People who know me are very aware of how much I love boats and getting out on the water. My father was a Merchant Seaman and my spouse and close friends tend to all have seawater in their veins. This love of the water includes a deep respect for the power and unpredictable nature of the ocean. Most misadventures at sea seem to be a case study in the precise definition of a “Cluster F&$@”. Every major and even minor disaster at sea seems to always involve several of the fates conspiring together to allow the progress of a bad situation to become worse. Let’s take just one recent example from the news. Rob Konrad, a former player for the Miami Dolphins, was several miles offshore on his 36 foot fishing boat. He fell overboard and ended up swimming over 9 miles through shark infested waters to reach shore in Palm Beach. Several contributing factors put him in that water swimming for his life. Almost any other person would have become another sad obituary but his physical conditioning overcame some really bad decisions on his part:
- He was alone on a boat and had enabled his auto-pilot
- He got a big strike and left the helm to fight the fish.
- A large unexpected swell sent him over the side and into the water. He watched his boat continue towards the Bahamas without him.
- He was not wearing a floatation device which is more common than you might think.
- No floatation device meant no signal mirror, C-Light or EPIRB, all of which are generally attached to your life-vest.
He had set his wife’s expectations for where he was and when he would be home. Not a great “Float Plan” but enough to have her call the Coast Guard and get them looking. Our hapless swimmer indicated that search boats and helicopters came within a few hundred yards but with no signaling device or geo-locator he could not get their attention. He doggedly swam toward shore as darkness fell. He oriented his direction first with the sunset and then with the lights from shore. It took him more than 16 hours to finally reach Palm Beach. I assume the boat continued on to Freeport and made some salvage operator very happy. Several elements could have averted or shifted the odds more in Rob’s favor:
- Not heading several miles offshore alone and without a detailed float plan.
- Autopilot should have been disabled when he left the helm.
- A flotation device with a mirror, battery powered C-lights and an EPIRB would have made locating him much easier for the rescuers.
If you look at the really serious problems you end up facing in your business or on the Plant floor it is almost never just one thing that went wrong. As Quality professionals, we are trained to drill in on root cause to address the fundamental problem and not stop at the contributing factors. This is the text book method for dealing with Corrective Action Analysis. In reality, the contributing factors are rich in opportunities for additional Corrective and Preventive Actions. Freeing ourselves from the “one and done” mindset is tough with all the competing demands for our time and attention. This is one of the primary reasons we will see an increased emphasis on applying Risk Assessment to quality and business processes in the next generation ISO standards. Many large corporations, including our parent Siemens, are aggressively requiring Risk Assessment starting early in the Marketing and Sales process, continuing through design, manufacturing, supply chain and service delivery. The goal is to drive earlier and better fact based business decisions. Taking this approach brings a whole new cast of characters into the process. Sales and Marketing have seldom been so included in quality decisions about what business to pursue based on associated identified risks. Can we support the requirements? Is this business engaged in activities we want associated with our brand? These are just some of the new considerations that will be involved in this evolution.
If you scale this paradigm across processes such as Internal Assessment, APQP and Management Review, it is clear that the increased transparency will be a game changer. Management will find it almost impossible to claim plausible deniability and circular firing squad approaches to post problem lessons learned will be all but impossible. In my opinion, this is a significant progression of the logic that gave birth to the original ISO quality standards. The Standards were expected to be a positive force for organizational change and consistency. This is the most significant update to the standard since its original release. Companies who see the updates as a value added tool set will reap more benefits faster than those who simply focus on the sweeping nature of the changes. Planning for risk and adversity is always preferable to engaging in reactive crisis management. I am sure that our lucky Fullback kept thinking about a steady stream of decisions he wished he had made differently during his long and dangerous swim. The outcome could have been very different for him and this story could have had a much sadder ending. My advice, whether you are on a boat or in a boardroom, plan and anticipate, don’t just react.