unnecessary complexity - a prime corporate hazard
TRANSCRIPT
Unnecessary Complexity, a Prime Corporate Hazard
Fernando Moraes RibeiroBMA Consultoria
Petrobras E&P Aviation Advisor
20 September
Tuesday, September 13, 11
Objectives
• NOT to reinvent the wheel
• NOT to rediscover the fire
• NOT to be boring
• Share a straightforward view of existing stuff that just seems to work
• Learn from the audience inputs
• Contribute to make our industry safer
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Tuesday, September 13, 11
Summary
• Introduction
• The problem:
- Sources of unnecessary complexity
• A solution:
- What corporations can do about it
• Why it can work:
- Crunching unnecessary complexity
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Tuesday, September 13, 11
Who prefers complexity?4
Tuesday, September 13, 11
And yet...
“For every complex problem there is an answer that is clear, simple, and wrong”.
H. L. Mencken
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Tuesday, September 13, 11
Complexity setbacks
Sometimes, no matter how good are the intentions, it’s
just too much
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Tuesday, September 13, 11
Complex systems defined
• “A system in which large networks of components with no central control and simple rules of operation give rise to complex collective behavior, sophisticated information processing, and adaptation via learning or evolution”; or
• “a system that exhibits nontrivial emergent and self-organizing behaviors”, e.g. “ants colony”
Melanie Mitchell, in “Complexity, a Guided Tour”, Oxford University Press 2009
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Tuesday, September 13, 11
• Effective management systems should not fit the definition of complex systems
• Even facing a lack of coordination, direction and control, companies tend to keep going like complex systems
• That drive turns what could be “clockwork” into a form of “ants colony” work, reducing predictability and increasing risk, in a unnecessarily complex system
Complex systems defined
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Clockwork or ants work?Your Organization
Effective Management
System?NoYes
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Tuesday, September 13, 11
My watershed event
• Brazilian Naval Aviation, solid safety culture, sustained success in high risk ops, but...
• June/2005: 2 pilots killed in single engine helicopter night VFR mishap over urban area
• More than17,000 potential system improvements treated in the previous 5 years
• What did we miss?
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Lesson learnt
Abundant risk controls do not compensate for their lack of assurance
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The problem:Sources of unnecessary
complexity
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Sources of unnecessary complexity
Lack of systems and process approach
Misconceptions about quality and risk management
Poor recurrence investigation
Outcome-centered improvement
strategies
Lack of systems and process approach
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Agreed definitions
Process
“a set of interrelated or interacting activities, which transforms inputs into outputs”
ISO/TC 176/SC 2/N544R3 October 2008
So much better than “set of interrelated or interacting elements” (ISO 9000:2005, 3.2.1)
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Agreed definitions
Inputs Activities Outputs
Work
So much better than “set of interrelated or interacting elements” (ISO 9000:2005, 3.2.1)
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Agreed definitions
System
“network of interdependent components that work together to try to accomplish the aim of the system”
W. E. Deming in “The New Economics”, MIT CAES,1994
So much better than “set of interrelated or interacting elements” (ISO 9000:2005, 3.2.1)
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System and process
Not a chance to solve the
puzzle!
Step 1:complete side,
considering sides interfaces
Rubik’s cube
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Tuesday, September 13, 11
System and process
Step 2:complete 2nd layer and keep
previous progress
Step 3:flip it upside down and complete final
layer, idem
Step 4:amaze your audience
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System and process• System interdependencies
do exist even if unknown
• Any change in a component affects the system
• Change can be managed so that previous progress is preserved
• Not following the process steps makes the solution very much harder
• Procedures effectiveness is heavily process-based
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Tuesday, September 13, 11
Rubik’s cube lessons
• The cube can assume more than forty-three quintillion different system states, so it is very unlikely that you solve it by managing to revert the original shuffling sequence, but...
• ... a handful of procedures, underpinned by a single defined process, allow the average Joe to benefit from the system interdependencies and solve it in less than one minute, no matter how masterfully has the cube been shuffled
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The systemProcessProcess
ProcessProcess
Interfaces
Interdependent components
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Work W
ork
Work
Work
Work
ProcessWork
Work W
ork
Work
Work
Work
Work
Process
When a process output is needed as an input for
another process
Process interfaces
Tuesday, September 13, 11
But how is the work generated?Like this?
(defined process, quality controls and assurance)
Tuesday, September 13, 11
Or like this? (well, you know...)
Or like this?
Tuesday, September 13, 11
"A rule of thumb is that a lousy process will
consume ten times as many hours as the work
itself requires."Bill Gates, in “Business @ the Speed of Thought: Succeeding in the Digital Economy”
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Lack of systems approach
• Symptoms:
- Implementing some system rather than approaching the work as a system
- Disregard of the dependencies between undesired outcomes and of potential synergies/conflicts between improvements
- Poor traceability of the system objectives within the actual work
- "Big picture" more spoken than actually seen
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Tuesday, September 13, 11
Lack of process approach
• Symptoms:
- Nature of the system’s interdependencies is mostly unknown
- Gaps, overlaps, and conflicts within the procedural baseline
- Lower predictability of the outcomes
- Inadequate framework for improvement and for automation
- “We used to have those diagrams, didn’t we”?
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Entrenching inefficiency
• ‘‘The first principle for any technology you contemplate introducing into a business is that automation applied to an efficient operation will magnify the efficiency”
• “The second is that automation applied to an inefficient operation will just entrench the inefficiency’’
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Quotes attributed to Bill Gates
Tuesday, September 13, 11
A quick recap
• Approaching the work as a process means to determine the inputs required and outputs provided by each activity and to sequence them efficiently and effectively
• Approaching the work as system means to consider the interdependencies (process outputs required as inputs for other processes) to achieve the work objectives
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Tuesday, September 13, 11
Lack of systems and process approach
Misconceptions about quality and risk management
Poor recurrence investigation
Outcome-centered improvement
strategies
Sources of unnecessary complexity
30
Tuesday, September 13, 11
Agreed definitions
Quality
“degree to which a set of inherent characteristics fulfills requirements”
ISO 9000:2005, 3. 1.1
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Agreed definitions
Risk
“effect of uncertainty on objectives”
ISO 31000:2009, 2.1
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Agreed definitions
Management
“coordinated activities to direct and control an organization”
ISO 9000:2005, 3. 2.6
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Tuesday, September 13, 11
Work
Work
Work
Work
Work W
ork
Work
Objectives?Ha ha, what a
joke!
Daily firefighting
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Hard working people doing their best under the lack of coordination, direction and control
Objectives
Tuesday, September 13, 11
Work
Work
Work
Work
Work Work
Work
Objectives
“Coordinated activities do direct and control an organization”
Management
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Tuesday, September 13, 11
Work
Work
Objectives
Management system
36
Work
Work
Work
Work
WorkWork
Work
A network of interdependent and coordinated activities to direct and control an organization to accomplish its objectives
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WorkWork Objectives
Unc
erta
inty
Req
uire
men
ts
Ass
uran
ce
Protection against variance
All kinds of requirements go here(and compete for resources)
Protection against the effects of uncertainty
Degree to which a set of inherent characteristics fulfills risk management requirements = SAFETY
Risk and quality management approached as a system
37
A valid argument providing confidence
RM QM
Tuesday, September 13, 11
A challenge:
Could “safety” be defined independently of any need to
fulfill requirements (i.e. quality)?
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Let’s try...
Safety:
“A vague assumption that supposedly takes place between accidents” ???
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Tuesday, September 13, 11
Safety: “There will always be holes in the cheese, so we need more slices for our protection”
Quality: “The holes in those cheese slices are nonconformities. Just eliminate their root-cause and we will be OK”
Reason’s
Swiss
Cheese
Model
Typical safety and quality mindsets
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Tuesday, September 13, 11
Lower quality, increased risk
Level of risk
ALARP
Risk controls
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Tuesday, September 13, 11
Lower quality, increased risk
Level of risk
ALARP
Risk controls
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Tuesday, September 13, 11
Lower quality, increased risk
Level of risk
ALARP
Risk controls
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Tuesday, September 13, 11
Lower quality, increased risk
Level of risk
ALARP
Risk controls
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Tuesday, September 13, 11
Both more (or better) cheese slices and less holes can improve the
protection of the system’s objectives
Tuesday, September 13, 11
But how to determine the quality and risk
management failures related to an intolerable
outcome?
Tuesday, September 13, 11
“God, grant me the serenity to accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference”
by Reinhold Niebuhr
The Serenity Prayer
Scope of risk management Scope of quality management
Our next slide47
Tuesday, September 13, 11
What went wrong?Intolerable Outcome
Could it be prevented?
Failed Quality ManagementFailed Risk Management
“Hell, yes”Risk control requirements not
fulfilled under predictable conditions
“No, we never saw it coming”Effect of uncertainty on inadequate or absent
requirements
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Includes tolerability assessment failures
Tuesday, September 13, 11
What went wrong?
49
Replay
Tuesday, September 13, 11
Misconceptions on quality and risk management
Mindset
QualityUncertainty is not considered as a
cause
SafetyUncertainty is assumed as the primary cause
Symptom (In)Effect Why
QM solutions for RM
problems Recurrent ineffectiveness
, leading to “more from the same” solutions
There will always be
uncertainty
RM solutions for QM
problems
Recurrent ineffectiveness
, leading to “more from the same” solutions
Lack of assurance
stays untouched
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Tuesday, September 13, 11
Lack of systems and process approach
Misconceptions about quality and risk management
Poor recurrence investigation
Outcome-centered improvement
strategies
Sources of unnecessary complexity
51
Tuesday, September 13, 11
Poor recurrence investigation
• Recurrence: a golden opportunity to make process or system level improvements...
• ...usually wasted by an absent or superficial investigation of why previous improvements were not sustainably successful
• A Safety Case can be extremely helpful in this regard
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Why did it go wrong again?
Intolerable Outcome Effective investigation?
Recurrent intolerable outcome
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Well conceived solutions?
Well implemented
solutions?
Recurrent intolerable outcome
Recurrent intolerable outcome
Yes
Yes
No
No
NoPlease go and take your bad luck
elsewhere!
Yes
Tuesday, September 13, 11
Poor recurrence investigation
• Symptoms
- Absent or lifeless Safety Case
- Memory-based recurrence threshold
- The adequacy of previous improvements is not validated
- Outcome-based rather than process-based classification systems
- Sisyphus mindset
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Tuesday, September 13, 11
Outcome-based classification systems
“Needles and haystacks and such” by Jessica Haggy in www.thisisindexed.com
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Tuesday, September 13, 11
Lack of systems and process approach
Misconceptions about quality and risk management
Poor recurrence investigation
Outcome-centered improvement
strategies
Sources of unnecessary complexity
56
Tuesday, September 13, 11
Outcome-centered improvement strategies
• Symptoms
- Recurrent, uncoordinated and redundant efforts, which tend to fade away over time
- Ever-growing list of pending actions
- Prescription creep
- Resources exhaustion: “If it ain't broke, don't fix it”
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Tuesday, September 13, 11
Example of an outcome-centered strategy
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Tuesday, September 13, 11
Lack of systems and process approach
Misconceptions on quality and risk management
Poor recurrence investigation
Outcome-centered improvement
strategies
Sources of unnecessary complexity
59
Tuesday, September 13, 11
A solution:What corporations can
do about it
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Tuesday, September 13, 11
What does the first ranked result on Google image search for “complex”, “process” and
“flowchart” look like?
Tuesday, September 13, 11
Business Process Improvement (BPI) Objectives
• Effectiveness: Does the process produce the desired results and meet the customer’s/client’s needs?
• Efficiency: Does the process minimize the use of resources and eliminate bureaucracy?
• Adaptability: Is the process flexible in the face of changing needs?
Susan Page, in “The Power of Business Process Improvement”, AMACOM , 2010
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Tuesday, September 13, 11
The Ten Simple Steps to BPI
Susan Page, in “The Power of Business Process Improvement”, AMACOM , 2010
1 - Develop the Process Inventory 6 - Apply Improvement Techniques
2 - Establish the Foundation 7 - Create Internal Controls, Tools, and Metrics
3 - Draw the Process Map 8 - Test and Rework
4 - Estimate Time and Cost 9 - Implement the Change
5 - Verify the Process Map 10 - Drive Continuous Improvement
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Good points, but how truly
new is all this process stuff?
Tuesday, September 13, 11
ISO 9000-1:1994
• Organizations are made up of processes
• Organizations must identify, organize, and manage this network of processes
• The link or interface between each process must be clearly defined and well managed
• 20 prescriptive Quality system elements
Praxiom Research Group, http://www.praxiom.com/iso-9000-1.htm
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Tuesday, September 13, 11
ISO 9000:2000
Figure 1 — Model of a process-based quality management system66
Tuesday, September 13, 11
Tough questions
• How much change did the ISO 9000:2000 process-based management system model brought into the actual work of certified Organizations?
• How many times has your continuous improvement effort focused not on the blocks, but on the arrows of the process-based QMS model?
• Can you “see” those interfaces in the real world?
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68
But, hang on, flight safety
pro’s have been studying interfaces way before that!
Tuesday, September 13, 11
CAP 719 - Fundamental Human Factors Concepts, 2002
Without these interfaces...
... no work is actually done
Edwards, 1972 + Hawkins, 1975
S = Software (procedures, symbology, etc.)H = Hardware (machine)E = EnvironmentL = Liveware (human)
In this model the match or mismatch of the blocks (interface) is just as important ad the characteristics of the blocks themselves. A mismatch can be a source of human error
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Tuesday, September 13, 11
The corporate responsibility
* That includes health, safety, security, environmental
How to create the conditions to drive contracted aviation Operators towards an
effective process-based management system, suitable to support the accomplishment of the system’s objectives* whilst fulfilling the
applicable requirements?
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Tuesday, September 13, 11
Current Petrobras contract requirements• The Aviation Operator shall have a fully
operationalized process-based management system
• SGSA (portuguese acronym for Aviation SMS) process framework, entirely based on Steve Walter’s Integrated Management System (IMS)
• Yearly process and contract 2nd party audits
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SGSA process frameworkSGSA process frameworkSGSA process framework1. Management Commitment and Leadership 12. Assurance of Competence 23. Execution of Daily Operations
2. Culture 13. Communication 24. Process Metrics
3. Customer Focus 14. Service and Product Acquisition
25. Audit
4. Policy 15. Hazard and Effects Management
26. Investigation
5. Objectives 16. Safety Case 27. Evaluation
6. Organizational Structure 17. Procedures28. Quality Assurance in Flight Operations and Maintenance
7. Roles and Responsibilities 18. Planning and Plans 29. Action Plans
8. Process Definition 19. Change Management 30. Records and Data
9. Documentation of the Management System 20. Asset Integrity 31. Management Review
10. Resources 21. Work Environment 32. Continuous Improvement
11. Standards22. Contingencies and Emergency Response 33. Human Factors
Tuesday, September 13, 11
Current Petrobras contract requirements
• For each of the 33 SGSA processes there is a single paragraph description, for which the Aviation Operator shall demonstrate:
- Documented inputs, activities and outputs
- Effective process operationalization
- Dedicated metrics and performance criteria
- Regular review and continuous improvement
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Tuesday, September 13, 11
Not bad!74
A process-based management system for an air transport service provider,
specified by the Client through just 33 non-prescriptive single paragraph process descriptions and 4 single-lined questions?
Tuesday, September 13, 11
Auditor AuditeeLet’s have a look at your Process 4 - Policy Here is our Quality policy.
OK. Now, perhaps you could show me the process whereby such a neat product was generated.
I don’t know such process, but is it there a problem with our policy?
Not a problem at all, but I must determine if your Company has the ability to sustainably reproduce such “absence of problems” in any other policies.
If this one is good, why wouldn't the others?
Well, according to your reasoning, if there was no accident last year, there will be none ever. Should we worry about this? (resignated yet revengeful silence)
Anyway, although there is no defined process, your policy is good work and can evidence some operationalization. (stressed smile, sighs of relief)
Now, although there is no defined process, could you evidence a metric applied to your policy product? But who in the world does it anyway?
Mostly, Organizations committed to know if their policy generation skills are improving or degrading, and Operators aspiring to work for our Client.
(I hate you. Die at once)
Now, what can you show me about review and improvement? Management Review default agenda includes policy as a topic
Good stuff! When was the last time a meaningful improvement has emerged from such strategic activity? I have no record of this...
Hmmm,,, I see. Now, heads up for process 5 -Objectives... (Drunken Auditee tries to hang himself at the nearest tree)
Typical SGSA first time audit
Tuesday, September 13, 11
76
Ok, I’ve got it. But how
can you recognize a process-based
management system in the real world?
Tuesday, September 13, 11
Process-based management system traits
• Processes and their interfaces are the primary focus of the investigation of any undesired outcome or variation
• Processes are the primary focus of the improvement effort
• Processes and practices monitoring is paramount
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Process-based management system traits
• Higher level documents (e.g. Management System Manual) containing the process’ definitions tend to be the most frequently updated
• Operational documentation (procedures, work cards, checklists) cascade from validated process improvements
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A neat addition to...
Prof. James Reason “Errore Umano” presentation, 20 March 2007
Process-based MS investigation
Tuesday, September 13, 11
Why it can work:Crunching unnecessary
complexity A sample of SGSA processes descriptions
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8 - Process definition
• The process whereby the full scope of work is approached as a set of interrelated or interdependent activities which transforms inputs into outputs, which are then documented and integrated to form a system, in support to the achievement of the organizational objectives.
Lack of systems and process approach
Misconceptions about quality and risk management
Poor recurrence investigation
Outcome-centered improvement strategies
✓ ✓ ✓ Tuesday, September 13, 11
26 - Investigation
• Process to determine the root causes or failures in the prevention, control or mitigation of any undesired outcome, variation or condition with the the potential to adversely affect the achievement of the organizational objectives.
✓ ✓ Lack of systems and process
approachMisconceptions about quality
and risk managementPoor recurrence
investigationOutcome-centered
improvement strategiesTuesday, September 13, 11
27 - Evaluation
• Process whereby the mass of data generated against process metrics and performance criteria is systematically assessed, consolidating trends and variation as strategic information to support informed management decisions
✓ ✓ Lack of systems and process
approachMisconceptions about quality
and risk managementPoor recurrence
investigationOutcome-centered
improvement strategiesTuesday, September 13, 11
29 - Action Plans
• Process whereby the Organization continually determines, sequences and documents the leanest set of viable actions that will maximize overall improvement, based on a informed system's approach to the bulk of recorded undesired outcomes or trends.
✓ ✓ Lack of systems and process
approachMisconceptions about quality
and risk managementPoor recurrence
investigationOutcome-centered
improvement strategiesTuesday, September 13, 11
SGSA process modularity
• Even a process-based management system may have similar activities named differently within different processes.
• Each SGSA process has been tailored for its uniqueness within the framework
• This means that an entire SGSA process can be an activity within another process
• Let’s see a quick sample of this...
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19 - Change management (sample)19 - Change management (sample)
Inputs
• Incoming change from:- Action plans (output of process 29)- Regulation, Client and internal requirements- Business Plan- Other sources
Activities
• Assess the change: mandatory/proposed, criticality, complexity, time frame, adaptation time, individuals/departments affected
• Assess system resilience to the effects of change• Determine the need of a change management plan• Assess the risk of change implementation (interface with process 15 - Hazards and
Effects Management)• Determine the resources and competences required to control the assessed risk
(interfaces with Process 10 - Resources and Process 12 - Assurance of Competence)• Determine the required authority level to approve the change (interface with process
7 - Roles and Responsibilities) • Approve/discard change (interface with Process 1 - Management Commitment)
Outputs
• Change is approved or discarded• Change management plan is mandated/dismissed• Planning information (input for process 18 - Planning and Plans): time frame, risk
controls, resources and competence required to effectively manage proposed change• Review information (input for process 31 - Management Review)
Tuesday, September 13, 11
Advice on the transition to a process-based MS
• Define and document, for each process, inputs, activities and outputs based on the elements of the work as performed that match the given process description
• Investigate undesired outcomes starting from your documented process definitions. Challenge their effectiveness
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Tuesday, September 13, 11
Advice on the transition to a process-based MS
• Adopt the number of correlations with undesired outcomes as the default metric for process performance
• Improve processes definitions and/or related work, after assessing the framework for potential conflicts or synergies
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Advice on the transition to a process-based MS
• Once your process definitions are able to withstand the reality check against the process related work, as actually performed, and the 33 given process descriptions, it is time for the next big move: matching your procedural baseline with your process definitions
• Final move: detailing individual activities at task level, based on your process-enhanced procedural baseline
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90
Integration through shared processes
• SGSA framework modularity and non-prescriptive nature allows processes to be shared across systems required by specific standards, including ISO QMS, ICAO SMS, IOSA, occupational health, environment, security
• Process sharing, rather than documental integration, makes life easier in document-centered audits, while preserving system cross-functional effectiveness
Tuesday, September 13, 11
91
Integration through shared processes
• Integrate the management of requirements from different standards through shared processes, instead of through integrated docs
• Develop standard-based compliance docs, cross-referencing the processes shared, to make your life easier in audits. This would be your “Quality Case”
Tuesday, September 13, 11
Final thoughts
• Don’t take systems approach and process approach for granted - extremely low acceptable means of compliance on those two principles haunt QMS certification in our industry
• Removing useless stuff from your system can be more effective than adding “more from the same” stuff - relief all the “bench sentinels” from duty
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Tuesday, September 13, 11
Final thoughts
• Unnecessary complexity does not happen at once, but incrementally over time
• Unfortunately in aviation, a few good people performing a really fine work may sometimes not to be a sustainable exercise
• Such sustainability can be more easily assured in aviation through effective process-based management systems
• That is a Petrobras requirement for their contracted aviation Operators
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Tuesday, September 13, 11
Unnecessary complexity
The equation above provides the following strategic information:
Equations provided by Prof. Gustavo Maia (In memoriam)
94
1 + 1 = 2
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Tuesday, September 13, 11
Unnecessary complexity
1 + 1 = 2
What your management system should be able to deal with:
What most of your workforce should need to know:
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Tuesday, September 13, 11
Questions?
Tuesday, September 13, 11
Contact
• + 55 21 91938861
• Skype ID: fermrib
• Blog: www.process-based.com
Tuesday, September 13, 11