Asiana Boeing 777 crashed into the runway at San Fransico’s International airport. The National Transportation Safety Board is planning to interview all four pilots who were onboard the Boeing 777 jet that crashed. Asiana Airlines says the pilot in control of the plane had little experience flying it and was landing one for the first time at that airport. Now this is not uncommon, but there is a coaching pilot that is ready to take control if there is a problem. We are still waiting for more information to come forward but, my question is this. Where was this coaching pilot? 

Asiana Boeing 777 that crash landed at SFO

"A lot is focused on the crew’s experience, their training, how they worked together, crew resource management, the way that they communicate and how they divvy up their responsibilities. We’re looking into all of those things right now," NTSB Chairman Deborah Hersman told Fox News.

First HOLE in the Swiss Cheese:

Asiana spokeswoman Lee Hyomin told the Associated Press Monday that Lee Gang-guk was trying to get used to the 777 during Saturday's crash landing. She said the pilot had nearly 10,000 hours flying other planes, including the Boeing 747, but had only 43 hours on the 777. I would submit that this fact was only a factor in the crash and that other factors were present. 

Second HOLE in the Swiss Cheese:

Four seconds before impact, a “stick shaker” – a device that emits an oral and physical warning to the crew that the plane is about to stall – sounded off, Hersman said.The crew then asked to abort the landing and make another attempt 1.5 seconds before impact. The minute the shaker engaged, why wasn’t there immediate corrective action?

Asiana Plane doused with foam to prevent fire rekindle

Third HOLE in the Swiss Cheese

There was also a shut down of a key pilot navigational aid. Earlier Sunday, Hersman said on CBS' "Face the Nation" that the glide slope system is a ground-based aid that helps pilots stay on course while landing and it has been shut down at the San Francisco airport since June. The pilots, however, were notified before the crash that the system wasn't available.


"The pilots would have had to rely solely on visual cues to fly the proper glide path to the runway, and not have had available to them the electronic information that they typically have even in good weather at most major airports," said Captain Chesley "Sully" Sullenberger, who crash landed a plane in New York's Hudson River in 2009, told a CBS news affiliate, according to Reuters.

The Swiss Cheese Model with
Process Control added to fill the holes.

I am sure we will learn more about this crash. It is important to understand that there was a clear trail of “Out of Control” condition present. As I have mentioned in previous blogs, it is possible to close up the holes in the "Swiss Cheese Model." Were there procedures on "training" a new pilot? Should the airport use that runway with ILS not working? Should there have been better "control" on the approach by the experienced pilots on board. It is clear that procedures need to be examined. Policy on training needs to be reviewed. I am sure we will learn more that may add additional holes in the Cheese! NOTE: Please see post "Safety Through Control" in this blog, May 13, 2012. 

NOTE: This and other crashes will be discussed at specific control workshops at the QA/SMS Symposium being held at the Coronado Hotel DisneyWorld Florida Sept 29-Oct 2, 2013. Goto: www.dtiatlanta.com click on symposium. 

Read more: http://www.foxnews.com/us/2013/07/08/boeing-777-crashes-at-san-francisco-international-airport/#ixzz2YU690jkj

Corrective Action Plan – The Nut To Crack Is In The Cards.

 Corrective Action Plan – The Nut To Crack Is In The Cards. 

A Corrective Action Plan (CAP) in a Safety Management System (SMS) is to change a process which is not effective in producing an acceptable outcome or desired result. A CAP is a proposed layout of a new and improved process to ensure desired result is achieved. 

It is not a simple process to find the correct process. A process should be based on Enterprise Policy, Objective, Goals and Parameters. Let’s take a moment and apply a proven process to a card game. 

An Organization decided that applying a recreational activity during working hours could increase the production level.

Policy:

The Organization has established recreational activities for all staff.

Objective:

The objective of recreational activities is to achieve organizational continuous satisfaction in job performance. 

Goal:

The goal of continuous satisfaction is to be able complete assigned task right the first time.

Parameters: 

The parameters established are for staff to chose recreational activity based on their own interest.  

Based on the general policy an operational system, or game rules, are established for the game itself. These game rules are Policy, Objective, Goal and Parameter. 

The Policy of the card game: Apply a regular 52 card deck to play game.

The Objective: Find out what card another person is thinking of.

The Goal: To pick out the correct card each time.

Parameter: Deal 52 cards randomly in 4 rows. 

There are Standard Operating Procedures to this process, but since they are simple, they are unwritten and learned during training. 

By following a proven process it is possible to do the job right the first time; over and over again.

In this example the cards are dealt as in image 1. The process requires that one person is asked to think of a card and then identify the row where the card is. This row-identification could be verbally with pre-set identified row numbers or pointing at the row without pointing over the cards, or touching any of the cards. The cards are then placed with the identified row as the 2^nd row in the deck and cards are dealt into 4 rows and question to identify the row is asked again. The process is repeated one more time, including asking to identify the row. The card the person was thinking of is number 5 in that row and is 3 of diamonds.

By following a simple process, it is possible to pick out what card another person is thinking of, time after time. 

However, there are factors which could affect the desired outcome. These factors are Human, Organizational and Environmental factors. 

Human factor could be that the person thinking of a card becomes distracted and during the process forgot what card it was. Organizational factor could be how clear the process is written and how simple it is to understand and follow. If the process is ambiguous it is possible to apply personal interpretations and a change in the process occurs. The process in example above may not be clear for someone who has not been trained. Training is an Organizational factor. Environmental factor could be that this recreational activity is required to be performed outside where strong winds could disturb the process. 

Applying these simple principles of a road-map with Policy, Objective, Goal and Parameter to SMS processes are fundamental to know what result and outcome to plan for. 

BirdsEye59604