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. 


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