JUST PLANE CULTURE
but the point is that production (the push back) was stopped because of an improper process. That reaction, which is typical, sends an inadvertent message. If you are in the same situation, you have a choice: stick a screwdriver or anything in to replace the by-pass pin and avoid the scolding and have an on-time departure, or stop the process and correct the problem. It’s easier to use the screwdriver and then fi nd a pin later (or maybe steal it from another tow bar, which is probably how this all got started). These issues are small but occur numerous times in the
work day, but we say our quality and safety numbers are good. That might be true, but it is because the issues are being buried and only present themselves when they turn into a problem when they can’t be hidden. The majority of problems go out the door, out the hangar, and off the gate and they reoccur daily. We have seen risk matrices and they typically measure
severity and probability. An example is the fi ve-by-fi ve matrix on the opposite page. In the aforementioned tow bar by-pass pin incident , you could say the risk of severity is Negligible but what about the Probability? We don’t know that until we do some investigating. If we don’t have a solid quality/safety culture, we will probably not be able to uncover the real answer as it has become buried. We deal with an insidious probability but this was a consequence to the culture at hand. It wasn’t intentionally designed to be this way — it just grew that way. If we see someone raise their hand and it gets chopped off , what would motivate us to raise ours? As that culture grows, this scenario develops a life of its own and becomes ingrained so those far removed from the original action are still motivated not to speak up. Add to that the factor that we don’t know what we don’t know and we wind up with detectability, another facet with which to contend. Now we deal with a 3-D graphic with lots of unknowns. With a solid organizational culture
built on mutual trust, the third dimension will remain low. Issues aren’t buried because there is the freedom from retaliation to speak up. Accidents are painful but the accident should be looked at as an opportunity for improvement. Something slipped through the Swiss cheese, so let’s fi x it. Potential surprises are also brought to the forefront instead of ignored and probability issues decrease. The next guy isn’t going to catch it as we might be the next guy. Management
can’t build this — they can only supply the material and support. Organizational culture is peer driven and it is truly wonderment when you see it change from “us and them” to “us and we.” If you are involved with this, you will fi nd it painfully slow, but the rewards are worth it! You can dynamite a mountain face quickly but water can do the same thing over time — plus, the mountain sculpted by water is more elegant, less prone to quick erosion and uncovers a solid base. Be patient. The soft stuff takes time.
Patrick Kinane joined the Air Force after high school and has worked in aviation since 1964. Kinane is a certifi ed A&P with IA and holds an FAA license and commercial pilot certifi cate with instrument rating. He earned a bachelor of science degree in aviation maintenance management, MBA in quantitative methods, master of science
degree in education and Ph.D. in organizational psychology. He has been involved with 121 carriers and held positions from aircraft mechanic to director of maintenance. Kinane currently works as senior quality systems auditor for AAR Corp. and adjunct professor for DeVry University instructing in organizational behavior, total quality management (TQM) and critical thinking. PlaneQA is his consulting company that specializes in quality and safety system audits and training. Speaking engagements are available with subjects in critical thinking, quality systems and organizational behavior. For more information, visit
www.PlaneQA.com.
CON C ORDEBA TT ER Y. C O M FLEET OPERATORS
Trans Maldivian Airways operates their DHC-6 Twin Otter fleet with Concorde Batteries. Concorde’s STC No. SA03971AT is FAA, Canada and EASA approved to convert from Ni-Cd to Concorde’s higher capacity main ship battery and/or the emergency battery replacement (if required).
Depend On Concorde
Main Battery RG-380E/60L, 48 Ah RG-380E/44, 42 Ah
Emergency Battery
RG-300, 3.3 Ah CONCORDE BATTERY CORPORATION 626-813-1234 | ISO 9001 + AS9100 | Crafted for Quality in the U.S.A.
11.12 2013
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Photo by Darren Caple
DOMmagazine.com
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