Santa’s Business Approach To SMS
Some years ago, Santa started his Streamlined Mission Service, or SMS as a businesslike approach for the safe delivery of gifts around the world. Since everyone around the globe celebrates Christmas on the same day, Santa has only 24 hours to deliver to every home and every child on all world’s continents. Over the years he experienced rooftop landing incidents and chimney-stuck approaches. Most of the incidents were caused by faulty sleigh equipment, while other were cause by the reindeers. In addition, and especially after an extremely exhausting day, the incidents were caused by Santa himself. Since 1776 Santa kept track of hourly incidents which was entered the incident into an SPC graph (Santa’s Professional Care). Santa had a feeling that the job could be done better, but until he applied SPC he didn’t have anything else but opinions to address issues.
|Unreported occurrences were unknown to Santa|
When Santa implemented SMS some years ago, he discovered that the reindeers and himself needed training for roof-top approaches prior to heading out on the gift delivery trip. Santa had also applied the incident pyramid, or the incident triangle, which apply as a fact that every 300 undisclosed occurrences produces 30 incidents, which again produced 1 accident. Santa had over the years kept track of incidents, but not of near-misses or occurrences. As he applied the incident pyramid to his operations, he discovered that he did not know how many undisclosed, or non-reported, occurrences he had during these 24-hour trips. He also discovered that he could not apply the incident-triangle concept as fact since he did not know how many undisclosed occurrences he had experienced. Santa went back to review his incident reports over the years and found that after all the incidents, he had not experienced one single major accident. Santa had been bruised up and required medical attention after the most terrible roof-top landings, and minor repairs to the sleigh, but himself and all the reindeer were always able to continue the trip. In addition, time of incidents were reported, but had not been entered into the tracking system. All incidents had been entered at the end of the day as total for that day and as roof-top crash, chimney-stuck, sleigh-breakdown, reindeer error or Santa error. However, Santa could not find any trends to the root cause.
The reindeers became more profici.ent at the end of day
Santa had applied the simple root-cause concept that if a reindeer stumbled on landing the reindeer was at fault. With the root-cause identified as the reindeer at fault, the black nose was replaced with a red nose as a reindeer-error root-cause identification. Over the years, this approach didn’t seem to work since it was not the same reindeer that was at fault all the times. In addition, when there was a Santa failure, or Top-Management failure, there were no replacements available. Santa just realized there were hidden trends, or latent hazards, within the delivery system itself and decided to update the SMS system to track the time of incidents. Santa analyzed the result and discovered that the sleigh incidents occurred towards the end of the journey and several during the 23rd hour of work.
The next step for Santa was to analyze the reindeer failures and he discovered that most of the reindeers were blamed during the first few hours of work. What Santa now had to work with was that reindeer-failure was assigned the root-cause for the early stage of gift delivery, while the sleigh failure was assigned root-cause at the end of the day.
Sleigh failed towards the end of the run.
After months of analysis, Santa concluded that he had incorrectly assigned root-causes to a short-term CAP and not considered the high-level system root-cause at all. Over the years Mrs. Claus had told Santa that he needed to fix the system, but Santa didn’t think that was necessary. His excuse for not fixing the system was that the reindeers should know better than to fail on roof-top landings and the elves should know that the had to build a sleigh that could last the whole day. Santa had stubbornly refused to believe that there could be a system root-cause. In addition, if he applied a system root-cause, Santa himself would be implemented in the failures, which would not be good for his reputation.
As Santa pondered on the root-causes he reviewed the data points in the SPC graphs and discovered that his assumption and opinions of the reindeer and sleigh quality was wrong. He had to accept the data showing that the reindeers were not properly trained, and the sleigh needed to be upgraded in quality. He also discovered that applying a high-level system root-cause would improve his reputation by reducing interruptions and frustrations of incidents.
A survey concluded that most of the children around the globe supported Santa in being accountable to system-failures and quality delivery. His reputation would improve by being accountable. Santa upgraded the reindeer training program in preparation for the next trip and the sleigh was upgraded from wood to composite of fiber-glass and carbon fibers. Santa estimated it would take five years to implement the CAP of systems and to build a shop to manufacture the composite sleigh and reindeer roof-top landing simulator. However, a short-term training CAP was already in progress and initiated for the next run.
Mrs. Claus approved of the changes and Santa was proud of his achievement that he had discovered the unknown hazards.