I am confident that many who read this post do share a similar view in terms of, “How can this type of error or failure occur?”
Last night, while millions of people worldwide watched on, the Oscars™ came to a awkward end when Warren Beatty and Faye Dunaway announced the winner of the award for Best Picture… and awarded the prized golden statues to… the wrong team! Oops… Apologies to both “La La Land” and “Moonlight”, the latter being the actual winner. To see the video and PWC apology, go to;
A few days ago, I boarded an Air Canada flight in Ottawa at 5:40 AM, scheduled to arrive in Toronto at 7:00 AM where I would connect with ground transportation with ample time to get to the class I would be teaching that day at 8:30 AM. Plane fully loaded with passengers and minutes before pulling away from the gate, the Captain announces a “slight problem” – the fuel handlers had fueled the wrong tank on the plane and as a result, the weight and balance was compromised.
With the assistance of maintenance, initial attempts were made, I assume, to transfer fuel internally and rectify the weight and balance issue.
Approximately 40 minutes into the procedure, as passengers anxiously waited for the announcement that the flight could depart, we were advised that additional fuel would be added to the other tank(s) to resolve the issue, and thankfully, the plane departed, one hour behind schedule. Many passengers with connecting flights, of course, missed those connections and I arrived 30 minutes late to teach my class.
In both of these cases, our “quality manager” logic kicks in. Both failures were associated with processes. Both were dependent on “good” people doing the “right” thing at the "right" time.
Effective Process Management incorporates six key elements;
Current and validated process (flow) map
Standardized Work (Standard Operating Procedures, check lists, etc.
Failure Mode and Effects Analysis (PFMEA)
Control Plan and Process Control Charts
Required “Gemba” Walks by Managers
Click here for more information on Effective Process Management and why all Managers need these tools and methods.
Hindsight is usually 20/20. In both cases, we can retroactively investigate how each failure occurred and, hopefully, take action so future incidences can be avoided. But, if Failure Mode and Effects Analysis (PFMEA) had been proactively employed in the process design or ongoing evaluations as part of effective process management, could these mistakes have been avoided?
Constructing an FMEA – Summary
1. Map the process (the more detail, the better) 2. Go to each process step an ask the following questions; • What can go wrong at this step of the process? • How bad (severity of effect) is each failure in terms of outcome? • What might be the potential causes for each failure? • How often might each failure (or cause of failure) occur? • What controls (detection and reaction plan) are in place to deal with each failure?
Note: FMEAs also include rankings/scales for severity, occurrence and detection (SOD) that, when multiplied together, provide a resulting “Risk Priority Number” (RPN) that can be used to compare or provide relative rankings for each failure mode.
After completing an FMEA, take appropriate action (ex. employ error-proofing techniques) to address failure modes with a goal of eliminating the risk entirely or reducing risk to an “acceptable” level.
We can be sure that both Air Canada and the Oscars™ (and PriceWaterhouseCoopers) have learned something from their respective failures and actions will be taken to address same for the future.
In the case of Air Canada, one might assume that some form of process management and risk management was already in place for the refueling. If an FMEA existed for that process, then the specific failure we experienced was likely already identified and the ultimate source of the ensuing error was simply the “human condition”,… a process reliant on the “right” person doing the “right” thing 100% of the time – something we know human beings are not capable of. We make mistakes. A check list wasn’t followed. The “wrong switch” was pressed. No doubt, Air Canada already has investigated this incident and action has already been taken.
With regards to the Oscars™, I will take the large leap of faith to assume that FMEA was not a tool employed in the design of their processes, even though a lot of thought, by extremely competent and knowledgeable people went into the design.
PriceWaterhouseCoopers knows, teaches and practices Lean Six Sigma: https://goo.gl/OTzg1R
Perhaps they can share with us what went wrong from their perspective. Did they apply the same tools they strive to teach? Was FMEA employed in their process design for the Oscars™?
In hindsight, the Oscars™ are entertainment, and when things like this go wrong, perhaps it is not all bad. Certainly some excitement and buzz was created but no one, in the end, was harmed.
As quality specialists, life offers us lessons and examples every day to learn from as well as leverage for teaching purposes. With that in mind, we can thank both the Oscars™ and Air Canada for a safe and poignant reminder of why the tools of basic Effective Process Management are so important in the pursuit of process excellence.