Why systems?

During the 1930's much work was done, particularly in the aviation industry, to improve technical factors. Improvements in design of aircraft, early motor vehicles, factories and many other devices led to increases in safety and quality of products. Unfortunately accidents continued to occur.

In the 1960's and 70's more research was conducted into human factors. For example, researchers began to understand the effect of "flicker vertigo" on pilots. Evidently, several crashes were due to the impact on the human brain from rotating blades causing a strobe effect at certain frequencies. However, be the 1990's it became increasingly obvious that most accidents are rarely the result of a single point of failure. Typically, many things go wrong before a failure. For example, on 10 June 1990 (during a flight from Birmingham, UK, to Malaga, Spain) British Airways flight 5390 experienced explosive decompression when the windscreen blew out, sucking the pilot out of the cabin.

Investigations revealed that the design of this type of windscreen, fixed from the outside, was certainly a contributing factor. However, the direct cause of the failure was that 84 of the 90 bolts used to hold the window were the wrong size (too narrow). An aircraft mechanic had replaced the windscreen the night before and substituted "like for like" bolts rather than selecting bolts from the specifications in the aircraft maintenance manual. Unfortunately, when he selected the bolts (in poor light), he chose the wrong ones.

Investigators found fault with British Airways' policies which should have required testing or verification by another individual for this critical task. Finally, investigators blamed the local Birmingham Airport management for not directly monitoring the Shift Maintenance Manager's working practices.

It became apparent that the real cause of this problem was not a single failure but a failure of the entire system (design, maintenance, checking and inspection, staffing, etc). Time and time again, success or failure is traced back to the system, rather than an individual or an event.

If you want to improve quality, you can certainly gain improvements from machines, staff, programs, etc. However, if we are truly serious about improving quality for the long haul, we can only succeed if we address the system. Some would go so far as to suggest that 90% of results are due to the systems (processes) and not the individual.

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