Problem Analysis Article
"Computers cannot make decisions involving values and risk preferences. Here, human judgment is required" (Bazerman, 2002, p. 5); hence, the primary problem being that the Person in Charge (PIC) is not familiar with scale read-outs and therefore requires the assistance of the Mass Production Engineer (MPE) to complete the task safely and successfully. Due to a serious lack of judgment, miscommunication, and role ambiguity the uploading process had to be shut down in order to avoid a safety hazard. This series of problems violated safety measures and had the potential to negatively impact the companies bottom-line.
When the Spacecraft was being transferred from tooling to the transportation cart the PIC alerted the Manager that there was a problem, which led to the operation being halted. Once the Spacecraft was off-loaded, the PIC, Quality Inspector, Quality Engineering, Vehicle Engineer, and Manager assessed the situation. An Incident Report and an Electronic Process Anomaly Record were generated and an immediate investigation was launched. All personnel involved in the situation were interviewed and all data was collected. Additionally, photographs were taken of all the pertinent tooling and flight hardware.
The goal was to get to the root cause of the problem. The objective was to prevent this situation from recurring and to disseminate the findings to the enterprise. A Root Cause and Corrective Actions (RCCA) method, using Six Sigma, was used to frame the problem. When the RCCA committee gathered, a brainstorming session was initiated to obtain maximum information. A problem statement was formed and the background of the problem was investigated, which led to the exercise of containment actions. The result of the investigation was documented using a fault tree, of which the root causes were determined. Corrective actions were assigned to the responsible parties and estimated completion dates were announced; all findings and actions were implemented. All information and findings were then disseminated to the enterprise. The process was concluded when the Corrective Action Board documented all lessons learned in order to help the enterprise be proactive in all future activities.
The problems encountered with the PIC and MPE have made the organization liable for physical injuries and monetary losses. Due to the lack of judgment, product knowledge, and the breakdown of communication the organization is now required to thoroughly investigate the matter. The organization also has to invest additional time and money toward the formation of a Root Cause and Corrective Action Team. Additionally, the organization has the added expense of cross-training and offering continuing education in order to reduce the risk of the same problem happening again.
The problem that occurred is easily resolved, but if left unchecked the problem can cause further problems that affect the organization and its members. The decision-making models show many methods of solving problems, but mostly that the circle of improvement goes on. The company could implement an "always at your station" guideline, among others. The guideline, however, is not going to help the team solve the underlying problem of bad judgment. If common sense is used, the problem will be solved immediately. If the employees have difficulty using good judgment the team could possibly implement additional safety training as a reminder of how to stay safe.
The causes and forces of influence are relatively intangible because they have their root in the minds of all the employees involved in the operation. A foundation must first be laid in order to prevent similar incidents. The foundation, in this case, will indeed be a large quantity of paperwork, which includes many different forms and reports. Once proper information has been gathered and organized the information will then need to be disseminated and incorporated into existing procedures, and more notably, into the minds of the employees. The main force needed to accomplish the desired influence will be primarily monetary. Money is needed because physical documents, training, and man-hours all come at a price. Although money can and will fix the problem, funds must be carefully allocated and controlled.
Calibrating, training, and communication are some measurements that can be used to prevent reoccurring problems. To ensure the scale read-out is working properly, the scale should be calibrated once a month and logged for tracking purposes. The PIC and MPE should be aware of each other's job responsibilities in order to reduce role ambiguity; therefore, additional training should be given to both. Because the PIC and MPE are required to work together as a team, each party needs to remain in constant communication during lift operations; abandoning ones station is not an option. Furthermore, the PIC and MPE should ask questions when in doubt; this will help to reduce safety hazards.
One of the most effective methods for measuring a desired result is constructing a checklist of all the necessary procedures to be carried out. The checklist would consist of observations of proper calibration, lifting technique, communication, and all other necessary procedures. In order for the checklist to be properly evaluated it should be completed and carried out by an objective observer. Monetary resources are undoubtedly tight in the organization; therefore, said resources should be periodically monitored. However, the identity of the person doing the evaluation should be kept confidential. The criteria should be based on the checklist of all the necessary procedures including dynamic communication. The organization should conduct an example lift with a top PIC and MPE, wherein every employee is required to observe and thus base his or her actions on. A history of flawless execution of the procedure would be used to determine a successful outcome.
Alternative solutions include the PIC and MPE taking into consideration that each party will inevitably make individual decisions; however, when said decisions affect all aspects of the operation, each party needs to communicate his or her thoughts because one wrong decision could wipe out the entire operation and/or cause physical injury. "Tough decisions can produce bad outcomes no matter what precautions decision makers take, because key factors that influence the outcome is often governed by chance events. Bad decisions occur when foreseeable events are not recognized and managed" (Nutt, 1989, p. 42). The MPE could have avoided the risk of safety hazards by determining the scope and limitations before leaving his post, as the MPE had more experience and was directed to assist the PIC. Making a decision implies different alternative choices to be considered, but the key is to choose the solution(s) that best fits with company's goals and desires.
In conclusion, the MPE's bad judgment was due to his lack of critical thinking skills. Using a decision-making model, even in the simplest form, may have prevented the problem from occurring in the first place. Sometimes, when minute decisions are made, one may think that he or she does not need to analyze said decisions thoroughly; however, the above example proves otherwise. This example should help many understand why the critical thinking process is so important and how even the smallest of choices can make a tremendous impact.
References:
Bassham, G. (2002). Introduction to Critical Thinking. In (Ed.), Critical Thinking: A Student's Introduction, 1e (pp. 1-65). New York, NY: The McGraw-Hill Companies.
Jones, S (2012) http://www.study-aids.co.uk/busman/busman_essays.html
Bazerman, M. H. (2002). Introduction to Managerial Decision Making. In (Ed.), Judgment in Managerial Decision Making (pp. 5-29). New York, NY: John Wiley & Sons, Inc.
Nutt, P. C. (1989). Preventing Debacles by Improving Decision Making. In (Ed.), Making Tough Decisions: Tactics for Improving Managerial Decision Making (pp. 1-43). New York, NY: John Wiley & Sons, Inc.
