The Killer Bee
NOTE: This post is from one of our frequent contributors to this blog, "Birdseye59604."
Since the European bees did not perform well in the tropical
climate of Brazil a plan was introduced to breed European honey bees with
African honey bees. The goal was to create a bee which was gentle, highly
productive and successful in the tropics. However, there was a system failure
in the process which caused the creation of a Killer Bee.
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The Killer Bee was genetic alternation by good intent
of creating a super bee.
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After major airline accidents Corrective Action Plans, (CAP), were implemented to satisfy the flying public that flying would be safe again. Some
of these improvements were Pilots Flight and Duty Time limitations, Traffic
Collision Avoidance System, (TCAS), Crew Resource Management (CRM), Flight Deck
Bolted Doors, and several other changes to the airline industry.
In preparation of the implementation of a CAP multiple risk analysis scenarios may be conducted
to establish the effectiveness of the hazard mitigation. In addition to a risk
analysis of the new process, other risk analyses should be conducted of residual risks.
Residual risks are hazards generated due to implementation
of a new process. If residual risk analyses are not conducted, unexpected
hazards may not be discovered until there is an incident.
A residual risk of flight time limitations could be rushed
discussion by pilots due to time constraint, or bolted doors causing hazards to
be transferred from passengers to crew and other areas of flight operations.
Since residual risks are not identified by incidents they
are more complex to mitigate. Further, personal experience and opinions also plays
more of a significant role in mitigations than mitigation of identified hazards.
Throughout a process, Statistical Process Control, (SPC), is
applied to monitor and control the process. Monitoring and controlling a
process ensures with a higher degree of certainty that the process operates at
its full potential.
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SPC ranges from complex mathematical formulas to simple
practical tests.
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Human behavior is what makes a difference in a process. This
goes from the person who is applying controls, to the person who is inputting
for automated operations. Just as there was a “hole in the fence” in the
process of genetic alternation of bees to create a super-bee, there could be
unidentified hazards in the processes of improving aviation safety.
BirdsEye59604
Birdeye has brought up an excellent point. Many times companies come up with what they feel is good Corrective Action. But, the root cause elimination or mitigation actually causes more problems for the company’s system. It reminds me of the airport that had a problem with deer on the runway. The solution, install a “deer fence” all around the runway area. Two weeks later a small plane approaching for a landing hits the deer fence. Risk assessment on the results of the Root Cause Analysis is important to make sure we are not making things worse.
ReplyDeleteThe use of SPC to monitor processes for “Variation” is a great idea. After implementing a new process or procedure, we should analyze the process to see what kinds “Variation” from “NORMAL” were introduced.