INTERMISSION
During this break, I'll pass some other items your way. Lets
start with some random thoughts.
AVCO LYCOMING'S
MASTERPIECE
The 4435
horsepower Avco
Lycoming AL5512 is a commercial variant of the T55-L712 Boeing
Chinook helicopter engine. This powerful engine
only weighs 830 lbs. It powers Columbia
Helicopters'
Boeing
234 heavy lift helicopters capable of 26,000 lb
lifts. Columbia bought the
entire world fleet of 234's, a total of 10
helicopters. They were my main customer as a tech rep for this
engine model. This masterpiece of
engineering from 1955 was the brainchild of
Germany's Third Reich turbine engine scientist Dr. Anselm Franz.
Dr. Franz developed
the famed Junkers
Jumo 004
turbojet engine for the Messersmitt ME262 jet of WWII. He created
the Gas Turbine Division
of Lycoming where I worked for 9 years. He
retired in 1968 as a vice president of Avco Lycoming and
consulted for them up to about the time I started
working
for them. Dr. Franz developed the AGT1500
gas turbine tank engine for the M1 Abrams Tank, our main battle tank
today. He was considered the "Werner Von Braun" of
the gas turbine engine. In the 1930's Dr Franz
developed hydraulic torque converter technology and much
of the turbocharger technology used in this day and
age.
DISTRACTIONS
Screwups by technicians aren't the only ones that are costly.
Administrative errors can be costly too. Many of those are a
little more "revokeable" than the assembly error a tech can make,
hence, they aren't usually subject to an "investigation" except in the
case of Boeing and other forward looking companies who've chosen to do
so. More on these other areas later.
As
techs, we need to maintain focus. In the smaller branches and
businesses where only two or three techs are working, sometimes one has
to assume a role of leadership because perhaps he is a "go to"
guy. That person has to deal with unrelenting distractions and
yet keep from forgetting a key task in the piece of hardware he is
dealing with at the time. Distraction leads to forgetting.
Some are better at coping with distraction than others. I can
usually cope with it but my repair times can suffer.
ASE (Automotive Service Excellence) determined in a study that if a
tech is interrupted by a simple question requiring an answer, the
minimum time penalty to the repair time is 12 minutes. Figure
that times 10 or 12 and you'll see what it can do to standard repair
times. I'm still trying to
relocate that study but haven't so far. If I find it, I'll post
it on this page.
ADMINISTRATIVE AND SUPERVISIONAL ERROR TOLERANCE THRESHOLDS
As offensive as it might be to administrative staff, bear with me here.
I've often made the cold remark that "If we on the shop floor
made as many uncaptured errors as the front office, we would only have
lasted several weeks in this trade." It's not that
simple of course. But on the
shop floor, tolerance of human performance errors is low, and in the
office it is to a certain degree a little higher. It's just a
different set of tasks with different risk levels. Many of the
mistakes made in administration such as parts that don't get ordered
and phone calls that don't get placed can be smoothed over later
without severe financial liability or reputation damage.
The
threshold of tolerance is different in the two environments because of
the nature of the tasks at hand. It's not a criticism, it's just
a fact.
Once a tech
makes an uncaptured error on an assembly job and it leaves the shop
that way, it cannot be revoked.
Money is lost on comebacks and damages. Reputations are
damaged. It can take many years to repair a bad reputation.
Customers speak of bad experiences for many years, sometimes a
decade. They may rarely speak of a routine or successful
experience with a tech or repair agency.
If the error is recognised before it
leaves the shop, the hardware can be disassembled, error corrected and
it can leave the shop assembled correctly. That is a captured
error.
Error capturing also uses a strategy of having a system in place to
render the error as harmless as is possible. An example in my
case would be that I
always carry two small high intensity flashlights and two utility tools
on my person. If I leave one on a bench or tool box, I still have
one
on me if I'm under a vehicle working. I have at least two
of many
things for the same reason. I don't have to go looking for a
misplaced
tool immediately when I need it. I have a second copy in the
tool's
proper place. That is an error capture strategy.
Error
capturing is an interesting
subject. You can get good at it.
ERROR CAPTURING AND RESILIENCE ENGINEERING
Error Capturing is a strategy put in place to render an error
harmless or corrected before it harms. A spell checker in a word
processor would be a good
example. Resilience Engineering is a relatively new field whereby
the trait of "resilience" is defined and engineered into a system or
workplace to predict or foresee a harmful and unwanted outcome.
Researchers in Systems Resilience Engineering recently identified the
need to:
- Get smarter at reporting the next adverse event
- Detect drift into failure before breakdown occurs. Large system
accidents have revealed that what is considered to be normal is highly
negotiable.There is no operational model of drift.
- Constantly test whether ideas about risk still match reality
So resilience is an anticipation strategy that hopes to predict
unwanted outcomes. As an example, the researchers said that
operators with a deep understanding
of an
application area are an important source of resilience and are examples
of
"expertise in action". They allow two sources of resilience, that
of knowing sooner when things are going to go wrong, and secondly
having knowlege that allows them to develop adaptive resources "on the
fly". Good companies with brilliant people do this without
thinking about it.
So since error capturing gets put in place to prevent an error from
going unchecked, it a resilience strategy.
THE BOEING MEDA RESILIENCE STRATEGY AND TECHNICIAN ERRORS
A company that practices resilience wishes to predict unwanted
outcomes. Technician errors and administrative errors would be
two areas ending in unwanted outcomes. The forward looking
company would use errors made by technicians to prevent future unwanted
outcomes which increases their resilience level.
The AERO article mentioned is clear about when and when not to
discipline a tech for an error resulting in an unwanted outcome.
DISCIPLINARY ACTION
Boeing's MEDA investigation process is very specific regarding
punishment of technicians who've errored, but it also says there must
be a discipline policy in place. The referenced 2007 Boeing AERO
article stated the following about punishment:
- The
central philosophy of the MEDA process is that people do not make
errors on purpose. While some errors do result from people engaging in
behavior they know is risky, errors are often made in situations where
the person is actually attempting to do the right thing. In fact, it is
possible for others in the same situation to make the same mistake.
- In a
typical event investigation, as conducted at many airlines in the
past, a maintenance event occurs, it is determined that the event was
caused by an error, the technician who did the work is found, and the
technician is punished. Many times, no further action is taken.
However, if the technician is punished but the contributing factors are
not fixed, the probability that the same event will occur in the future
is
unchanged. The MEDA process finds the contributing factors and
identifies improvements to eliminate or minimize these contributing
factors
in order to reduce the probability that the event will recur in the
future.
- During a MEDA investigation, it is still necessary to determine
whether the event is caused by human behavior and find the
individual(s) involved. Instead of being punished, however, the
technician is interviewed to get a better understanding of the
contributing factors and get the technician’s ideas for possible
improvements. The information can then be added to a database.
It is important
to have a discipline policy in place to deal with
violation aspects of maintenance events. However, discipline or
punishment is only effective for intentional acts. Boeing suggests a
policy that:
- Does not punish honest errors.
- Does not punish routine violations.
- Considers punishment for situational violations.
- Provides punishment for exceptional violations.
The AERO 2007 document defines the specific violation types.
PAGE FOUR
The answer to what happened in the quadruple fatal airplane crash from
the first page will be on page four.
Back to TM page one