Comments on life, science, business, philosophy, and religion from my personal public health viewpoint
Sunday, May 13, 2007
Powerpoint on why too much quality doesn't work
It seems to me that there can be such a thing as too many procedures, to the point where, as John Gall would say, the component that will fail is sthe one that you put in to make the system "fail-safe". That is, the thing that will kill you is the thing that you put in place to save you.
This may have been true of Comair Flight 5191, that crashed while attempting a mistaken takeoff from the wrong runway in Lexington, Kentucky last August.
Some pilots have wryly compared the pre-takeoff check list on a 727 to a "Michner novel", in terms of its length. In the case of Comair 5191, judging from the transcripts of the cockpit voice reocorder, the right-hand seat co-pilot apparently spent the entire taxi-time with head down, going though the checklist, while the left-hand seat pilot taxied the plane to the wrong runway, opened the throttles and told the copilot "you've got it."
We have some mixed signals on how to deal with this. In a perfect case, even a very "lightweight" solution is more than adequate. The picture illustrates a single sheet of typing paper rolled up and taped into that shape, holding up 3 books.
However, when it comes to checklists, or standard operating procedures (SOP's), sometimes there are simply too many. Cultures in the red-quadrant of the "competing values" diagram think that the problem is always too few procedures, and want to add more. They think the graph of reliability versus standardization goes up forever. In practice, the graph seems to be more hill-shaped, going up to a point, then somewhat down as more and more procedures start getting in the way, and finally result in catastrophic failure as the system crashes under the weight of it's own safety system. One can think, perhaps, of the "right number of laws" to have optimal regulation of an industry, and which of those two curves applies in whatever is your own case.
I put up a powerpoint slide presentation (no audio) considering this issue.
you can get it here, titled "spectacular.ppt".
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