“Biggest Cause of Serious Error…Is A Failure of Communication”

Finn O’Sullivan is a project executive for a company that builds skyscrapers.  He is quoted in The Checklist Manifesto: How to Get Things Right, by Atul Gawande. Those who construct skyscrapers rely on one checklist to make sure all the many steps in planning and construction are completed. (more…)

Posted June 16th, 2010 in Human Factors, Leadership, Operational Excellence

To Call or Not to Call; To Facebook or Not – Part 1

I teach 11th graders in Sunday School and have been teaching youth for over 30 years. in the early years of teaching, I contacted the youth by mail or on their home phone or even visited their homes. Mail still works, even though it is a quaint practice. When I want to talk to a parent or a younger sibling, I call the home number. The youth give me their cell phone numbers, but don’t like phone calls as much as they do text messages. Teens do not want to talk as much as they want to text.

For a few years, e-mail worked well for communicating and it still does for me. It’s a passive channel, however, and feedback would be nice. Now the youth tell me to send a message via Facebook. That works well for them and for me.

What is the primary mode of communication in your company’s daily operations? Phone, texting, e-mail, radios, Facebook (probably not yet)

What issues will companies face dealing with preferences of different generations? I remember that a pipeline scheduler e-mailed a change in the pumping schedule to a pipeline operator. Guess what? The pipeline operator did not check his e-mail. The operator was used to schedulers calling on the phone with changes. The operator was 20 years older than the scheduler, and the scheduler used e-mail all day in his office job. When the schedule was not changed, the batch was not pumped. This error of omission caused problems.

Posted February 24th, 2010 in Human Factors, In the News, Observations

Getting Off “Most Wanted” List: Relief for PHMSA

The National Transportation Safety Board (NTSB) announced that it had removed an item from its “Most Wanted Transportation Safety Improvements” list. For a number of years, “Reduce Pipeline Accidents Caused by Human Fatigue” had been on the list. The Pipeline and Hazardous Materials Safety Administration (PHMSA) has been working with the pipeline industry to develop regulations that would address maximum hours of service and related issues for pipeline controllers. I think this work began in the 1990s.

A final rule was issued by PHMSA in 2009 that addressed enough of the NTSB’s concerns that the Board voted to remove the pipeline transportation mode from its “Most Wanted” list. The aviation and marine transportation modes still need to address accidents caused by human fatigue.

While I do not think the final rule will address all the initial concerns of the NTSB, it is a good step. And I suspect the final rule will be amended in the future. My suspicion is based on general statements in the rule, the revised accident or incident report form, and the future development of inspection criteria. The main reason for my thought is that most pipeline companies will not develop a rigorous and thorough fatigue risk management system.

Posted February 24th, 2010 in Human Factors, In the News, Managing Fatigue