Comments on: This Pilot Didn’t Follow Standardized Work? http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Thu, 09 Feb 2012 22:59:58 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: LeanJeff http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4626 LeanJeff Mon, 02 Mar 2009 11:38:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4626 Mark,<br/><br/>Another great post. As a former private pilot myself, I think back to the NOTAMS (notices to airmen) that highlight air accidents. The vast majority of accident investigations cite "pilot error" as the primary cause. I have many thoughts on this, but, relative to your post, much of flying is about judgment. In some cases, too much latitude is afforded the pilot because the standard is intentionally ambiguous to cover a range of conditions.<br/><br/>This post struck a chord. It makes me want to go to every ISO document in my clients' factories and highlight every instance of "should" as a judgment land mine toward which great scrutiny must be applied, since standard work is poorly defined. Mark,

Another great post. As a former private pilot myself, I think back to the NOTAMS (notices to airmen) that highlight air accidents. The vast majority of accident investigations cite “pilot error” as the primary cause. I have many thoughts on this, but, relative to your post, much of flying is about judgment. In some cases, too much latitude is afforded the pilot because the standard is intentionally ambiguous to cover a range of conditions.

This post struck a chord. It makes me want to go to every ISO document in my clients’ factories and highlight every instance of “should” as a judgment land mine toward which great scrutiny must be applied, since standard work is poorly defined.

Like or Dislike: Thumb up 0 Thumb down 0

]]> By: Sandeep Chatterjee http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4619 Sandeep Chatterjee Sat, 28 Feb 2009 05:43:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4619 In one of my earlier blogs, I had mentioned the pitfalls of using a ‘Pull Production’ in case of a remanufactured product where there is a combination of new and salvaged percentage of components. Even with a new product manufacturing and pull production, you may not have optimized your global supply chain.<br/><br/>http://www.infosysblogs.com/oracle/2009/02/pull_production_have_you_achie.html In one of my earlier blogs, I had mentioned the pitfalls of using a ‘Pull Production’ in case of a remanufactured product where there is a combination of new and salvaged percentage of components. Even with a new product manufacturing and pull production, you may not have optimized your global supply chain.

http://www.infosysblogs.com/oracle/2009/02/pull_production_have_you_achie.html

Like or Dislike: Thumb up 0 Thumb down 0

]]> By: curiouscat http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4587 curiouscat Sun, 22 Feb 2009 19:45:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4587 As soon as the "cause" is said to be personal error due to not following guidelines the very next question I want to know the answer to is <a HREF="http://management.curiouscatblog.net/2006/11/18/european-blackout-human-error-not/" REL="nofollow">how often is that guideline followed</a>? And how often other similar guidelines are followed. Are they just dead guidelines sitting on paper to assign blame once something goes wrong or part of an active strategy to manage how work gets done. As soon as the “cause” is said to be personal error due to not following guidelines the very next question I want to know the answer to is how often is that guideline followed? And how often other similar guidelines are followed. Are they just dead guidelines sitting on paper to assign blame once something goes wrong or part of an active strategy to manage how work gets done.

Like or Dislike: Thumb up 0 Thumb down 0

]]> By: David http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4582 David Fri, 20 Feb 2009 17:55:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4582 Federal Aviation Regulations:<br/><br/>Sec. 91.3 - Responsibility and authority of the pilot in command.<br/><br/>(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.<br/><br/>(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.<br/><br/>(c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator.<br/><br/>Paragraph (b) recognizes that it is not possible to write a set of rules to cover every imaginable situation. Checklists and procedures are very important, but so is the use of human judgment, which must sometimes override them. Federal Aviation Regulations:

Sec. 91.3 – Responsibility and authority of the pilot in command.

(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.

(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.

(c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator.

Paragraph (b) recognizes that it is not possible to write a set of rules to cover every imaginable situation. Checklists and procedures are very important, but so is the use of human judgment, which must sometimes override them.

Like or Dislike: Thumb up 0 Thumb down 0

]]> By: Quarterman Lee http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4581 Quarterman Lee Fri, 20 Feb 2009 17:20:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4581 There is another aspect to this problem. When flying through clouds, the pilot has no outside visual reference and must depend upon instruments for orientation. On autopilot, it is unlikely that the pilot would be attending to the airspeed indicator, artificial horizon, altimeter and vertical speed indicator. When the autopilot shuts off, especially if the stick has just moved forward, it would take several seconds for the pilot to check the isntruments, get reoriented and move the controls in the proper directions. The liklihood of panic is very high. <br/><br/>This may also be a case of overautomation. There is no way to program automation for every conceivable situation. This is why pilots exist. It may be that the stick shaker and mover created more problems than they solved. <br/><br/>The automation can induce complacency as well and that probably contributed. As a former pilot of light aircraft, I find it hard to imagine putting my life in the hands of an autopilot under such conditions. However, I can understand how continual flying with more sophisticated autopilot would induce a complacency that one would not have with more primitive systems.<br/><br/>A lot of this applies to factories as well. More factories are ruined by over-automation than by insufficient automation. There is another aspect to this problem. When flying through clouds, the pilot has no outside visual reference and must depend upon instruments for orientation. On autopilot, it is unlikely that the pilot would be attending to the airspeed indicator, artificial horizon, altimeter and vertical speed indicator. When the autopilot shuts off, especially if the stick has just moved forward, it would take several seconds for the pilot to check the isntruments, get reoriented and move the controls in the proper directions. The liklihood of panic is very high.

This may also be a case of overautomation. There is no way to program automation for every conceivable situation. This is why pilots exist. It may be that the stick shaker and mover created more problems than they solved.

The automation can induce complacency as well and that probably contributed. As a former pilot of light aircraft, I find it hard to imagine putting my life in the hands of an autopilot under such conditions. However, I can understand how continual flying with more sophisticated autopilot would induce a complacency that one would not have with more primitive systems.

A lot of this applies to factories as well. More factories are ruined by over-automation than by insufficient automation.

Like or Dislike: Thumb up 0 Thumb down 0

]]> By: Lee Stacey http://www.leanblog.org/2009/02/this-pilot-didnt-follow-standardized/#comment-4580 Lee Stacey Fri, 20 Feb 2009 14:21:00 +0000 http://leanblog.bigbigdesign.net/2009/02/this-pilot-didnt-follow-standardized-work/#comment-4580 Very good post, Mark. The trouble is that the pilot will probably be blamed for this.<br/><br/>Is it his fault? No.<br/><br/>"Should not" roughly translates to: We don't think it's a good idea but it's up to you.<br/><br/>Maybe this isn't actually an error? By leaving things open like this, it allows for blame to be easily placed on the pilot, thus saving a lot of bottom line. Very good post, Mark. The trouble is that the pilot will probably be blamed for this.

Is it his fault? No.

“Should not” roughly translates to: We don’t think it’s a good idea but it’s up to you.

Maybe this isn’t actually an error? By leaving things open like this, it allows for blame to be easily placed on the pilot, thus saving a lot of bottom line.

Like or Dislike: Thumb up 0 Thumb down 0

]]>