Human Error or a Bigger Problem? When to Dig Deeper

by Julius DeSilva

In the world of process improvement and problem-solving, human “user” error can often become the go-to explanation when things go wrong. A mis-entered data point, a forgotten step in a procedure, or a misconfigured setting—blaming the user is quick and easy. But how do you know when an issue is bigger than just user error?

Understanding when to dig deeper and identify systemic flaws is critical. By integrating structured approaches like Root Cause Analysis (RCA) and the PDCA (Plan-Do-Check-Act) cycle, organizations can shift from a reactive blame culture to a proactive, continual improvement mindset that eliminates recurring problems at their source.

The Prevalence of User Error in Different Industries

Human error has been identified as a significant contributor to operational failures across multiple sectors:

  • Cybersecurity: According to the World Economic Forum, 95% of cybersecurity breaches result from human error.
  • Manufacturing: A study by Vanson Bourne found that 23% of unplanned downtime in manufacturing is due to human error, making it a key contributor to production inefficiencies. The American Society for Quality (ASQ) reports that 33% of quality-related problems in manufacturing are due to human error.
  • Healthcare: The British Medical Journal (BMJ) estimates that medical errors—many due to human factors—cause approximately 250,000 deaths per year in the U.S. alone.
  • Aviation & Transportation: The Federal Aviation Administration (FAA) attributes 70-80% of aircraft incidents to human error, but deeper analysis often reveals process design issues, poor training, or missing safeguards.

These statistics reinforce a key point: Human error isn’t always the root cause—it’s often a symptom of a deeper, systemic issue.

Recognizing When to Look Beyond User Error

Here’s how to tell when an issue isn’t just a one-time mistake but a signal that the system itself needs improvement:

  1. Recurring Issues Across Multiple Users – If multiple employees are making the same mistake, the problem likely isn’t individual human error—it’s a flaw in the process, system design, or training. For example, if multiple operators incorrectly configure a machine setting, it might indicate confusing controls, inadequate training, or unclear documentation rather than simple user mistakes.
  2. Workarounds and Process Deviations – If employees consistently find alternative ways to complete a task, the system may not be designed for real-world conditions. If workers routinely bypass a safety feature because it “slows them down,” the process needs reevaluation; either through retraining, redesign, or better automation. At QMII, we always reinforce building a system for the users, built on the as-is of how work is done and then making incremental improvements.
  3. High Error Rates Despite Training – If errors persist even after proper training, the issue might be process complexity, unclear instructions, or a lack of intuitive system design. If employees consistently make minor mistakes, the system interface or workflow rules might need simplification rather than just retraining staff.
  4. Error Spikes in High-Stress Situations – Mistakes often increase under time pressure, fatigue, or stress. This suggests a workload or process issue rather than simple carelessness. In a maritime environment, high error rates during critical operations could signal staffing shortages, inefficient safety interlocks, or poor user interfaces on devices.

Instead of just fixing errors after they happen, organizations should use the PDCA (Plan-Do-Check-Act) cycle to continually improve processes and reduce the probability of recurring failures.

The PLAN-DO-CHECK-ACT Approach

PLAN – Identify the context and potential risks

  1. Identify the context of the process including the competence of personnel, user environment, complexity and influencing factors.
  2. Apply Failure Mode and Effects Analysis (FMEA) to predict where failures are likely to happen before they occur.
  3. Identify and involve representatives of users through the development of FMEAs and the process.
  4. When predicting controls and resources, determine the feasibility of implementing and providing them.
  5. Simplify procedures, redesign workflows, or introduce automation to eliminate failure points.

DO – Implement the Process and Improvements

  1. Implement the process and test it to check its effectiveness. In the initial stages more frequent monitoring and measurement will be required. The periodicity between checks can be reduced as the process matures.
  2. Provide user training and assess its effectiveness. When errors occur retrain personnel, but only if training is truly the issue—don’t use training as a Band-Aid for bad system design.
  3. Look beyond documented “standard-operating” procedures. As an example: The company implements a visual step-by-step guide near machines to ensure operators follow a standard calibration process.

CHECK – Evaluate the Results

  1. Track performance data to see if the changes have reduced errors.
  2. Get user feedback to ensure the new system is intuitive and efficient. For example, Error rates drop by 40%, but operators still struggle with a specific step—prompting another refinement.

ACT – Standardize & Scale

  1. If the improvement is successful, integrate it as the new standard process.
  2. Scale the change across other departments or sites where similar issues might exist. For example, the company implements the same calibration guide and training approach across all locations, preventing similar errors company-wide.

Conclusion: From Blame to Solutions

While human error is a reality, it’s often a symptom of a deeper process flaw, not the root cause. Those involved in conducting a root cause analysis process or investigation process, must ask “How did the system fail the individual” and “Why did the system fail the individual”. By shifting from a blame mindset to a continual improvement approach, organizations can:

  • Reduce costly errors and downtime
  • Improve employee engagement (less frustration = higher productivity)
  • Enhance conformity and compliance
  • Increase process reliability and efficiency

Monitoring the system will continue for as the context changes the controls implemented may not be as effective as before. A proactive system will not guarantee that things never go wrong. When they do, however, the key is to dig deeper. Using tools like PDCA, FMEA, and RCA will help in identifying long-term solutions to recurring problems. Because in most cases, fixing the system is better than blaming the human.

ISO 13485: QMS Requirements of Medical Devices for Regulatory Purposes

by Dr. IJ Arora

ISO 13485:2016 is a standard that addresses quality management system requirements for those within the medical device industry. It is based on the systems-based approach found in ISO 9001:2015, but because it emphasizes requirements for regulatory purposes, it does not align with ISO’s harmonized structure (HS). In many ways, ISO 13485 does align with the HS, particularly in the structure and foundational principles of quality management.

The introduction of ISO 13485 explicitly states that the standard is aligned with ISO 9001, and this connection is important for understanding how the two standards relate to each other. I am a bit surprised as to why ISO 13485 isn’t fully harmonized with the HS as defined in Annex SL, which is the specific document within ISO standards that outlines the HS. I believe that if this standard were aligned to the HS, it would make implementation much less laborious for all involved.

The ISO 9001 foundation

The 2015 version of ISO 9001, which is presently under revision, provides a good basis for all standards. As mentioned, ISO 13485 has its roots in ISO 9001, which is why the key QMS principles (e.g., customer focus, leadership, process approach, continual improvement, and evidence-based decision making) central to ISO 9001 are also embedded in ISO 13485.

ISO 13485 includes several core concepts and clauses from ISO 9001. Clause 4 on quality management systems (e.g., structure, documentation requirements, and the scope of the QMS); cause 5 on management responsibility (e.g., top management involvement, resource allocation, and internal audits); and clause 8 relating to measurement, analysis, and improvement (e.g., monitoring, corrective actions, and continual improvement), are just some of these examples.

As I study, teach, consult, and audit using ISO 13485, I wonder why the standard Is not fully harmonized with similar standards as laid out in Annex SL. In consulting, I feel the pain of organizations that must meet regulatory requirements and so tend to overlook the process-based management system (PBMS) approach as the fundamental to the plan-do-check-act (PDCA) cycle. This regulatory focus is one reason why, although ISO 13485 shares many similarities with ISO 9001, it is not fully aligned with the HS. ISO 13485 places a strong emphasis on compliance with regulatory requirements specific to the medical device industry. The standard’s clauses addressing design and development, post-market surveillance, risk management, and traceability requirements are all far more extensive than those found in ISO 9001. Annex SL focuses more on general management practices and less on industry-specific regulatory controls. The detail and specificity required for medical device safety and compliance often necessitates a structure that goes beyond the framework of the HS.

Overcoming differences

Different scopes and audiences are also a consideration in that, while ISO 9001 is a general quality management standard applicable across industries, ISO 13485 is designed specifically for organizations that manufacture medical devices. These organizations must meet stringent regulatory requirements that go beyond what ISO 9001 addresses. Because of this, ISO 13485 requires more detailed processes related to product lifecycle management, post-market activities, risk management, and regulatory controls, which aren’t adequately covered under the more generalized HS. ISO 13485 includes a much stronger emphasis on managing the product’s entire lifecycle, from design and development to post-market activities (e.g., complaint handling and vigilance). Although ISO 9001 mentions product realization, ISO 13485 goes into much greater depth, including extensive requirements for design control and risk management. These elements reflect the higher level of scrutiny needed in the medical device industry, where safety and compliance are paramount.

With that said, I believe that these differences don’t prevent ISO 13485 from being organized according to the HS format. The standard would not only help medical device manufacturers’ management systems conform with specific regulatory requirements but also meet the obligations for continual improvement. After all, registered organizations in the aerospace and automobile industries already do just that via sector-specific management system standards that are harmonized with ISO 9001.

The structural differences in the clauses found in ISO 13485 and the standards adopting the HS are not too far apart. Although ISO 13485 is aligned with ISO 9001, it diverges when it comes to specifics that are unique to the medical device sector and regulatory requirements.

ISO 13485’s clause 7, “Product Realization” includes additional elements, such as design controls and regulatory compliance requirements, that are critical in the medical device industry. Post-market surveillance and complaint handling are central to ISO 13485, but the HS doesn’t go to the level of detail necessary for medical device manufacturers.

ISO 13485 emphasizes the need for continuous monitoring of device performance, even after they are on the market, ensuring any issues are identified and addressed in a timely manner. I believe ISO 9001’s subclause 9.1.2, “Customer Feedback,” can be updated to incorporate this requirement.

Risk management is a vital consideration. ISO 13485 integrates risk management into the standard in a way that is far more structured and pervasive than what is found in ISO 9001. ISO 13485 has a more detailed approach to identifying, assessing, and mitigating risks throughout the lifecycle of medical devices. However, these added requirements could be added to subclause 6.1.1 (““Actions to Address Risks and Opportunities”) or subclause 8.1.1 (“Operation Planning and Control”) found in the HS.

ISO 13485 includes specific requirements for design and development processes, which are critical in medical devices due to their complexity and potential risk to patient safety. The HS doesn’t provide this level of detail for other types of products or industries.

Identifying similarities

Notwithstanding the differences between ISO 13485 and the standards that align with the HS, there are also some key similarities. As with ISO 9001, ISO 13485 is built around seven quality management principles: customer focus, leadership, engagement of people, process approach, improvement, evidence-based decision making, and relationship management. Continual Improvement of the quality management system is part of both standards, emphasizing the need for a strong focus on monitoring, auditing, corrective actions, and reviews. Document control is another similarity. Both ISO 13485 and ISO 9001 stress the importance of clear and accurate documentation to ensure that quality management processes are defined, monitored, and maintained effectively.

In keeping itself separate from the HS, ISO 13485’s clause structure, despite being based on ISO 9001, serves to meet the unique needs of the medical device industry. The decision not to fully harmonize the standard with the structure seen in Annex SL likely stems from the need to ensure a tailored regulatory focus. ISO 13485 is aligned with a variety of regulatory frameworks across different countries and regions (e.g., FDA, EU MDR, TGA, etc.). These regulations require specific processes that go beyond the generic, high-level harmonized framework provided by Annex SL to facilitate combined/ integrated management systems. The structure of ISO 13485 allows for a more detailed, industry-specific approach to product safety, efficacy, risk management, and compliance. Product lifecycle control is an essential part of the medical device industry, and it has a complex lifecycle that includes design controls, manufacturing processes, and post-market activities that require more attention than the HS would provide.

Looking at a few additional clauses reveals that ISO 13485 follows a specific structure that allows it to emphasize the unique aspects of medical device quality management while maintaining consistency with other ISO standards.

For example, Clause 1, “Scope,” is relatively straightforward and outlines the scope of the standard, which is specific to organizations that design, manufacture, and maintain medical devices. The clause also highlights exclusions (for example, aspects not applicable to the organization), which is quite typical in a quality management standard.

Clause 2, “Normative References,” lists the documents referenced within ISO 13485, which is typical for any ISO management system standard. The important point here is that ISO 13485 requires compliance with relevant regulations and standards, particularly those in the medical device sector.

Clause 3, “Terms and Definitions,” is crucial because the terminology in the medical device industry can be very specifically. Definitions clarify terms that might have different meanings in other industries (e.g., what qualifies as a “medical device,” “design verification,” or “post-market surveillance”). This ensures uniformity and understanding across the industry.

Clause 4, “Quality Management System (QMS),” describes the basic requirements for establishing and maintaining a QMS, which is a fundamental aspect of ISO 13485. This clause outlines the need for a quality policy, the establishment of objectives, and the requirement to continually improve the QMS. These are common in all ISO standards but are tailored here to fit the needs of the medical device industry.

Clause 5, “Management Responsibility,” covers executive involvement as a key theme. In ISO 13485, it emphasizes top management’s responsibility for ensuring that quality objectives are met. This clause also requires that management provide resources for quality activities and review the performance of the QMS regularly, ensuring alignment with regulatory requirements and customer needs.

Clause 6, “Resource Management,” could have been aligned to clause 7, “Support,” found in the HS. This clause in ISO 13485 requires the organization to manage resources effectively, which includes personnel training and competence (a critical area in the medical device industry). This ensures that employees have the skills needed to produce safe and effective devices. It also covers infrastructure and the control of the work environment, ensuring that conditions are suitable for maintaining product quality.

Clause 7, “Product Realization,” diverges further from the HS. Product realization in the medical device sector involves the entire lifecycle of the device—from planning, design, development, and manufacturing to service and post-market activities. This clause is extensive and includes requirements for design controls, risk management, validation, and traceability, all of which are critical in the medical device industry. The detailed focus on design and development, verification and validation, and product monitoring ensures that all aspects of a medical device’s journey, from conception to post-market surveillance, are covered.

Clause 8, “Measurement, Analysis, and Improvement,” requires organizations to evaluate the effectiveness of their QMS through regular monitoring, measurement, and audits. It also focuses on corrective and preventive actions (CAPA) to improve quality. Preventive action in the HS has not been thrown out like the proverbial baby with the bath water. It has instead been replaced by requirement to appreciate risk. For medical devices, complaints and nonconformance reporting are key to ensuring ongoing safety and compliance. ISO 13485 could also have gone from preventive action to risk.

Post-market surveillance and vigilance is a requirement of the medical device standard. Unlike many other ISO standards, ISO 13485 places significant emphasis on post-market surveillance, which is the process of monitoring the performance of medical devices once they are in use. This is a major distinguishing factor from other ISO standards. Manufacturers are required to establish processes for post-market feedback, complaint handling, and field safety corrective actions (FSCA), which are essential for identifying and managing risks after the product is on the market.

In conclusion, I would opine and agree that although ISO 13485 is indeed based on ISO 9001, it diverges from the HS identified in Annex SL because the unique needs of the medical device industry—such as regulatory compliance, product lifecycle management, and patient safety—require a more detailed and specialized approach than the HS can provide. The clause structure of ISO 13485 reflects these specific requirements, making it a robust and industry-specific standard that ensures the safety and quality of medical devices while maintaining alignment with the foundational principles of quality management in ISO 9001.

This balance of maintaining core quality principles while addressing the needs of the medical device industry is why ISO 13485 has not fully adopted the HS but instead continues to incorporate elements of ISO 9001 alongside medical-device-specific regulatory needs. That it could still at the least attempt to align the primary clauses as risk to the HS would help all parties involved.

Note – The above article was recently featured in Exemplar Global’s publication called “The Auditor”. Click here to read it.

One-Off or Systemic: The Search for Root Causes

by Julius DeSilva

Accidents and failures, whether in maritime, aviation, healthcare, or nuclear settings, are often subjected to intense scrutiny to determine their root causes. However, the challenge lies in distinguishing whether an event is an anomaly or a symptom of a deeper systemic issue. This analysis is crucial as it directly influences the actions taken to prevent a recurrence or occurrence elsewhere. A management system approach, such as those outlined in ISO 45001 for occupational health and safety, ISO 9001 for quality management, or ISO 14001 for environmental management, provides a structured framework for systematically and proactively addressing risks when data exists.

Analysis of root causes: systemic failures

Root cause analysis is a fundamental investigative tool used to trace an incident to its origins. However, many organizations focus on immediate, apparent causes rather than examining systemic contributors and true root causes. Systemic failures result from weaknesses in policies, processes, or culture, and therefore, often recur in different forms over time.

The management system approach advocated by ISO standards and other industry-specific standards like the ISM code emphasize continual improvement and risk-based thinking. The intent of these standards is to reduce the probability of systemic failures by integrating safety, quality, efficiency, security, and environmental management into everyday operations.

Systemic failure example: Chernobyl

I recently read the book Midnight in Chernobyl, which outlined the 1986 Chernobyl nuclear disaster and the underlying systemic failures that contributed to this incident. Unlike isolated accidents, Chernobyl resulted from a combination of design flaws, operational errors, and a deficient safety culture. Key systemic issues included:

  • Design flaws. The RBMK reactor used in Chernobyl had an inherent positive void coefficient, meaning an increase in steam production could accelerate the reaction uncontrollably.
  • Operational failures. A safety test was conducted under unsafe conditions, including a reduced power level and disengaged emergency shutdown mechanisms.
  • Cultural and regulatory gaps. A lack of safety culture, insufficient training (and thus competency), and an authoritarian management style amounting to complacency discouraged questioning of unsafe practices.

These root causes culminated in an explosion that released massive amounts of radioactive material. European countries are so tightly packed that winds freely spread the outfall without borders. The systemic nature of the disaster was later addressed through international nuclear safety reforms, including the establishment of the International Atomic Energy Agency’s safety standards and stricter ISO frameworks such as ISO 19443, which outlines quality management system requirements for organizations working within the nuclear sector.

Other systemic failures

Deepwater Horizon oil spill (2010)

Another example of a systemic failure is the Deepwater Horizon oil spill. This incident was not merely the result of a single mistake but a consequence of systemic lapses in safety practices, regulatory oversight, and risk management. Contributing factors included:

  • Cultural deficiencies. The organization prioritized cost cutting over risk mitigation
  • Inadequate risk assessments. There was poor well-integrity testing and misinterpretation of pressure data.
  • Regulatory weaknesses. There was insufficient government oversight and a lack of stringent industrywide safety protocols.

This catastrophe led to significant regulatory changes, including the implementation of stricter safety and environmental policies within the oil and gas industry, aligned with ISO 45001 and ISO 14001.

The Boeing 737 MAX crashes (2018, 2019)

The Boeing 737 MAX crashes further illustrate systemic failure. Investigations revealed that flaws in the aircraft’s Maneuvering Characteristics Augmentation System (MCAS) were not adequately addressed due to:

  • Design and engineering oversights. Critical safety features were made optional rather than standard.
  • Regulatory gaps. The FAA relied excessively on Boeing’s self-certification.
  • Organizational pressures. The corporate culture emphasized speed-to-market delivery over comprehensive safety testing.

This resulted in significant regulatory reforms, including tighter oversight and compliance with international aviation safety standards.

Fixes vs. systemic longer-term improvement

Addressing failures can be approached through quick fixes or long-term systemic improvements. Each approach has its advantages and disadvantages:

Quick fixes

Pros:

  • Immediate resolution of pressing issues
  • Cost-effective in the short term
  • Prevents further damage or loss

Cons:

  • Does not address underlying systemic issues
  • Can lead to recurring problems if not supplemented with deeper analysis
  • Often reactive rather than proactive

Systemic longer-term improvements

Pros:

  • Addresses root causes, reducing the likelihood of recurrence
  • Enhances organizational resilience and safety culture
  • Aligns with ISO management systems, ensuring continuous improvement

Cons:

  • Requires significant time and resources
  • May face resistance from stakeholders due to cultural inertia
  • Implementation complexity can slow down immediate corrective actions

A balanced approach is often necessary—implementing short-term fixes to mitigate immediate risks while developing long-term systemic improvements to ensure sustainable safety and risk management practices.

What if we cannot foresee all risks?

Even with rigorous management systems and risk assessments, not all risks can be predicted. Organizations must be prepared to address unforeseen risks through:

  • Resilient systems. It is important to develop adaptable and robust safety management frameworks that can respond effectively to new threats.
  • Proactive learning. The organization can encourage a culture of continuous learning and scenario planning to anticipate emerging risks.
  • Redundancies and safeguards. Implementing fail-fail safe redundancies and contingency plans can mitigate the effects of unforeseen events.
  • Stakeholder collaboration. Engaging industry experts, regulators, and other stakeholders to share knowledge can help improve collective risk awareness.

Despite the lessons from Chernobyl, 25 years later the Fukushima disaster occurred. An earthquake of this magnitude was not foreseen as a risk even though in 1896 (as highlighted by an engineer on the project) an earthquake of magnitude 8.5 hit near the coast where the reactor was to be built. After Chernobyl, the 1970s-built reactor in Fukushima was not upgraded with the latest safety features due to high costs. Japan’s nuclear industry had a history of regulatory complacency and reluctance to accept international recommendations

ISO 31000, which addresses risk management, emphasizes the importance of resilience and adaptability in the face of unpredictable risks. By fostering a commitment to learning and preparedness across the organization, businesses can better navigate uncertainties while maintaining operational safety and efficiency.

The benefits of a management system approach

A management system approach, as defined by ISO standards, provides the following advantages:

  • Structured risk management. ISO 31000 ensures systematic identification, assessment, and mitigation of risks.
  • Continuous improvement. The Plan-Do-Check-Act (PDCA) cycle described in ISO 9001, ISO 45001, and ISO 14001 encourages learning from incidents to prevent recurrence.
  • Organizational culture change. Implementing ISO standards fosters a risk-oriented mindset, reducing the likelihood of systemic failures.

ISO management systems, when implemented and sustained, can act as a preventive tool to proactively manage risk.

Conclusion

Understanding whether an accident is an anomaly or a systemic failure is critical in determining the appropriate response. Sadly, at times industry must incur the cost of the nonconformity to learn the lesson. Organizational “can-do” attitudes lead to risk normalizations where dangerous conditions are seen as normal. Further, organizational and demographic cultures do not encourage challenging authority or questioning of decisions. Absence of accidents, incident reports, and near misses give a false sense of complacency that things are working well. This may lead to over-confidence in decision making, lapses in regulatory oversight, and deferring of resource allocation to other “priorities.”

Systemic failures indicate deeper vulnerabilities requiring long-term corrective actions. The application of ISO management systems offers a proactive and structured approach to accident prevention, ensuring that organizations move beyond reactive responses to fostering a culture of continuous improvement and risk management. By embracing these principles, industries can mitigate systemic risks, ensuring safer and more resilient operations.

Note – The above article was recently featured in Exemplar Global’s publication ‘The Auditor’. Click here to read.

The Role of Management Systems in the Tragic Collision Over the Potomac

by Dr. IJ Arora


A significant tragedy occurred in Washington D.C. on January 29, 2025, with the deadly collision between a U.S. military Black Hawk helicopter and a regional jet flying for American Airlines. The resulting crash caused the loss of 67 precious lives and pointed to a multilayered failure of safety mechanisms.

In a short article like this it is not my intent to explore the reasons for this event, and I have neither the expertise nor the authority to investigate, anyway. The U.S. National Transportation Safety Board (NTSB) and other relevant agencies will do that in a most professional manner. However, I do have a degree of experience relating to the systems approach for managing processes at large and complex organizations. I feel called to share my perspective on this disaster with a systems approach in mind.

Proactive appreciation for risk

Hindsight, it has been said, is 20/20. I am aware that I’m writing this after the tragedy has already occurred. However, management systems should be proactive, where data drives the understanding and mitigation of risk. As a practitioner and advocate of process-based management systems, I believe that well-implemented procedures give an organization the best chance to produce conforming products and services.

A systems approach, based on ISO 9001’s subclause 4.4., which relates to quality management system processes, could have played a role in preventing an incident of this type. Subclause 4.4.1 states, in part, “The organization shall establish, implement, maintain and continually improve a quality management system, including the processes needed and their interactions….”

Following this requirement is no guarantee of safe and successful outcomes, but it is surely the best bet. I had similar thoughts on the tragedy of the implosion of the Titan submersible and the Baltimore Bridge collapse. The core principles of ISO 9001, especially risk-based thinking, continual improvement, and process interaction, align well with safety imperatives, particularly safety management for the aviation industry. The systems approach is a fundamental that organizations often neglect at their (and their customers’) peril.

ISO 9001—and for that matter, the aerospace standard AS9100—is built on risk-based thinking. A structured process aligned with the risk management standard ISO 31000 and aviation safety management systems are required by ISO 9001 subclause 6.1, regarding actions for addressing risks and opportunities, and subclause 8.1 concerning operation planning and controls. Conformance with these requirements can help identify and mitigate collision risks between civil and military aircraft.

Process interaction and communication are vital in such situations.  A failure in communication between air traffic control, military operations, and civilian aviation may have contributed to the crash. Of course, we will wait for the full report from the NTSB investigation. However, it is never too late (or for that matter, too early) to be proactive and implement a process approach to ensure that all stakeholders follow well-defined communication and coordination protocols.

PDCA, SWOT, and FMEA

Being proactive requires an appreciation of risk at the Plan stage of the Plan-Do-Check-Act (PDCA) cycle. Note that preventive actions and continual improvement are integral to the system approach.

The media have reported on the details of numerous previous aviation incidents. Analyzing near-miss incidents and integrating lessons learned into improved procedures could enhance safety protocols. Human factors and process redundancy must be considered in a systematic manner. Human errors (e.g., miscommunication, misinterpretation of airspace usage, etc.) can be minimized with automated systems and via decision-making redundancy checks.

In principle, the process approach found in ISO 9001 emphasizes addressing process issues as opposed to blaming individuals. However, in the aviation field, the human factor is important; clause 10.2.1 b2 of AS9100 expresses the importance of this concept. The industry-specific interpretation of requirements as seen in this standard provides a robust framework (via a clause structure) to design an efficient management system. This, together with auditing and compliance requirements, gives leadership confidence that their system can and will produce conforming products and services.

Further to this point, regular audits of flight coordination between civilian and military aviation could highlight gaps before they lead to accidents. As such, integrating ISO 9001 with AS9100 and AS9110 (the aerospace quality standard specifically designed for maintenance, repair, and operations) as well as ISO 45001 covering the management of operational health and safety will provide a solution to proactively address risks in the context of the aviation industry. This would cover all interested parties, as per clauses 4.1 and 4.2 of ISO 9001. Although aviation already has strict regulatory frameworks (e.g., FAA, ICAO, etc.), the structured process management systems required by ISO 9001 and AS9100 can complement these frameworks by embedding the statutory and legal requirements into the management system.

If the organizations involved focus on how specific elements of ISO 9001 can be applied to aviation safety, particularly in preventing collisions, I would first recommend that they look at risk-based thinking as seen in clause 6.1, addressing actions related to risks and opportunities. This can partially be accomplished by undergoing a strengths, weaknesses, opportunities, and threats (SWOT) analysis. ISO 9001 emphasizes risk assessment and mitigation throughout processes.

In aviation, a structured risk-based approach would identify potential hazards (e.g., conflicting flight paths, miscommunication, system failures, etc.). The system would also assess risk severity and likelihood of occurrence and probability of detection, using tools like a failure modes and effects analysis (FMEA). Controls could be implemented (e.g., enhanced air traffic control coordination, better radar tracking, AI-driven airspace monitoring, etc.). For example, aviation safety bodies could require all civilian and military flights to undergo a real-time risk assessment check before takeoff, considering airspace congestion, weather, and military training exercises.

Potential solutions

Process interaction and communication (as seen in ISO 9001’s clause 4.4.1 b regarding understanding process interactions) would systematically improve the system. Aviation operations involve multiple stakeholders, such as airlines, air traffic controllers, military operations, ground crews, etc. A process approach would ensure defined standard operating procedures for communication between civilian and military aviation. These could include real-time data sharing using standardized digital platforms and/or automated conflict-resolution systems that detect and alert pilots and controllers regarding possible mid-air conflicts. An integrated civil-military coordination dashboard could be established, where both parties have real-time visibility on flight plans, airspace restrictions, and emergency deviations.

Risk appreciation and continual improvement (as seen in ISO 9001’s clause 10.2 regarding nonconformity and corrective action, clause 10.3 on continual improvement, and clause 5.1.2 regarding customer focus) require organizations to analyze failures, investigate causes, and take corrective actions. In aviation safety, this could mean automated reporting and analysis of near-miss incidents and regular safety audits to evaluate procedural weaknesses and machine learning-based predictive analytics to foresee and prevent future crashes.

When a near-miss incident occurs, such a system could automatically trigger a root cause analysis and recommend safety adjustments for all stakeholders. Human factors and redundancy (as seen in clause 7.1.6 regarding organizational knowledge) promote knowledge management and human reliability strategies. In aviation, this could mean mandatory cross-training for military and commercial pilots on shared airspace procedures. AI-assisted decision-making tools that provide secondary verification for pilots and controllers could be a positive outcome of data analysis.

Data drives risk and trends. A digital co-pilot system could use AI to continuously monitor air traffic conflicts and intervene if human errors are detected. Auditing and compliance (as seen in clause 9.2 regarding internal auditing) would provide objective and independent inputs by regular safety audits of flight coordination. Air traffic control systems could ensure compliance with standardized airspace usage protocols, identification of gaps in inter-agency communication, and implementation of best practices from previous incident investigations. A shared civil-military aviation audit framework could ensure uniform compliance with risk management policies, reducing the chance of airspace conflicts.

I am not a technical subject matter expert in the aviation industry. My expertise is in looking at systems. My 30 years of experience suggests the importance of strengthening the Plan stage of the PDCA cycle. Things go wrong at the Do stage (i.e., implementation), however, if the plan itself is deficient and not coordinated, the implementation can and perhaps will go wrong.

By integrating ISO 9001 principles into aviation safety proactively and appreciating the risks, management can prevent mid-air conflicts. Process-driven coordination ensures better civil-military collaboration. Automated monitoring and auditing could improve response times to emerging threats.

Sadly, this tragedy once again bears out the wisdom of W. Edwards Deming when he said that a bad system will beat a good person every time.

Note – The above article was recently featured in Exemplar Global’s publication ‘The Auditor”. Click here to read it.

Are Provider Audits Mandated through ISO 9001?

by- Dr. IJ Arora

In relation to outsourced processes, the query (to paraphrase William Shakespeare) is, “To audit or to not audit?”

Take, as an example, the necessities from the principle process-based control machine usual, ISO 9001:2015. One would possibly imagine the machine way as equipped in clauses 4.4.1a thru 4.4.1h and conclude that tracking and regulate are had to recognize the dangers of the inputs and make sure persistent growth. The usual is supposed to be interpreted, and so not anything prescriptive is predicted. But, the query stays as to how organizations would possibly regulate the processes and ensure they’re assembly goals. Clause 5.2, “Coverage,” resulting in clause 6.2, “Goals,” supplies a touch that proof will have to be amassed of measurable goals being met. But, how can we get the inputs to attract a conclusion? The inputs are essential, and due to this fact there’s a want to decide the to be had accumulate and regulate knowledge.

In all probability the solution may also be discovered within the auditing serve as. By means of enforcing a strong provider analysis activity, together with audits as wanted, organizations can beef up the standard control machine and construct sturdy, dependable relationships with providers. Notice that requirements similar to ISO 9001:2015 don’t particularly mandate audits, but the intent of registration to a typical is to regulate the group’s processes. if now not auditing, then what different mechanisms can organizations use to regulate an outsourced activity and decrease dangers to their finish consumers?

Exerting regulate

Clause 8.4.2 of ISO 9001:2015 offers with the sort and extent of controls that a company should practice to externally equipped processes, merchandise, and products and services. The important thing sides on this dialogue come with making sure conformity, the kinds of controls wanted, and the level of those controls. Conformity has at its core the main to make sure that those exterior provisions don’t negatively have an effect on the group’s skill to constantly ship conforming services to its consumers. This implies the group should have mechanisms in position to make sure that the standard of the exterior inputs meet the group’s necessities and in the end fulfill buyer necessities.

Kinds of controls might be interpreted as acting a point of regulate, in all probability through auditing, even supposing auditing isn’t a selected requirement. The choice and analysis of the controls can be according to organising standards for deciding on and comparing exterior suppliers (e.g., a strong high quality control machine of their very own, previous efficiency, registration, and many others.) and/or undertaking thorough checks of doable providers (e.g., audits, questionnaires, web site visits, and many others.). As well as, you will need to installed position sturdy contractual agreements with exterior providers that come with transparent and measurable necessities, explicit key efficiency signs (KPIs), and acceptance standards for the needs of tracking and size. This may come with monitoring provider efficiency towards agreed-upon KPIs, examining knowledge to spot tendencies and spaces for growth, undertaking common efficiency critiques and comments classes, acting root purpose research and corrective and preventive movements when problems are known, and appreciating dangers through being proactive and the use of preventive measures.

The level of this regulate would rely at the criticality of the externally equipped activity, product, or provider to the group’s general high quality. For top-risk pieces, extra stringent controls (e.g., extra common audits or extra rigorous inspections) could be essential as, as an example, within the aerospace trade. In essence, clause 8.4.2 emphasizes the significance of proactive measures to make sure that exterior inputs don’t compromise the group’s skill to ship high quality services to its consumers.

Auditing supplies most of these inputs if the audit is appropriately deliberate and done. For instance, with approval, this stage of regulate might be completed through far flung cameras or the presence of the group’s inspectors on the provider’s amenities. The purpose is to care for the client focal point (clause 5.1.2) and include a risk-based way. The level of regulate will have to be proportionate to the related dangers. Power growth includes that the group will have to often evaluation and reinforce its processes for exterior controls.

Subsequently, even if clause 8.4 (particularly subclauses 8.4.1, 8.4.2, and eight.4.3) does now not explicitly mandate provider audits, it strongly implies their significance. Subsequently, a robust focal point on regulate should be interpreted. Clause 8.4 emphasizes the want to regulate externally equipped processes, merchandise, and products and services. Auditing is a a very powerful instrument for comparing a provider’s skill to fulfill high quality necessities and care for regulate over their processes.

Mitigating menace

To verify ok menace control, one should imagine if the provider’s efficiency at once impacts the group’s skill to ship high quality merchandise or products and services. Audits assist establish and mitigate doable dangers related to the use of exterior suppliers. Power growth is the most important consequence of auditing and offers precious comments on provider efficiency. This allows the group to spot spaces for growth of their processes and their practices round provider variety and provider control. Subsequently, even if now not strictly mandated, provider audits are extremely really useful for organizations in the hunt for to successfully put into effect ISO 9001 and make sure the standard in their services. The important thing issues can be:

  • Chance-based way. Auditing efforts will have to be desirous about providers that pose the easiest menace to the group’s high quality goals.
  • Number of analysis strategies. Audits are only one manner of provider analysis. Different strategies come with efficiency tracking, comments research, and web site visits.
  • Documentation. Care for transparent documentation of all provider analysis actions, together with audit findings, corrective movements, and growth plans.

When taking into consideration the outsourcing of a activity, the group should assess and decide the factors through which providers are decided on. Via systematic analysis, a company can put into effect a rigorous provider variety activity that comes with:

  • Detailed questionnaires to collect knowledge at the provider’s high quality control machine, processes, and features
  • Reference exams made through contacting earlier consumers to evaluate the provider’s efficiency and reliability
  • On-site visits to watch the provider’s operations and assess their amenities, apparatus, and body of workers
  • A risk-based way matrix to prioritize providers according to the possible impact at the group’s high quality goals

In making plans bids, growing contractual agreements, or different processes involving outsourcing, the next will have to be regarded as:

  • Transparent specs. Outline transparent and measurable necessities for the outsourced services or products.
  • Efficiency metrics. Determine KPIs to trace provider efficiency, similar to on-time supply, defect charges, and buyer delight.
  • Contractual consequences. Come with clauses for non-compliance with contractual tasks, similar to past due deliveries or subpar high quality.

The procedures for tracking and measuring outsourced processes should be nicely idea out and will have to be carried out when tendering a freelance. Consider, including necessities due to this fact is continuously tricky. Imagine the next:

  • Common efficiency evaluation. Behavior common efficiency critiques with providers to trace their efficiency towards agreed-upon KPIs.
  • Knowledge research. Analyze knowledge on provider efficiency, similar to defect charges, supply instances, and buyer proceedings to spot tendencies and spaces for growth.
  • Comments mechanisms. Determine a machine for gathering and examining comments from interior and exterior consumers relating to provider efficiency.

Whether or not a company prefers to audit or use different way of controlling the outsourced activity, a well-thought-out collaboration and verbal exchange plan will have to be made, taking into consideration:

  • Open verbal exchange channels. Care for open and common verbal exchange channels with providers to deal with issues, percentage knowledge, and collaborate on growth tasks.
  • Joint drawback fixing. Paintings collaboratively with providers to spot and unravel problems associated with high quality, supply, or different efficiency issues.

Power growth is integral to any excellent control machine. As a abstract I’d recommend the next:

  • Common critiques and updates. Often evaluation and replace your provider control processes to verify they continue to be efficient and aligned with converting industry wishes.
  • Provider construction. Enforce methods to assist providers reinforce their high quality control programs and function.

By means of enforcing a mixture of those mechanisms, organizations can successfully regulate outsourced processes, decrease dangers, and make sure that they obtain fine quality services from their providers.

Clause 9.2.1 of ISO 9001 does certainly recommend that auditing outsourced processes is excellent follow. This clause states that organizations will have to habits interior audits to guage the effectiveness of the standard control machine. The scope of interior audits generally comprises all related processes and actions inside the group. How this pertains to outsourced processes is the place the requirement turns into open to interpretation. Despite the fact that it does now not explicitly state “provider audits,” the clause means that comparing the effectiveness of processes which might be outsourced is a part of assessing the total effectiveness of the QMS. If the outsourced processes considerably have an effect on the group’s skill to fulfill buyer necessities, then the ones processes will have to be integrated within the scope of interior audits.

Dr. IJ Arora’s article was published in the Exemplar Global Publication “The Auditor”. Click here to read the featured article.

The Baltimore Bridge Collapse : Another Case of a Failed Management System ISO 55001:2024

By – Dr. IJ Arora

Can good management systems make organizations immune to disasters? The Baltimore bridge or simply the Bay Bridge or more precisely the Francis Scott Key Bridge that collapsed in 2023 because of the allision with the container vessel MV Dali is a tragedy, perhaps caused by the failure of several management systems, the ship, the port, the state and whoever else was involved.   

The National Transportation Safety Board (NTSB) investigation is ongoing, and will no doubt look at the part played by the MV Dali, its crew and operator. However, my thought is the MV Dali or other ships plying the waters by simple statistical probability were considered as a risk by the authorities. I mean there is the water channel, ships sailing in and out, and a bridge, there was likely to be an allision someday. Perhaps not a matter of if but when! Thus should the bridge have been safer and better designed, based on known and appreciated risks? After all, not all accidents can be completely avoided. However, each tragedy has lessons learnt as responsive action. The lessons become the data that drive risk identification and trends and, thus making the system proactive.  I am sure  the NTSB is considering all this. In the meantime, without going into the ongoing investigation, are there some basics which are common indications of failures of the system. Be it the Titan submersible, or the Boeing management system,  as an SME in  process-based process-based management systems I see a common cause; the failure of the system to  deliver conforming products and services. 

In this short article I want to discuss this bridge collapse in the context of the management system, considering ISO 9001:2015 generically and ISO 55001:2024 Asset Management System requirements specifically. Could simply designing a good system based on the standard have enabled the organization to better assess the associated risks? Perhaps they were assessed and justified as a low probability of occurrence. If that were the case, the discussion would be on prioritization of risks. ISO 55001 was first published in 2014. It was developed as a standalone standard for asset management, building upon the principles of ISO 9001 (quality management) and other relevant standards. 

I am aware that as of September 2024, the investigation into the Baltimore bridge collapse is still ongoing.  Therefore, while the exact cause of the collapse remains under investigation, we can consider several factors that could have contributed to the incident. MV Dali, experienced a series of electrical blackouts before the allision.  The vessel SMS (safety management system based on the ISM Code) implementation could be a factor. Bridge stability, its age and condition are I am sure are being investigated as a potential contributing factor. Then there is always human element.  There may have been errors on the part of the ship’s crew or bridge operators. Was the system designed to support them in such a scenario? What factors may have caused operators at all levels to perhaps not follow requirements, to justify the risks. The NTSB’s investigation will highlight a detailed analysis of the ship’s navigation systems, the bridge’s structural integrity, and the actions of the individuals involved in the reasons for this tragedy. Their final report will provide a comprehensive understanding of the incident and may include recommendations to prevent similar occurrences in the future. 

However, even at this stage we can agree that bridges in general are national assets. They are valuable infrastructure that provides essential services to communities. While it is not publicly known whether the State of Maryland specifically implemented ISO 55001 for its bridges, the principles and practices outlined in this standard could have been beneficial in managing the risks associated with the Baltimore bridge. The implementation of this standard and or even if the generic standard ISO 9001 were implemented the authorities could have performed: 

  • Risk Assessments: ISO 55001 requires organizations to conduct regular risk assessments to identify potential threats and vulnerabilities. A thorough assessment of the bridge’s condition, age, and traffic load could have helped identify potential risks and inform maintenance and repair decisions, as also change in procedures, protection of navigation channels and so on. 
  • Life Cycle Management: The standard emphasizes the importance of managing assets throughout their entire lifecycle, from planning and acquisition to maintenance and disposal. By following ISO 55001, the state could have developed a comprehensive plan for the bridge’s maintenance, upgrades, and eventual replacement. 
  • Performance Measurements: ISO 55001 requires organizations to establish measurable Objectives or Key Performance Indicators (KPIs) to measure the effectiveness of their asset management activities. This could have helped the state monitor the bridge’s condition and identify any signs of deterioration. 
  • Continual Improvement: The standard promotes a culture of continual improvement, encouraging organizations to learn from past experiences and make necessary adjustments to their asset management practices. 

I agree, it is impossible to say definitively whether ISO 55001 would have prevented the Baltimore bridge collapse. However, the principles and practices outlined in the standard could have helped to reduce the risk of such incidents. By adopting a systematic and proactive approach to asset management, organizations can improve the reliability and safety of their infrastructure. A systematic study must go beyond what the MV Dali contributed to the Baltimore bridge collapse, it is also important to consider the broader context and the potential contributions of other factors: 

  • Bridge Design and Maintenance: The age and condition of the bridge are likely to be factors in the investigation. Older infrastructure may be more susceptible to damage or failure, especially if it has not been adequately maintained or upgraded. 
  • Vessel Traffic: The frequency and intensity of vessel traffic in the area can also influence the risk of collisions. The bridge is in a busy shipping channel; therefore, the likelihood of incidents was higher. 
  • Safety Measures: The presence or absence of safety measures, such as buoys, warning systems, or restricted areas, can also impact the risk of collisions/allisions. This needs to be studied and are factors the authorities would know. 
  • Human Element and Factors: Errors on the part of both the ship’s crew and bridge operators can contribute to accidents. Factors such as fatigue, inexperience, or inadequate training may play a role. What led to these?  Error proofing, mistake proofing and FMEA (Failure Mode Effect & Analysis) are tools that could be part of the effective management system. 

Let us therefore consider ISO 55001 and the relevant clauses of the standard which could apply to the collapse of the Baltimore Bridge. 

Clause 4: Context of the Organization 

  • Clause 4.1: Understanding the external context, such as the age of the bridge, traffic volume, and environmental factors, is crucial for risk assessment. 
  • Clause 4.2: Identifying the needs and expectations of relevant interested parties, including the public, commuters, and regulatory bodies, is essential for effective asset management. 

Clause 6: Planning 

  • Clause 6.2.1: The bridge’s asset management plan should have included clear objectives for its maintenance, repair, and replacement. 
  • Clause 6.2.2: Specific objectives related to safety, reliability, and cost-effectiveness should have been established. 
  • Clause 6.2.3: Detailed planning for maintenance, inspections, and upgrades would have been necessary to ensure the bridge’s structural integrity. 

Clause 7: Support 

  • Clause 7.1: Adequate resources, including funding, personnel, and expertise, should have been allocated for bridge maintenance and inspection. 
  • Clause 7.2: Ensuring that personnel involved in bridge management have the necessary competence and training is essential. 
  • Clause 7.3: Raising awareness among all relevant stakeholders about the importance of bridge maintenance and safety is crucial. 

Clause 8: Operation and Maintenance 

  • Clause 8.1: Regular inspections and monitoring of the bridge’s condition would have helped identify potential problems early on. 
  • Clause 8.2: A well-defined maintenance schedule, including preventive and corrective maintenance, would have been necessary to address issues before they escalated. 

Clause 9: Performance Evaluation 

  • Clause 9.1: Establishing key performance indicators (KPIs) to measure the bridge’s performance, such as safety records, traffic flow, and maintenance costs, would have provided valuable insights. 
  • Clause 9.2: Regular monitoring and evaluation of these KPIs would have helped identify areas for improvement. 

Clause 10: Improvement 

  • Clause 10.2: The bridge’s management should have implemented a system for monitoring and measurement, including data collection and analysis. 
  • Clause 10.3: Predictive maintenance techniques could have been used to identify potential failures before they occurred. 

My objective of writing this article is to awaken this basic thought in organizations that by applying the principles of a standard, be it generic ISO 9001 or an industry specific standard or as in this case the asset management system standard ISO 55001, the organization (State of Maryland) could have strengthened its asset management practices and potentially mitigated the risks associated with the Baltimore bridge collapse. 

The above article was recently published in the Exemplar Global publication – ‘The Auditor’.

Excellence in Auditing Presented by Dr. IJ Arora for Exemplar Global

“How Auditing Helps Prevent Tragedy,” presented by Dr. IJ Arora with Wendy Edwards (Project Director of Exemplar Global) at the Exemplar Global’s Excellence in Auditing Expo!

Click the link here to understand the critical role auditing plays in averting potential disasters. Whether you’re in risk management, quality assurance, or simply interested in safety and security, this discussion offers valuable perspectives and actionable takeaways.

Link to the Presentation

Can Boeing Ship a Lengthy-Time Period Approach to their 737 MAX Issues?

Dr. IJ Arora

Boeing is within the highlight once more with its 737 MAX planes, that have already had a deeply bothered historical past. Buyer center of attention (which is clause 5.1.2 of ISO 9001 and AS9100) turns out to were misplaced someplace.

I’ve learn a number of contemporary articles on those incidents in addition to Peter Robison’s ebook Flying Blind: The 737 MAX Tragedy and the Fall of Boeing, all of which level to a worsening scenario for Boeing. The general public belief of this nice American corporate, which has all the time been dedicated to top-class engineering and depended on merchandise, is converting from one among admire to one among warning. Vacationers are questioning, “Must I fly in a 737 MAX?”

Boeing and the aerospace {industry} normally have excessive requirements for high quality and product protection. On this article, I postulate whether or not an organization’s high quality control machine can ensure that not anything is going fallacious for patrons. Can it make certain perfection? If no longer, what are the choices—and why have one in any respect?

What took place and who’s accountable?

For the ones no longer acquainted with the 737 MAX incident in January, in a while after an Alaska Airways flight departed from Portland, Oregon, a cabin door panel blew off. As investigations are nonetheless ongoing the reasons have no longer but been totally decided. Boeing additionally had a tool factor at the 737 MAX, ensuing within the crash of a Lion Air flight in 2018 and an Ethiopian Airlines flight in 2019.

Right here in the US, the Federal Aviation Management (FAA) performs a vital function in offering laws to make sure flight protection, and likewise supplies oversight of plane producers, airports, and upkeep suppliers. On the subject of the Alaska Airways flight, it kind of feels that the FAA didn’t uphold its depended on function. The FAA’s a large number of assessments and balances, maximum of that are meant to concentrate on buyer protection, had been like aligning holes in slices of Swiss cheese. It’ll be fascinating to peer what adjustments this incident brings about on the FAA. On the other hand, can regulatory oversight ensure protection of flight?

The AS9100 same old, which is restricted to the aerospace {industry}, isn’t the brainchild of a unmarried entity, however fairly a collaborative effort pushed by means of two key gamers:

  1. The World Aerospace High quality Staff (IAQG). This global group brings in combination representatives from aviation, house, and protection firms around the Americas, Asia/Pacific, and Europe. They actively take part in growing, keeping up, and updating the AS9100 same old.
  2. Standardization organizations. Those our bodies, such because the Society of Automobile Engineers (SAE) within the Americas and the Ecu Affiliation of Aerospace Industries (now the AeroSpace and Defence Industries Affiliation of Europe), formally submit and distribute the usual.

You will need to word that AS9100 builds upon the root of the extra normal ISO 9001 high quality control machine same old. Whilst ISO 9001 lays the fundamental framework, the IAQG provides industry-specific necessities a very powerful for making sure protection and high quality within the aerospace area.

Along with the producer and the FAA, the landlord/lessor of the plane additionally performs a task in making sure the aircraft is correctly maintained. This comprises settling on a reliable upkeep supplier, hiring competent engineers, and having powerful processes in position. With such a lot of other stakeholders, can blame be attributed to only one when injuries occur? Moreover, must blame be the secret? Possibly no longer! You will need to word that the machine is applied to toughen every consumer and that each one stakeholders within the worth chain play their phase as effectively.

Audits, inspections, and control methods: Are those the answer?

In the back of each tragedy, casualty, and mishap is a series of comparable occasions. The instant suspect when these kind of vital screw ups happen are deficient inspection protocols, possibly even the feared “human error.” On the other hand, this can be the low-hanging fruit and a deeper dive would possibly establish different causal elements, akin to asking if the standard audit failed.

What’s the distinction between an audit and an inspection? Can they change every different or are inspections by myself sufficient? The straightforward resolution is not any! Each are wanted because of elementary variations in method. Audits take a look at the processes to make sure the control machine produces conforming services and products. An effective control machine should come with the next, to call a couple of:

  • It should be well-defined, beginning with the “as-is” state of the machine.
  • Dangers should be known (clause 6.1) according to the context of the group (clauses 4.1 and four.2).
  • A transparent definition of the product should be known.
  • Efficient audits and periodic evaluation should be undertaken by means of control.
  • Outsourced processes should be managed.

Inspections play the most important function by means of figuring out defects previous to unlock, thus protective no longer most effective the buyer/buyer/consumer/warfighter, and so forth., but in addition the recognition of the group itself. With that stated, inspections don’t give a contribution to power development as a result of they center of attention on fixes versus long-term answers. In impact, they don’t in reality upload worth for the reason that group has already incurred the price of generating the faulty phase or product. The creators of the Toyota Manufacturing Machine (i.e., lean) got here up with the Andon procedure to catch a defect as early within the procedure as imaginable as a way to repair it sooner than the issue went too a ways down the road.

Control methods aren’t only a choice of paperwork. To serve as correctly, they require dedication in any respect ranges of the group, together with height control offering the wanted assets. It takes time to construct a tradition of high quality wherein shortcuts are have shyed away from and there’s no worry of talking up. Buyer center of attention should no longer be compromised. As an example, unlock of conforming product must cross throughout the procedure particularly referred to as out by means of clause 8.6; any interference by means of height control to truncate this procedure would suggest the lack of buyer center of attention. Is that this an opportunity? Possibly, however the investigation should expose the reality. On this case of the Alaska Air incident each the Boeing consumers and Boeing as an organization have suffered. It’s my hope that investigators will establish all failed portions of the machine from every accountable birthday celebration. Those would possibly come with no longer most effective failed inspections, but in addition suboptimal processes. This may finally end up taking us again to an insufficient high quality control machine.

High quality control methods: Can they ship?

Given the above, can a correctly designed and well-audited control machine (supported by means of excellent inspection tactics to assist make certain conforming product) ensure that not anything is going fallacious with a company’s output? My opinion is that no person can ensure this utterly. On the other hand, possibility can indisputably be very much decreased when the entirety is applied effectively. This comprises the educational of team of workers, which correlates strongly to competence; sadly, that is ceaselessly the primary price range to get minimize when assets are scarce.

When high-visibility incidents like those happen, it can be forgotten that airplanes stay the statistically most secure mode of go back and forth on earth. That is essentially because of powerful high quality control methods, well-adopted regulatory frameworks, and common oversight. People play the most important function within the good fortune of the control machine, from the dedication on the height to the buy-in by means of the body of workers (clause 5 to clauses 7.1.3, 7.1.4, and 10.3). Taken in combination, this is helping create an atmosphere the place high quality can flourish inside the group.

Boeing could also be doing so much accurately, and but the consequences may well be unacceptable relying at the efficiency of outsourced processes (clauses 8.41/8.4.2/8.4.3). In spite of everything, the fuselages for the 737 MAX are made by means of Spirit AeroSystems Holdings Inc. Spirit AeroSystems is positioned in Wichita, Kansas; as soon as those fuselages are manufactured, they’re shipped by means of rail to Boeing’s facility in Renton, Washington. Due to this fact, no longer most effective is a significant part of the 737 MAX outsourced, however the delivery and preservation of product (clause 8.5.4) additionally may just give a contribution to the product’s nonconformity. General, Boeing stays chargeable for all the provide chain (clause 4.3), with their legal responsibility to “make certain conformity of its services and products and the enhancement of shopper delight.”

Even with a cast high quality control machine in position, this or identical screw ups can happen. There’s no technique to guarantee the general public of 100-percent acting (i.e., highest) output. The worry within the minds of air vacationers is legitimate and can stay so till an exhaustive root motive research of this factor is carried out and the ones root reasons are resolved. The present occasions beg the query: Did Boeing make stronger their control machine after the Ethiopian Airways 737 MAX crash? If that they had bent to the oars and long gone deep into their evaluation to discover and completely repair the holes of their control machine, this tournament would possibly by no means have happened. Floor corrections, or what some organizations name “repair -it” answers, most effective take away the indications. The foundation reasons should be addressed and resolved (clause 10.2.1). There aren’t any shortcuts to high quality.

In conclusion

It has taken years for air vacationers to really feel protected and unconcerned about air protection. I go back and forth so much the world over, and ceaselessly select an airline according to their carrier and luxury, however now I (in addition to the wider public, I might consider) want to imagine which plane will delivery us. This can be a new worry about product protection that has its genesis in Boeing no longer working its control machine successfully and shedding buyer center of attention. The worst is the erosion of public self assurance in federal oversight and its intent to stay the client protected.

I’ve spent my lifestyles learning identical complicated issues and main groups in serving to organizations in finding long-term sustainable answers. This calls for daring and dynamic management (clauses 5.3 and 5.1) for leaders to plot and enforce alternate. Appreciating and accepting dangers (i.e., protecting the client in center of attention) and transferring ahead is integral to true management. Ethics continues to be no longer a clause of ISO 9001 and AS9100, however moral management is ready doing the proper factor for all stakeholders.

In seminars at which I provide, I ceaselessly ask senior managers: “When you have a decision between following the process and/or doing the proper factor, what would you do as a pace-setter?” The solution—I’m hoping—is to do the proper factor always. However then, hope isn’t a plan. Air protection can’t be according to hope and religion. Boeing wishes the management to revamp their machine if they’re to carry the general public consider again for this nice American corporate.

Concerning the writer

Dr. IJ Arora, Ph.D., is the President and CEO of QMII. He serves as a workforce chief for consulting, advising, auditing, and coaching relating to control methods. He has carried out many lessons for the US Coast Guard and is a well-liked speaker at a number of universities and boards on control methods. Arora is a Grasp Mariner who holds a Ph.D., a grasp’s level, an MBA, and has a 34-year file of accomplishment within the army, mercantile marine, and civilian {industry}.

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