Overcontrolling Or Adjusting
By OffRoadPilots
Overcontrolling of a stable process for a result that is undesirable, or for a result that is extra good, the output that follows will be worse than if the process had been left alone. Overcontrolling or tampering with a process is to make immediate modifications to a process in good faith with the intent for the process to produce a desired result. Adjusting a process is to adjust a process for drift, or identified work practices that are moved away from the pattern designed. An adjustment to a process is to move the process back on track and to adjust for drift. Overcontrolling and adjusting processes are two different operational tasks. Overcontrolling makes the result worst, while adjusting maintains a process on a predetermined path.
Control options are required to operate with a safety management system. These control options are designed, formalized, documented, and applied to all areas of operations for airports and airlines. Control options are used to maintain processes on track for a desired outcome. For airports and airlines to apply control options of processes, they must operate with a daily quality control system. Simplified, this is a system where each task is tagged to one or more regulatory requirements, a task is tagged to the SMS safety policy, and a task is tagged to one expected outcome. A task within a daily quality control system may be tagged to multiple regulatory requirements, an outcome will complete those requirements, but there is still only one expected outcome of the task.
For airport operators, a daily inspection task is expected to complete a daily inspection daily, or at shorter intervals as defined in their controlled manual. A daily inspection task, depending on tasks assigned to the daily inspection pattern, conforms to the accountable executive requirement for meeting the requirements of the regulations, the task conforms to the SMS requirement to maintain a quality assurance program, it conforms to the obligations of operator, and it conforms to the requirement for an SMS manager to identify hazards and carry out risk management analyses of those hazards, and to determine the adequacy of the training required for airside workers. For airlines, a pre-flight inspection is required prior to each flight and, depending on the size and complexity of the aircraft and airline operations, this inspection may be done by the flight crew, or other assigned personnel. A pre-flight inspection conforms to the accountable executive requirement for meeting the requirements of the regulations, the task conforms to flight operations requirements, and aircraft equipment requirements.
As a daily inspection, or pre-flight inspection progresses, each task assigned in the pattern is entered into a monitoring system. Upon completion, these two tasks must be analyzed in a statistic process control (SPC) system and viewed in control charts for process reliability and if a process is in-control, or out-of-control. The first level of SPC analysis is to analyze if the processes itself is in-control, as opposed to any findings documented during the process. A trap for both airports and airlines, is to immediately jump to target findings before it is known if their processes are in-control or out-of-control. Data collected from an out-of-control processes, and a processes with special cause variations, are unreliable data to be applied in a decisionmaking process.
A control chart is a chart with data point plotted above or below an average, and plotted within six zones, or 6-sigma. Zones C-B-A are above the calculated average, and 3-sigma are below the average. Zone C is the zone closest to the average, zone B is the middle zone, and zone A is the zone farthest from the average, where a point beyond its most outer limit is an out-of-control point. A control chart removes emotions from the analysis and without bias displays a process to be in- control, or out-of-control. There are several different control chart and different statistical analyses of processes available. One control chart displays out-of-control tests when 7 points in a row are trending up or down, or 2 points in zone A or beyond, or 4 points in zone B or beyond, or zone C when 8 points in a row on one side of average, or with 8 points in a row, but no points in zone C, or 15 points in a row within zone C, or 14 points in a row altering up/down. Out-of-control processes are caused by special cause variations, or variations that are not necessary to be a part of the process for the process to function. A common cause variation is required for the process to function, such as how long it takes to complete a daily inspection or a pre-flight inspection.
The rules of seven tests are often used as an initial test for SMS enterprises to learn a simple method for interpreting control charts. As above, the rule of seven test is when there are seven points in a row above the average, or seven points in a row below the average, or seven points in a row trending up, or seven points in a row trending down. The other simple test to apply as a beginner when using control charts for an airport or airline operator, is when there are two points in zone A or beyond.
An out-of-control process and special cause variation requires a root cause analysis. A root cause analysis within an SMS enterprise includes consideration of human factors, organizational factors, supervision factors, and environmental factors. There are two paths for a root cause analysis within an SMS world, and one is for regulatory noncompliance, and the other is for operational variations. Regulatory compliance is a prerequisite for both airline and airport operations. Without regulatory compliance, both airline and airport operations are operating outside of their authority given to them by their certificates. Regulatory noncompliance affects the whole operations, and not just affect the items that were noncompliant. Regulatory compliance is based on a static environment, without any movements. E.g. an operations certificate is issued prior to the fist flight or the first day of airport operations.
When an SMS enterprise is in noncompliance one day, and the noncompliance continues, a control chart will show another data point in zone A or beyond the next day. When a control chart displays an out-of-control process for regulatory compliance, a root cause analysis must be conducted as soon as the noncompliance is identified. A regulatory non-compliance is compatible to a system breakdown in manufacturing, where one breakdown has a fundamental impact on their processes. On the other path leading to operational noncompliance, a root cause analysis is applied to trends, or applied to a risk level severity. A daily inspection at an airport that normally takes 20-30 minutes to complete, may one day take over an hour due to a flat tire. The next day there is another flat tire and now there are two data points in zone A or beyond defining the special cause variation. Normally, this would generate a root cause analysis, but since all tires on the vehicle were changed to new tires, the issue was resolved, and there is no need for a root cause analysis of the special cause variation identified in the daily inspection.
On the other hand, if the tires keep blowing daily, then a root cause analysis of the daily inspection is required, and include considerations of human factors, organizational factors, supervision factors and environmental factors. When a special cause variation is identified with a severe outcome, then a root cause is required. E.g. an aircraft slides off the runway due to icy spots. A root cause analysis is required to identify the cause of icy spots, and a cause for not reporting or NOTAM the ice. In short, a root cause analysis is required when there is an event with an unacceptable risk level but is not needed when the event remains within an acceptable risk level until a trend is established.
Both overcontrolling and adjusting are linked to human factors, organizational factors, supervision factors and environmental factors. Overcontrolling in one area affects outcomes in the other areas. On the same note, adjusting in one of the areas for a process to remain within its assigned pattern, has an affect the other areas.
A controlling function is an accomplishment of measures that further makes progress towards the organizational goals and brings to light the drift and directs corrective action. A trap in process control is overcontrolling by feathering processes and to manipulate an outcome for any justified reasons. Overcontrolling is done in good faith to reach a goal, or to produce a perfect outcome. Perfectionism is a fundamental flaw in process management and is a hazard when causing overcontrolling. A crucial function of control is to be used as a tool for workers to know in advance what is expected of their job performance. Controlling is a motivational tool and helping workers to reach their performance potential. Overcontrolling has an opposite effect and is a motivational obstacle for performance improvements and causing a deteriorating working environment. There is overcontrolling in a process when there is interruption by management, or others for a worker to make immediate and unauthorized changes to their job task.
An air carrier normally departed without passengers and freight due to a short runway and flew to a longer runway 10 miles away. One day, the operations manager interrupted the process by overcontrolling and loaded more fuel, freight and passengers than the process pattern allowed for. The aircraft crashed on departure due to overload for what the runway environment could support. The intent of overcontrolling was to catch up to lost time and provide a better service to their customers.
Adjusting a process is to analyze drift and make correction to remain on track. In the aircraft crash scenario above, an operations manger may have detected a drift if the pilot had taken it upon themselves to accept the risk and deviate from the normal process. An option for the operations manager would be to adjust the drift and move the process back on track to depart empty. However, when overcontrolling becomes a part of the daily routine and process patterns are ignored, then workers become hesitant to follow an acceptable process without receiving pre-approval from an authority.
When a process is overcontrolled it might produce an acceptable outcome the first time, but as changes to the process are made, each change makes the point of origin in the process move farther and farther away from the original point of origin established by the pattern. One day, one passenger may be boarding for take off at the shorter strip, the next day two passenger, the third day three passengers and so on. They do not keep boarding passengers until an aircraft crash, but they are satisfied that their process is safe and acceptable. What is missing is that the process is so far removed from the pattern that when there is an undetected change, such as higher temperature, wind direction, or a change in runway surface conditions, an accepted overcontrolled process fails, and the aircraft crash.
A root cause analysis of an overcontrolled process includes consideration of human factors, organizational factors, supervision factors, and environmental factors. Human factors are the five senses of vision, hearing, smell, taste, and touch, and how they affect a reactive or proactive action. Human factors are not the same as human errors but is a description of a cause to justify overcontrolling a process. E.g. The accident happened because a pilot failed to follow the checklist. The five senses affect human behavior. Overcontrolling of human factors could be to ignore reactions to any of the five senses.
Organizational factors are the organization where a pattern is engaged. Organizational factors are the flight crew organization and their operations manual, or the airside operations organization and their airport operations manual. An organizational factor must be assigned to the patterns where their tasks belong. When organizational factors are assigned to top management, they are removed by several levels from where tasks are performed to be effective in operations. Overcontrolling of organizational factors could be to demand timely performance as opposed to pattern performance.
Supervision factors are the effect supervision has on operations. Supervision could by lines of authority and organizational charts, but also by self-supervision of checklists and acceptable work practices. Supervision is a function of accountability. Overcontrolling of supervision factors could be a self-induced expectation for a pilot to complete all tasks items of an approach and landing checklist without considering other factors, such as the most important task at hand at the moment, or to terminate the checklist and initiate a missed approach.
Three environmental factors are the
Designed Environment
o User Friendly Environment, Design and Layout, Accessibility, Tasks- flow
Social Environment
o Distancing, Experiences, Culture, Language• Climate
o Geo Location, Weather, TemperatureOvercontrolling environmental factors could be when a person in authority, such as an accountable executive, expects a worker to perform tasks flawlessly within these environments without first having received training.
Overcontrolling moves a process farther away from its original track, and is opinion based, while adjusting maintain a process on track based on data with a proven end results.
OffRoadPilots
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