Thursday, April 26, 2007

Seven Reasons Why Organisational Change Fails

From Tony Kenneson-Adams' website

Seven reasons why 70% of all change and transformation programs, acquisitions and downsizing efforts fail to meet the expectations of the managers that implement them?

1. Change is driven by a symptom not a cause.
Knee-jerk reactions to symptoms without analysis of the true problem. Classic example is is making staff redundant to reduce costs without analysis of costs. If the high costs is because of poor utilisation of machinery, rearranging shift patterns could improve utilisation and increase profits.

2. Businesses don't know where they are before committing to change.
This is like using a map to get from Derby to Bristol when in fact you are sat in Cardiff.

3. Organisations do not plan for success.
The journey from old to new must be clearly planned, milestones achieved and objectives set.

4. Business do not know when they have arrived.
Without a plan and objectives how do you know you have arrived at your new organization, structure target or what ever. Also, unless you measure success, how will you know if the change has improved anything. There is also no better way to disenfranchise your workforce than introducing multiple change and them seeing no real effect.

5. Approaches to change do consider the impact on the business
Change sends ripples across a the whole business and so must be looked at in the context of the whole business.

6. Staff enablers are victims of change.
Far too often the management have decided on the why, when, who, and when, of the change before they think of discussing the change with their staff. However, staff have a vested interest in change and will invest themselves in change if they are brought into the change process early enough. Not only can they suggest how best change can be brought about, as they truly know the 'nuts and bolts of the job, but working with the staff will reduce conflict, change intolerance and resistance.

7. Lack of Management Buy-in.
Management at all levels need to 'buy-in' to the change, and not just those that will be directly affected. By actively seeking buy-in you are adding a multiplication factor for your success, and a line of communication that you may need to access at some point in the change procedure.

Evidence that you are not managing change well include
* Losing valuable managers to other companies for the same or a lesser salary
* Staff suffering from stress related illness
* Managers putting in such long hours for a diminishing return
* Spending large amounts of money changing process and structure without improving the bottom line to the planned extent

Andy Brazier

Wednesday, April 25, 2007

Surviving a plane crash

Not quite sure why, but the Metro free newspaper published an article on 23 April 2007 by Ed West called "Landing on your feet." I was interested because it shows that training and behaviour can make a difference in many different types of circumstance.

Key points from the article are:

* Knowing the brace position means you are less likely to be injured in the impact and hence more likely to be in a fit state to get out
* Frequent fliers have heard the safety announcements and read the safety card more times; and consequently know what to do in a crash (including simple things like how to undo the seatbelt)
* Count the number of rows from where you are sitting to the emergency exit
* Wear full length cotton clothes and good footwear to give you a good chance of getting out, and it gives some fire protection
* You need to get out within 2 minutes if there is a fire
* Once out, stay at least 150 metres from the the plane

The article finishes by saying Aer Lingus has not lost a passenger since 1970, whilst Ryanair, Monarch, Easyjet and Air Kazakhstan have a 'perfect safety record.'

Andy Brazier

Demolition hammers

Article by Becky Schultz on 24 April 2007

It is about demolition hammers, and in particular changes that have been made to their design to reduce vibration for the users. These are a bit like a big electric drill where the bit goes in and out rather than around. The article makes some interesting points about perception, but also points out that the extra cost of avoiding vibration to the user is increased productivity.

One of the biggest marketing challenges for demolition hammer suppliers has been getting users to understand that less vibration doesn't mean less power. "There has always been this correlation, historically, that the more productive I am, the more the tool is going to vibrate," says Bernstein. Consequently, when low-vibration hammers were first introduced in the U.S., they encountered resistance. "[Users] would complain that the tool doesn't hit as hard as everyone else's only because they didn't feel that vibration back to their bodies, and they have this perception that vibration equals power," says Gallert [of Wacker Corp].

This perception is changing. "It's just within the last year or two that we're starting to get people to realize the benefits," says Gallert. "After they use the [hammer] all day, they see that the tool is working, they're getting the job done and at the end of the day, they feel much better."

Another obstacle has been cost. Vibration-dampening technology does, in some cases, increase the price of the tool. "But it's important to weigh the costs with the benefits you're getting down the road," says Cook. "On the one hand, productivity is immediately increased. And there is certainly a benefit down the road with the workers. Workers' comp incidents or claims shouldn't be as prevalent."

Ironically, when it comes to low-vibration hammer designs, productivity may prove to be the determining factor, not operator comfort.

"A lot of times the guys that are buying the tool aren't the ones using it," Bernstein points out. "What we found is these guys are really paying for productivity all day long. If the tool is more comfortable [to use] because we've taken the vibration out, then the user doesn't have to take as many breaks during the day. So a pretty interesting added benefit of the lower vibration is the added productivity that results. "That," he says, "is something the guy who's buying the tool is willing to pay for."

Andy Brazier

Edward De Bono

Quote from De Bono in an article in the Guardian on 24 April 2007

"Studies have shown that 90% of error in thinking is due to error in perception. If you can change your perception, you can change your emotion and this can lead to new ideas. Logic will never change emotion or perception."

I understand this to mean that people who can think creatively are more likely to make the right decisions and selections. Technical knowledge and written procedures are relatively unhelpful where problem solving is required. This does have an application to industrial safety. It is fairly well known that people often suffer from tunnel vision in high demand situations, often assuming the situation they have been presented with is the same as ones they have seen in the past, and so trying the same solution.

So it seems creative thinking needs to be part of the training for plant operators, maintenance technicians, supervisors and plant managers. Interesting idea!

Andy Brazier

Human error in maintenance

Below are excerts from article entitled "human error is preventable" by Daryl Mather. Published at the website in April 2007

Human error used to be an area that was only associated with high-risk industries like aviation, rail, petrochemical and the nuclear industry. The high consequences of failure in these industries meant that there was a real obligation on companies to try to reduce the likelihood of all failure causes, not just those related to “normal” or engineering failures. However, there is a lot to be gained, for relatively little outlay, by including a focus on human error within all maintenance operations.

Human error continues to be a common cause of asset failure, both in terms of how an asset is maintained, as well as how it is operated. We see this all the time in areas such as poor calibration, poor alignment, incorrect settings, and even poor quality workmanship.

If you look at the conditions involved in asset maintenance, there are a multitude of reasons why human error would occur which include frequent removal and replacement of large numbers of varied components, often carried out in cramped and poorly lit spaces with less-than-adequate tools, and usually under severe time pressure.

Equipment alignment is a prime example. Fixing a motor to a new plinth and then aligning it to whatever it is driving is a pretty standard task. Yet there are a large number of ways we can make mistakes. Poorly marking the footing mounts, poor drilling (too shallow, not in line) and poor alignment practices are all valid examples.

Also, after a few months new concrete plinths have a tendency to “settle,” often forcing misalignment through shifting of the motor. Failure to take this into account and to perform the necessary checks to correct it if it occurs, is also a human error related issue.

You’ll be surprised to learn that the work procedure helps to increase the likelihood of error, not reduce it. For example:

* Very wordy sentences and instructions will often be ignored. This is human nature. Make sure that the instructions are broken into logical parts, and that they are written in short concise sentences in layman’s terms.
* Studies have shown that when there is a long list of instructions, those in the middle will often be omitted. Make a quality assurance check at the end and ask the technician to double check whether they did certain frequently omitted tasks.
* Too many instructions will be ignored, as will too few. Procedures need to be aimed at presenting an accurate level of detail and instruction as is required.
* A lot of work instructions are focused on the present, but often there is a need for a re-check of alignment several months afterwards. Employ this in the work procedure; make it a task for the maintenance scheduler or to program a separate task once this task has been done.
* More than all of the above, procedures must not tell technicians how to perform basic skills, or they will be ignored. (E.g. don’t go into detail about how to torque a bolt or remove a screw.)

Procedures is one of the many areas where slight adjustments in current practice could have a big impact in reducing lost time and money due to human error. There are many others.

Thursday, April 19, 2007

Prescribing Errors

From Medical News Today on 7 April 2007

The GMC (General Medical Council) has announced funding for a £100,000 research project that aims to investigate the prevalence and causes of errors in doctors' prescribing.

Professor Peter Rubin, chair of the GMC's Education Committee said: "Safe prescribing is crucial to patient safety. Claims that there is a link between education, training and poor prescribing are, so far, anecdotal rather than based on robust evidence. The GMC takes a strong interest in these claims, and is committed to finding out more. We are confident that this research will help shed light on the extent to which this problem exists and identify its causes."

All very good, but £100k to examine what everyone knows, and no suggestion of developing solutions seems bizarre to me. This need to have all the supposed facts before doing anything is, in my opinion, why everything takes so long in the NHS. The trouble is during the time this study takes place, many more people will be harmed by the errors.

Andy Brazier

Research Centre for NHS Patient Safety and Service Quality

Article at Medical news today on 9 April 2007

Announced on 6 April 2007 the centre will bring together academic and clinical researchers. The £4.5m Research Centre for NHS Patient Safety and Service Quality will be one of two such Centres in the UK, funded by the National Institute for Health Research. It will be based in Imperial College's Biosurgery and Surgical Technology section, at St Mary's Hospital, London.

The Centre will trial new approaches and technologies to reduce human error and improve patient care, for example through the use of pharmacy robots to dispense medication, and the involvement of patients themselves in spotting and anticipating medical errors.

This is a lot of money, and of course has to be potentially a good thing. However, I note it brings academics and clinicians together, with no mention of practical human factors expertise, including that from other industries. The idea of using robots and patients, when little basic human factors work has been done in NHS leads me to be sceptical. Time will tell, and from what I have seen so far of the NHS results will be way off in the future.

Andy Brazier

Ergonomics at Britax

Article at 11 April 2007

Australian supplier of children’s car safety products Britax has installed a new lean assembly system as part of an ongoing improvement plan looking at ways to improve operator ergonomics, production efficiency and working environment.

Britax says it has dramatically improved the working environment, ergonomics, operator efficiency and material flow and has achieved the company’s goals with improvements in both production efficiency and materials handling.

Forklift traffic has been reduced and significant space saving has been achieved throughout the processing areas setting a foundation for a culture of ongoing continuous improvement.

Andy Brazier

Offshore safety

An interesting article on BBC website on 13 April following the capsize of the Norweigian rig support ship in the North Sea

Recent accident statistics from HSE (excluding helicopter)
2006/07 No fatalities, 7 major injuries
2005/06 One fatality, 28 major injuries
2004/05 No fatalities, 27 serious injuries

That seems pretty good to me given the industry employs 20,000 people

HSE has warned that an increasing number of the floating rigs were now beyond their planned life by as much as 10 years. While there was no question that they were in danger, they were needing increasingly regular maintenance.

Professor Mick Bloor of the University of Glasgow, who has studied the industry, described the North Sea oil rig support vessels as being "the quality end of the shipping industry." But a study he was involved in found the dangers of work at sea were made worse by the long hours and irregular working hours of those in the offshore industry. "That has implications for getting proper sleep and leads to the possibility of fatigue-related problems in what is an already demanding environment," he explained.

Andy Brazier

Mars-probe failure 'human error'

From BBC website on 14 April 2007

The US space agency, Nasa, has said that human error was to blame for the failure of the $247m (£124m) Mars Global Surveyor spacecraft (MGS). The craft was 10 years old, but changes made to the computer software caused batteries to overheat and fail 5 months later.

Also, in an article by Staff writers on 17 April 2007 from

It has been determined that someone uploading commands to update positioning in the High Gain Antenna's positioning for contingency operations wrote the information to the wrong memory address in the onboard computer.

"This resulted in the corruption of two independent parameters and had dire consequences for the spacecraft," the report released by NASA explained.

The corrupted upload happened, according to the report, because two previous updates conflicted and programmers were trying to fix the discrepancy.

NASA said the error caused problems with a solar array, which caused the craft to go into contingency mode, exposing batteries to direct sunlight and overheating. That ultimately depleted the batteries, most likely within 12 hours, according to the report. A second parameter error caused the antenna to rotate away from Earth, which blocked communications.

NASA said that more thorough operating procedures and processes and periodic reviews could have reduced the chance of errors.

Andy Brazier

Alert Bulletin

The Nautical Institute has published a series of bulletins related to human factors, which are now available on a dedicated website

They look good, with useful centre-page pull-outs on key issues. Also, some cartoons that can be used by others (with suitable credits). There is no list of contents, to date, which is a shame but they look very useful.

Andy Brazier

Human Focus online magazine

Lloyd' Register have published this magazine, available on their website

It is essentially a marketing exercise, but I guess it gives a reasonable overview of key human factors issues applied to the marine industry. I can't see anything revolutionary there, but it is a quality publication.

I do like their opening quote.

"There is a limit to the improvements in maritime safety that can be made by attending simply to the hull, machinery and essential systems. To ensure that further progress is made we need to focus on the way that the ship is used and, specifically, the people who interact with it."

Andy Brazier