Perfect Preparation Prevents Poor Performance
Disclaimer : I wrote this back in college so its likely to be a little 'unpolished'
The 4 conditions that spell out disaster!
A friend of mine once said "Around every corner looms a disaster" - Soon after this statement I stopped walking with him incase that turned out to be true. But seriously he said that.
Engineers think of disasters in two ways, something they can prevent, something they can not. Those that they can not often come in the form of earth quakes, comets destorying half the worlds population etc. Then there are things they can prevent.
Studies in the field of disasters and failure surprisingly enough found 4 common factors which in some way or another make up a failure condition. Now these conditions don’t have to exist in isolation or necessarily together, but there presents can spell failure and sometimes the presents of all 3 isn’t enough to cause the failure until the 4th comes along and breaks the camel’s back.
So here are the 4 most linked factors which effect disaster
- Time constraint – often if the clock is ticking and your running behind it can affect your performance, I mean how many of us break the speed limit so we aren’t late for work, or rush to finish a job on time. Time can cause failures because our judgment gets slightly burred to try and meet a deadline.
- Fatigue - Whenever you look at the story behind an air disaster or some kind of failure, someone is often fatigued, this doesn’t always mean ‘tired’ in the sense of the word lack of sleep, but physically or mentally taxed.
- Unfamiliar Circumstances or conditions - ‘ What am I looking at here’ were the words uttered by a control console operator at the Chernobyl reactor number 4 in 1988, about 4 minutes later the reactor exploded, (they obviously didnt say those exact words but probably something like "eta Mojoka Noraki") . When someone is thrown into an unfamiliar circumstance in a normal condition usually logic kicks in and some form of process kicks in, but add the other 3 factors to the equation and sometimes information becomes jaded and facts become blurred.
- Communications breakdown – A big problem is often communication, mis-communicating information or mis-interpreting information often leads to mistakes being made incorrect information being used and a failure or break down in some way.
So now, lets look at 3 cases where the 4 factors of Failure (or 4FF) have lead to the cause of a disaster. (Don't worry I wont keep using that! its a terrible acronym)
Case 1 – Tenerife Airport Disaster
On Sunday the 27th of March, in the small island airport of Las Rodeos two commercial Jumbo Jets collided on the runway as one attempted to take off while another was in its path. In this crash there were a number of fundamental factors which effected it
- Diversion – Both aircraft were due to land at Gran Canaria Int airport, but had to be rerouted to the much smaller Las Rodeos airport, because of a bomb which was planted at Gran Canaria. This introduced a factor of unfamiliarity to the different airport.
- Weather – During the takeoff the visibility was very poor due to the mountainous location – this further taxed the pilots ability leading to Fatigue.
- Flying Time – One of the aircraft involved was approaching its max flying time, meaning if the pilots went over it they would incur heavy fines. Adding a time element to the failure, the pilots of both aircraft had been in the air a long time, as well which further added physical fatigue
- Communication misunderstanding – During the initial taxing a number of miscommunications took place between the control tower and the flights, leading to the pilot believing he had permission to take off when in fact he did not and another aircraft was still taxing past him.
It caused the death of 583 people.
Case 2 – Pipar Alpha disaster
The Piper Alpha disaster was an explosion and oil gas fire on board the oil rid piper alpha on July 6th 1988. It killed 167 people and caused a massive environmental disaster as a result.
The cause of the accident was due to a build-up of gas pressure in one of the pipes, with a disabled safety valve.
Let’s look at the factors
- Maintenance of Gas Value A was scheduled but over ran – Time constraint.
- The shift change over didn’t tell the manager of the night shift of the disabled safety valve – Communication
- He also neglected to mention that the pumps for the automatic fire fighting equipment where turned off because divers were working under the sea floor. (another miscommunication)
- The oil rig had systems designed to handle fires only (they were originally built for oil) and an unfamiliar circumstance of an explosion confused a lot of the instruments in the control room.
- The overrunning work – the day shift has stayed to help the night crew but due to their level of fatigue had made mistakes in fitting a steel rig, this caused the pipe to burst.
- The major miscommunication was the fact that no one knew the safety release valve was missing.
- The firefighting equipment failed to activate due to an explosion destroying the electric pump and the diesel system being turned off ( Unfamiliar circumstance and mis communication)
How to reduce risk
The name of the game is to reduce that margin of error as much as you can. Attacking the 4 factors as they rear there ugly heads is sometimes too little too late Planning is often very effective to reduce risk.
Perfect Planning Prevents Poor Performance (the 5 P’s)
Plan what you’re going to do and how you’re going to do it. Once you have planned how you are going to do it, plan what happens if any of the 4FF’s come along.
Time Constraints – Set Achievable time lines, try and factor in all the elements of any design factor and any problems you may encounter, don’t forget to include Beta and Alpha time, and set a margin if things do go wrong, and you need more time. Setting unrealistic time scales often is the first factor to a failure.
Fatigue - Try and build an environment that can compensate for fatigue. When working on long periods, schedule breaks in , get some fresh air and come back. Don’t pull too many all night’s and when you are done working don’t do more work at home!
Its harder to go back and change mistakes made at 4am on a Sunday!
Unfamiliar circumstances - This is often the hardest thing to combat, as unfamiliarity is part of a creation process for any new product. Sometimes the most effective technique is to familiarise yourself with the unfamiliar. Put the project on hold until you are familiar with the task or subject, if this is not possible; re-evaluate your time scale to make allowance for learning about a specific subject.
Communication - This is by far the hardest to correct. Communication be it by Email, Phone or in person needs to be clear.
ABC – Accurate Brief Clear
Accuracy in the information you convey is clear, don’t be afraid to say “I don’t know but I can find out”, don’t make things up or make unrealistic guesses.
Brief - I can’t stand people who Waffle! When conveying key information, don’t double up efforts unless asked to repeat and don’t try and pad it out with unnecessary information, because usually when someone tries to remember what was conveyed they remember the waffle as well!
Clear – Try and convey information in a clear manner, be it by means of a diagram, a list or even if you are talking, talking slowly and clearly. If information is not clear sometimes people can ‘fill in the gaps’
The acronyms again for you:
The 5 P’s – Perfect Planning Prevents Poor Performance
The 4 F’s – Time Constraints, Fatigue, Unfamiliar circumstances and communication breakdown.
ABC – Accurate Brief Clear.