Reliability 4 Life

64 years ago in the world of reliability (18 SEP 1960) General Motors introduced the Chevrolet Corvair. Five years later consumer advocate Ralph Nader called the car "unsafe at any speed." The Corvair may not have been as dangerous as Nader claimed. There were latent weaknesses - a swing axle suspension, no sway bar on the rear, and lower tire pressure requirements on the front tires and higher on the back tires when virtually all other cars had equal tire pressure all around. But NHTSA testing in 1971 found the Corvair handled as well as other similar cars - cars like the Volkswagen Beetle. That was the problem. The Corvair handled like a VW Beetle and was marketed to drivers as a Corvette for the middle-class. When people drove the Corvair like a Beetle - the car was safe. When people drove the Corvair like a Corvette, they were the ones who rolled-up axles or rolled-over or spun-out. No car is so safe that the car can be operated unsafely. No task on the job is so safe that it can be done unsafely. No activity in life is so safe that it can be done unsafely. That is why Reliability 4 Life teaches #lifeskills to all people for all life spaces. Safety and high reliability are too important to save for the workplace. Use safety in all life spaces - where you work, live, learn, and play. #safety #highreliability #hro #lifeskills #safetyleadership

218 years ago (1 SEP 1806) the reliability world marked the death of Edward Nairne, an English optician and maker of scientific instruments. One of Nairne's innovations - the pencil eraser. Nairne discovered the erasing properties of rubber and sold the first rubber erasers, teaching us today a lesson in human reliability. Human error is a natural byproduct of people working in systems. Human error will always be with us. To approach zero events or zero harm or zero injury - our people must work in systems that are both error resistant and error tolerant. (Error resistant means the work system causes few human errors. Error tolerant means the work system has resilience to trap those few errors before they can result in loss events.) Safety leaders in high reliability organizations have forgiving and learning attitudes toward human performance in complex systems. The only person who never experiences error is the person who never does anything. See inset below. Use accountability skills (5:1 feedback, structured feedback, difficult or crucial conversations, and progressive discipline) to maintain safe practice habits. Use human factors principles to improve the reliability of work systems. Use just culture principles to learn about work systems and the proximate causes of error before deciding how best to proceed with the person who experienced the error. Our response to error matters. Be prepared to support your people and improve your work systems. Every pencil comes with an eraser for just that reason. #safety #highreliability #hro #lifeskills #safetyleadership

55 years ago in the world of reliability (28 AUG 1969) aerospace engineer Judith Cohen was solving another urgent guidance system problem. She took her computer printouts to the hospital, later calling her engineering manager to say, "problem solved and oh, yes - baby was born too." 28 AUG 1969 is the birthday of her fourth child, actor Jack Black. Judy Cohen was an engineer when there were few women in STEM. She was the only woman in her high school math classes (even though classmates paid her to do their math home work). Judy Cohen also danced with the Metropolitan Opera Ballet Company. She was the only woman in her undergrad and graduate engineering programs, and she attended at University of Southern California! Cohen (shown here with the Pioneer spacecraft in 1959) worked on the Abort Guidance System (AGS) for the Apollo lunar lander. Her system was used by the Apollo 13 crew (Lovell, Haise, and Swigert) when returning to Earth using the lunar lander as a lifeboat following a serious malfunction of the command module. Judy Cohen did everything well - engineer, mother, ballet dancer, and others. Everything worth doing is worth doing well. That is why we at Reliability 4 Life practice and promote human reliability for all life spaces. And that is why you too should practice and promote human reliability where you work, live, learn, and play. #safety #highreliability #hro #safetyleadership

155 years ago in the world of reliability (22 JUL 1869) American civil engineer John A Roebling died of tetanus acquired at the construction site of the Brooklyn Bridge. The Brooklyn Bridge was then completed by his son, Washington Roebling, and later his son's wife, Emily Roebling, when Washington was ill with the bends from excavating the caissons. John A Roebling was already famous for completing the Roebling Bridge over the Ohio River at Cincinnati. (See inset.) The bridge was the world's longest suspension bridge at the time of completion in 1867. Roebling was surveying the site for the Brooklyn Bridge at Fulton's Ferry on 28 JUN 1869. The arriving ferry crushed his foot between the ferry and the pier. Toes were later amputated. Roebling then refused further medical treatment thinking water therapy (treating with cold water) would cure his injured foot. He died of tetanus 24 days after the accident. Safety and reliability are too important to leave on the job. Practice safety and reliability where you work, live, learn, and play. Ironically - John A Roebling, the uber engineer known for knowing the right answers, was injured on the job AND chose poorly when deciding on treatment at home. Practicing #lifeskills prevents 70% of these loss events. Practice #lifeskills where you work, live, learn, and play. #safety #highreliability #hro #lifeskills #safetyleadership

91 years ago in the world of reliability (14 JUL 1933) Popeye debuted. Popeye gained his strength by eating spinach, and spinach was known to be a superfood. Wrong. The myth of spinach as a superfood started in 1870 when a German chemist and nutrition researcher misplaced a decimal point and entered the iron content of spinach as 10 times higher than actual. The error was corrected in 1937. But Elzie Segar, who created Popeye in 1933, had already chosen spinach as the source of Popeye's great strength in hopes that children would make better food choices. Use #lifeskills every day to prevent these attention to detail errors. High reliability is too good to save for the workplace. Use reliability principles where you work, live, learn, and play. Life skills may save a life - this is true. However, practicing life skills always improves every life. Had this German researcher practiced self-checking with STAR, uncounted millions of children would have been saved ..... from eating spinach. #safety #highreliability #hro #lifeskills #safetyleadership

Two years ago in the world of reliability (14 JUN 2022) Glacier Valley School in Juneau AK served floor sealant as milk to ten children and two adults. Only small amounts were consumed, about 3 ounces each, because the taste and smell were off. Poison control was immediately called. One of the children was hospitalized. Things are different in Alaska. The milk is shelf stable milk that arrives on barges from Seattle in large plastic bags in cardboard boxes. (See photo below.) The bags are then placed in dispensers and the milk is served in cups. One pallet of floor sealant, Hillyard Seal 341 also in plastic bags in cardboard boxes, was delivered in error to the food warehouse for the school system. Three schools received boxes of sealant from this pallet, only Glacier Valley used the sealant as milk. Supply chain problems from the CoVID shutdowns had resulted in many changes to names and packaging of products. The reliability keeping us safe in high-consequence industry is the same reliability keeping us safe in our daily lives. The loss event pattern here is familiar. One error puts the wrong product in the danger zone for others to use. Our heuristics then fail us. (In this case, supply chain disruption results in many changes to names and packaging.) Then our self-checking fails us. We do not put our finger on the boxes to read names and descriptions with our minds. We just look with our eyes, and the box looks the same as we expect. This is happens in power, transportation, manufacturing, and healthcare - and apparently in education. Use #lifeskills everyday where you work, live, learn, and play. #safety #highreliability #hro #lifeskills #safetyleadership

Two years ago in the world of reliability (8 JUN 2022) two workers fell into a half-full tank of chocolate. The two contractors were hired to clean mixing tanks for Mars Wrigley in Elizabethtown, PA - tanks of Dove chocolate. What would be a dream come true for many became a nightmare. 24 rescuers eventually cut the bottom of the tank to save the two. One was transported to hospital by helicopter, the other by ground. OSHA fined Mars Wrigley $14,500 for not preparing their contractor with the knowledge and skills necessary to safely perform tasks assigned. Contractors are often used in high reliability organizations. Often, contractors are used because of specialized knowledge and skills. Sometimes they are are used as extra, lower-cost hands. In any case - the HRO must assure knowledge and skills of the contractor before starting work. Job knowledge is very broad. Contractors can come with adequate technical knowledge. They are often chose because of expertise. But do they have process knowledge (how the client does work)? Do they have social knowledge (who to communicate and coordinate with)? And, do they have the psychological safety to ask questions and question answers? 200% accountability is having two people who are each 100% accountable. They as professionals are 100% accountable for their own knowledge, skills, and practice habits. You, being a safety and HRO leader, are also 100% accountable for your contractor(s). Be that HRO with 200% accountability for your contractors. #safety #highreliability #hro #lifeskills #safetyleadership

78 years ago in the world of reliability (21 MAY 1946) physicist Louis Slotin tickled the dragon. Slotin was a Canadian working with the US on the Manhattan Project to develop the atomic bomb. WW2 had ended - but the research at Los Alamos continued. Slotin was performing a criticality experiment (tickling the dragon) by placing two half-spheres of beryllium around a plutonium core. Slotin used a screwdriver blade to control the gap separating the half-spheres. The blade slipped. A blue flash of high energy neutron and gamma radiation flooded the room, exposing Slotin and six observers. Slotin died nine days later in the Los Alamos hospital of acute radiation syndrome. (The six others survived. Three were hospitalized for weeks. Two never fully recovered.) For high reliability, work systems must be error resistant and error tolerant. The system must help us humans limit the numbers of human error, and the few errors that inevitably happen cannot result in an actual loss event. Slotin's experimental apparatus (shown below in recreation) was neither error resistant nor error tolerant. Human reliability is too good to save for high-risk industry. Use human reliability where you work, live, learn, and play. But when you tickle the dragon (and we know you will), be sure to plan your work so that your system is error resistant AND error tolerant. #safety #highreliability #hro #lifeskills #safetyleadership

174 years ago in the world of reliability (15 MAY 1850) Ignaz Semmelweiss urged his fellow physicians to save patient lives with 3 words - wash your hands. The story of Semmelweiss and hand hygiene is well known. Physicians in his OB service in Vienna had a mother - baby mortality 10 to 20 times higher than midwives delivering moms at the same hospital. The physicians would finish an autopsy of one patient and then attend the delivery of another. Deadly bacteria were transmitted in the process. Without knowing why (germ theory would come later), Semmelweiss required his physicians to wash hands. Mortality improved. Today, hand hygiene is a cornerstone of infection prevention. We must still improve our reliability in doing hand hygiene - but the practice is universally accepted. That acceptance was not always the case. Semmelweiss started hand washing in 1847, three years before he shared with other physician groups. Semmelweiss did not publish for another 13 years. Then tens of years to become an accepted practice and hundreds of years to become a high reliability practice. This time for spread is too slow for a reliability revolution. Everett Rogers published Diffusion of Innovation in 1962. New ideas progress from innovators to early adopters to early majority to late majority to laggards. Rogers identified success factors important to us as reliability leaders today: 1. build social capital 2. explain the why (especially to the science-minded) 3. show results in early applications 4. use that social capital to change thinking (one conversation at a time) Culture changes one conversation at a time. Use safety moments and time on the floor for these conversations. Ironically, if you are speaking of hand washing, you would be using a 62-year-old spread strategy for a 174-year-old practice. #safety #highreliability #hro #lifeskills #safetyleadership

One year ago in the world of reliability?(8 MAY 2023)?a tourist in Hawaii drove into the ocean. GPS directed the driver down the small boat ramp of Honokohau Harbor on the big island of Hawai'i. The driver later explained, "I saw the water but thought it was a puddle." Nearby fisherman saved the tourist. All human-based systems are socio-technical systems. There is a technical system made of methods and processes and devices, including computers. There is also a social system made of people and relationships among people and those devices. The social system is always running in the background. When the technical system fails (and it does), the social system is there as a back-up. Global Positioning Systems (GPS) is a good technology assist for driving unfamiliar routes. Operators in high reliability organizations (HROs) are trained to "always believe your indications." Operators are also trained and empowered to think. Complex systems always operate in a degraded mode - there are always problems with the technical system, including faulty and misleading indications. Complex systems also require continual human intervention. So, think about the indications. Act when the indications do not make sense. Questioning attitude as a thinking skill is the best #lifeskill for sense making. We can see from our Hawaiian tourist that Life Skills sometimes save lives but always make life better. No one was harmed in this loss event - yet driving your minivan into the Pacific Ocean does NOT make for a good day. (Think of the paperwork at the car rental company!) #safety #highreliability #hro #lifeskills #safetyleadership