Académique Documents
Professionnel Documents
Culture Documents
At Risk Behavior
People Systems - Culture
Mike Henry
September 25, 2002
THIOKOL PROPULSION
Process Reliability
Process reliability initiatives in place over the years to
mitigate process creep and maintain the recipe:
Requirements
Knowledge
Techniques
Equipment/tools
Maintenance
People
Fairly successful, but
One area that requires special attention is mitigating people
creep motivation, mindset, sense of belonging/contributing
and ability to use proper judgment
Understand and avoid at risk behavior
Significant time and effort spent working to enhance this one area
THIOKOL PROPULSION
At Risk Behaviors
Not communicating adequately to next shift or supporting
group
Improvising and/or using unauthorized tools/materials/
processes
Incorrect lifting or handling
Action taken to understand why people put themselves in
at risk behavior
Three focus groups formed
Touch labor (operators and inspectors)
First line supervision (operations and quality)
Executive/Senior management
Reviews, interviews, offsite (2 months)
Consensus on root cause and actions
THIOKOL PROPULSION
General Observations
General Observations
General Observations
People have good intent, but may also have too much can-
do attitude
People using judgment when it appears they have lack of
adequate options
Procedures dont always apply
Help chain non-responsive
Solution seems obvious
Getting job done more rewarding/satisfying/feeling of
accomplishment than strict compliance
General frustration due to inability to improve things and/or
even be listened to
See painful process for getting things changed
Someone else must often solve operator/inspector problems
Suggestions get lost not capturing their knowledge
THIOKOL PROPULSION
General Observations
General Observations
System Weaknesses
Change too difficult
Corrective action lacks floor input and follow-up
Too many decisions made in offices/conference rooms
PPIAs could have corrected
Stress from last minute projects
Obvious lack of timely help chain
THIOKOL PROPULSION
Summary
Summing up root cause of issues
Lack of clear customer-supplier relationship from topbottom
Mistakes
System complacency Bad decisions
Reduces workforce ability to: Missed
Be engaged opportunities
Always on-guard for disconnects Weaker PPIAs
Motivated to stop and get help
Generate ideas for continuous improvement
THIOKOL PROPULSION
Challenge
Overall challenge:
Strengthen customer-supplier relationships in all directions
and make roles/responsibilities clear
Create an effective and timely help chain
Show leadership interest and support
Recommendations
General recommendation discussion
Enhance understanding of why requirements exist
Recognize operation/inspection process owners
Create clear and timely help chain
Follow-thru on fixes/changes
Enhance engineering-floor relationships
Make operation/inspection roles/expectations clear
Strengthen PPIAs and PFMEAs
Enhance responsiveness of change system
Assure cause and corrective action process involves
operations and human element
More management face time
Call off scheduling hounds
THIOKOL PROPULSION
(Operators/Inspectors)
Hardware
Processing
Capturing IPT
Knowledge
Design Intent
(DE/ME/QE)