Two worlds – One Approach – Operational Excellence in Aviation
“LEAN Management” was developed by Toyota starting in the 1930s. Its development was derived from a thinking and culture of deep problem-solving-process with the target of zero waste in processes and 100% quality right-the-first-time.
While in the 1990s the Toyota Production System became famous, especially after “Womack and Jones” analysed it in depth [1], it spread first across the whole automotive sector and afterwards to more (not only production related) industries around the world.
In aviation however, it is rare to hear flying personnel speak explicitly about the application of LEAN tools or emphasising that their company is following a specific LEAN approach. Surely, on the production lines of the big aircraft manufacturers and their suppliers or maintenance organisations it is a different story; nevertheless, speaking about flying personnel, ground staff or even sometimes the C-Levels of the airlines, it is safe to say that the term “LEAN” is a rare one.
Anyhow, mostly all companies and entities involved in aviation processes embrace implicitly and intrinsically methods strongly related to LEAN Management approaches, especially the principles of Continuous Improvement, Problem Solving and Root-Cause-Analysis as well as Leadership and employee empowerment – the question is why?
The reason can easily be identified. While in other industries a faulty part might simply lead to a malfunction of the related product, in a complex and safety impacting environment like aviation, a fault might cause a catastrophe. While this may sound rather crude, it is unfortunately accurate, as recently evidenced by the 737-MAX catastrophes: In aviation, improvements might have been paid with blood!
Based on this thought and precisely because of the high level of risk associated with aviation as an industry, the Continuous Improvement Process (CIP) in this sector is heavily based on the “Safety Management Systems” (SMS) of all operators and providers. The CIP is especially fed by root cause analysis from everyday occurrences, accidents and incidents and the corresponding findings based on investigations.
One example showing the importance of good root cause analysis in aviation is the catastrophe of Tenerife in 1977. Due to a series of challenging factors, the airport in Tenerife was very crowded. On top of that the weather was bad with low visibility and aircrafts had to use the active runway for taxiing. Because of a misunderstanding between pilots and Air-Traffic-Control, a Boeing 747 departed colliding in the take-off run with another Boeing 747 still taxiing on the runway leading to a total of 644 deaths.
One of the changes implemented globally as an outcome of this accident was the simple change of two words in the standard radio transmission phraseology: “Take-Off” and “Departure”. After this tragic accident aircraft reporting ready to the tower, were not allowed anymore to use the word “take-off” but have to report “ready for departure”. Only once an actual clearance by the controller is involved, the phraseology changes to “Cleared for Take-Off” to avoid misunderstandings. As you can see from this example, a little word can make a considerable difference in communication!
In general, since the 1980s, there is a very big focus on the topic “communication”, especially relating to the interaction between crew members, commonly termed “Crew-Resource-Management” (CRM).
Research has shown, that about 80% of all accidents are not solely due to technical problems but instead also heavily related to suboptimal communication or behaviour between involved parties, especially crew. A study from Jan U. Hagen even revealed, that 80% of the accidents were caused by captains and not the Co-Pilots because of too steep hierarchical gradients and the resulting hindering of communication [2].
This is the main reason why airlines created very strict selection processes especially for pilots as well as Cabin Crew Members, as behaviour and communication are key to reduce the possibility of an accident. Studies have shown that the probability of an accident is increased by over 30% if a crew faces CRM-issues whereas a technical problem only increases the accident probability by 8% [3]. The reason might be related to the fact, that normally for technical problems exist high level of redundancy and on top of that "Standard-Abnormal-Procedures" which can be strictly followed according to the manuals, whereas it is much more challenging to identify and solve unclear communication or interpersonal problems in high-stress-situations.
Having emphasised on the importance of good communication and working standards, this should encourage you reflect about your company, your management team and your industry – how much are you training your management team in topics related to “CRM”, like leadership, hierarchy, communication, feedback, etc.?
From the aviation culture of continuous improvement have evolved a lot of concepts which are comparable to usual LEAN Management approaches, beginning with preventive maintenance, known as Total Productive Maintenance (TPM) in the Operational Excellence world, quick aircraft turnarounds, known as Single Minute Exchange of Die (SMED) as well as the general high standardisation in all processes.
The message of this article is that using terminologies such as LEAN, Operatinal Excellence or Systemcial Approaches is not a requirement to nevertheless be carrying out best practices! Important is that you assure continous improvement within your Operational Excellence approach. Every company, every industry, every manager can embrace such approach. In aviation CIP can simply mean to change two words in phraseology because of the outcome of a thorough root cause analysis. As an example I could imagine similar problems within any co-working team, e.g. in hospitals in the communication between doctors and nurses. Classically root-cause-analysis does not only lead to faulty material, machines or process steps itself but reveals deeper issues in KPIs, communication between co-workers as well as management, standardisation or (technical) education.
What are your approaches for your company to raise the level of Operational Excellence? I will be happy to share ideas and experiences.
Sincerely yours,
Moritz Hirscher
References
Co-Autor: Juan Pablo Alvarez
[1] James P. Womack, Daniel T. Jones: Lean Thinking: Banish Waste and Create Wealth in Your Corporation, New York, 2003
[2] Jan U. Hagen: Fatale Fehler, Berlin, 2013
[3] Joachim Schneider, Hans-Joachim Ebermann: Human Factor sim Cockpit, Heidelberg, 2011
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