The Wisdom of Technicians: Improving VOR Performance at the Federal Aviation Administration

Clarissa Sawyer, Ed.D.

Presentation for Beyond High Reliability: Improving Patient Safety Through Organizational Resilience, June 3-4, 2010, University of British Columbia School of Population and Public Health

The Problem

Why do FAA VORs in 1 Region perform worse than the other 8 Regions?

How can their performance be improved?

VOR (VHF Omnidirectional Range navigation system )

Measures Approaches To and From the Station

VOR Indicator Instrument in Aircraft

VOR

“Probably the most significant aviation invention other than the jet engine.”

Introduced early 1950s; being replaced by GPS.

Primary navigational aid used by civil aviation.

Pilots use to navigate from Point A to Point B.

Measures approaches TO and FROM the station

Methods - Best Practice Study + Action Research Goal: Tap the tacit wisdom of the technicians —what

they knew, but didn’t know they knew. Use that wisdom to improve performance.

How: Conduct Best Practice Study, followed by Action Research

Project Team: mirrored the organization – (2) front-line technicians, (2) middle management/engineering, and (2) executive staff responsible for performance, (1) organization development consultant.

Sponsorship: by the Region’s senior executive and his union representative.

Best Practice Study

Face-to-face focus group interviews with VOR technicians belonging to the same work group

Asked them to share success stories

Strategic sampling: Work groups responsible for High, Medium and Low performing VORs in the Region

Analysis: Compare success stories – patterns? Relationship between VOR performance and practices?

Analysis of Success Stories Revealed Best Practices About ….

Technician Expertise

Maintenance Philosophies

Teamwork

Leadership

Culture

Results - continued Technicians responsible for higher

performing VORs used more best practices. Three practices cut across the 4 categories

of practices: Being proactive Seeking and sharing information Building trust

Technician Expertise

Technician Expertise refers to themes in stories about:

Breadth and Depth of Knowledge o Intimate knowledge of VORs using all senses:

touch, sight hearing, smell o VOR “tips and tricks” o Knowledge of more than one technical

discipline (i.e., navigation, radar, electrical)o Systems view: how various equipment

systems integrateo FAA orders and directives

Technician Expertise - continuedAs well as to specific personal characteristics: o Love their work, it’s play o Proactive, involved o Actively builds relationships and trust with

everyone o Proud, conscientious, dedicated, bulldog

determination and perseverance o Sees importance of their role in “preventing a

pattern of events that can lead to error”o “Information seeking magnet” when solving

problems

Maintenance Philosophies

The success stories revealed two underlying schools of thought about the maintenance of VOR equipment:

• Hands on – Better performance of VORs was believed to result from more frequent maintenance and monitoring.

• Hands off – Better performance was believed to result from as little contact as possible, “If it ain’t broke, don’t touch it.”

“Hands On” Maintenance PhilosophySituation Operating

AssumptionsActions Results

(Intended)Results (Unintended)

Conducting scheduled maintenance

Be thorough and meticulous.

Interpret the maintenance order conservatively.

Enjoy working on the equipment .

Use scheduled outages more often.

More frequent site visits.

Remove each electronic board, and visually inspect it.

Better Reliability of VOR.

Average Mean Time to Restore.

Above Average Mean Time Before Outage.

Really “know” VORs using sight, sound, smell, touch.

Reduced Availability of VOR.

Increased risk of equipment failure due to more frequent removal and reinsertion of boards.

“Hands Off” Maintenance PhilosophySituation Operating

AssumptionsActions Results

(Intended)Results (Unintended)

Conducting scheduled maintenance

“If it ain’t broke don’t fix it.”

If equipment is performing well, leave it alone.

The more you touch it, the more chance of problems.

Interpret the maintenance order more flexibly.

Only 1-2 scheduled outages a year by: Combining semi &

annual Required Maintenance.

Using Remote Maintenance Monitoring to conduct quarterlies (no shut down).

Using cursory visual inspection (no “hands on”).

Use an air compressor to clean and inspect components.

Increased VOR Availability due to fewer scheduled outages

Reduced Mean Time to Restore VOR

Reduced Mean Time Between Outages

Increased possibility of unscheduled outages due to less thorough maintenance

TeamworkTeamwork refers to themes in stories about : Building trust, camaraderie Sharing information (versus hoarding it) via:

• Meetings (in person and virtual teleconferences)

• Shadowing those more experienced, Mentoring those less

experienced

• Web pages, chat rooms, forums

• Green books

• Cheat sheets Appreciating differences in perspective and skill, and recognizing that

knowledge is partial and no one knows everything

LeadershipRefers to themes in stories about leaders who: Appreciate, recognize and reward people Trust employees and empower them Affirm the value of teamwork Support open communication, sharing information, and new ideas Are hands on, hold people accountable, back them up, buffer employees

from their customers (air traffic controllers) and from upper management Are respected by their employees Are stable and consistent Are proactive, plan, and think ahead Know the funding process and how to acquire resources

Culture

Refers to themes in stories about cultures that: Value communication and sharing information Create trusting relationships Promote being proactive, involved, and having a

sense of ownership Encourage technicians to actively seek

information to solve problems

Action Research

A series of actions were carried out over the next 24 months, sponsored by Regional Senior Executive and his union representative :

1. Creation of a VOR “Swat” Team

2. Monthly Regional “knowledge sharing” teleconference for VOR technicians

3. A Regional VOR conference for technicians

4. Team Action Learning Performance Improvement Projects with work groups (maintenance team supervisors, technicians, and union representatives; by request only)

Result: In 18 months, the Region’s VOR performance leapt from 9th to 5th place.

VOR SWAT Team

Volunteer team of 6 VOR “super techs” led by Region’s 2 technical evaluators (who conducted technical inspections of all equipment as part of their day-to-day work)

Over 3 years, the team visited the Region’s 32 VORs, made on-the-spot repairs when needed, and submitted proposals to secure funding for more extensive repairs

Wrote annual reports detailing efforts

Created a VOR website for technicians to share knowledge and learning

Received a Regional award and bonus pay

Knowledge Sharing Region-wide VOR Conference mid-way through the Best Practices

Study: Focused on needs of technicians

Speakers included Regional & national experts and members of the Best Practices Study team

1 day only to minimize time away from work

Monthly VOR Teleconference: For technicians to share experiences, ask questions.

Hosted by a young, respected mid-level manager (engineer and MBA) who had been a member of the Best Practices Study team and had previously led 1 of 2 teams that provided consulting services to technicians across the region.

Team Action Learning Performance Improvement Projects Jointly sponsored by management and union

Focus: help technician teams and supervisors improve how they work together in order to improve technical performance

Worked with teams across the Region, by request only

Process:

1. Assessment (Individual interviews: What’s working, what’s not, any changes needed?)

2. Design Action Learning Project

– Use Success Stories to discover best practices related to the top issue or challenge

– Use best practices to design to action experiments intended to improve performance

3. Review Lessons Learned

Results: improved relationships, morale, and team work.

Wider Adoption of Methods

Success story method used to: Conduct after action review of Regional response to

September 11th 2001 crisis from perspective of front-line, middle, and senior Regional office levels (2002)

Help executive responsible for implementation of massive restructuring of his division of the FAA (12,000 employees) conduct dynamic evaluation of his implementation efforts (2004-05)

Sources

“Best Practices in Facility Performance,”  Airway Facilities,  New England Region, Best Practices Study Team, October 25, 2000.

VORs:

– http://www.navfltsm.addr.com/vor-nav.htm, copyright Charles Wood, 1999-2009, accessed 1-30-2010.

– http://www.americanflyers.net/aviationlibrary/instrument_flying_handbook/chapter_7.htm, accessed 1-30-2010.

For more information please contact

Clarissa Sawyer, Ed. D.

LinkedIn  

978 - 844 - 3823