Friday, August 16, 2013


Slowly Sliding to Mediocrity or Worse

First Nations vs. Canadian Military at the 1990 Oka Crisis

The Oka Crisis and other events prompted Canada's Federal Government to re-consider its policies towards the First Nations' people.  A Royal Commission on Canada's Aboriginals was formed in 1991, which outlined many serious problems in their 4,000 page report of 1996, and the recommended solutions.

One Federal Department that the Royal Commission found negligent was Health Canada.  Health Canada agreed with the findings of the Royal Commission, and was told to fix it.

To find out how well Health Canada had responded to the problems identified by the Royal Commission, Canada's Auditor General ("AG") did an audit on Health Canada in 1997.  The AG was disappointed by the lack of effort and results that Health Canada had achieved in the year after the Royal Commission's report.  The AG made many recommendations to help Health Canada to get back on track and make progress on the problems identified by the Royal Commission.

The AG gave Health Canada another 3 years to get these 1997 AG recommendations completed, then did a follow-up audit on Health Canada in Year 2000.

I recently had occasion to read the Year 2000 Auditor General's followup report on Health Canada.  Health Canada had accepted and committed to implement the AG's recommendations, but unfortunately little or no progress on the AG recommendations had occurred in this second follow-up audit.  The AG did another followup audit in 2004 (same problem again), and another follow-up again with a 2006 followup audit  (same problem again).

Just how many chances does Health Canada get?

It's good to see that the AG does followup.  Too often, there is a 15 minute flash of infamy to an AG report or other negative story, then the government, the press, and the public are distracted to something else, and things quickly go back to "business as usual", with no significant change having occurred.  Followup and historic memory within organizations (or their watchdogs) is a sign of both excellence and effectiveness.

More recently, 2012 academic research paper has been written about the ongoing abuse of the prescription drug plan for First Nations people, and its continuation for the last 16 years, still the same or similar to the 1996 Royal Commission finding.

It seems that Health Canada moves significantly slower than a glacier. In spite of the many caring people who work at Health Canada, perhaps they are close to being a truly fossilized bureaucracy.

I assume that the government's intent behind the providing of prescription drugs to First Nation people is to help them.

Providing excessive amounts of psychotropic drugs (eg. opiates such as Oxycodone, Percoset and other addictive narcotics) to anybody is clearly not helping.  Why government would enable and encourage addiction and illegal trafficking in narcotics by providing these drugs for free and without adequate controls to prevent abuse is hard to explain.  Could Health Canada not see this coming?  Did they not think about unintended consequences from their plans, or were these risks known and too easily dismissed?

Did Health Canada use known, effective tools such as FTA (Fault Tree Analysis), or FMEA (Failure Mode Effect Analysis)?   PQA used these techniques in a detailed risk management report we did for Health Canada on Hepatitis C around that time, so I know some people at Health Canada were aware of these techniques.

Knowing that most First Nations communities have significantly lower income and standard of living as compared to main stream society, then dropping huge quantities of addictive, free, high value prescription drugs into these impoverished communities seems like gross negligence, or worse.

The overall result is the government forcibly takes money away from taxpayers so that the government can use it to create bigger, more expensive problems (eg. chronic addictions, trafficking, illegal activities, social and familial dysfunction, etc.) in First Nation communities. The government needs a new program to fix the unintended consequences from the previous program.  Talk about a make-work project!

While Health Canada has made some small improvements over the last 1.5 decades, they would seem to have been distracted or working half-hearted to take 16 years, and still haven't fully addressed the Royal Commissions recommendations, nor the AG's recommendations.

Unfortunately, it isn't just Health Canada who fails to change their mediocre ways.

Over the last 35 years of my career, I have seen too many other organizations fall into the same trap as Health Canada and the AG.  Everybody has problems.  However, it is the response to those problems that separates the excellent from the mediocre.

I have seen that problems were identified, but people then stepped over those problems every day, or swept them under the carpet so they could be out of sight and out of mind.  Management usually allowed this corporate blindness to occur, and continue.  Neither the workers nor management wanted to address these messy problems, so they didn't.  After 20 years of this behaviour, you have an organizational swamp filled with unresolved problems that taints the drinking water of everybody downstream.

What is the solution?  How do we avoid this natural human frailty?

You hire and enable an Auditor General for your organization.  Somebody who is outside of the normal channels who is paid to hire excellent auditors to help identify the polluted swamps, encouraging you to drain them, find the rotting festering problems, and get them taken care of in a timely and effective manner.  If your organization isn't fortunate enough to have an AG today, pick up the phone now and call somebody to get the help you need.

Allowing 3 years to elapse between follow-up audits, as demonstrated by AG and Health Canada, isn't effective either.  Organizations often need help in getting started and keeping it going.  That's where a good facilitator comes in.  Both Health Canada and the Auditor General can learn from this tragedy for Canada's First Nations people.  You can learn from their mistakes too.

If you don’t call somebody for help right now, but wait another 15 minutes, the pangs of guilt about the festering swamp in your organization will soon pass.   Call now, operators are standing by to receive your call.

If you choose not to call, you may already be on a slow slide towards mediocrity or worse.

Glenn Black P.Eng. CQE CQA
Process Quality Associates Inc.

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Wednesday, August 14, 2013


What Golf has taught me about Excellence

I've been playing golf on and off for nearly five decades. I stopped playing several years ago because I'm far from the player I wish I were. But this past year I've taken the opportunity, for the first time in many years, to play golf nearly every week. My game has slowly gotten stronger. I've had a number of heady moments during which I've almost played like the player I long to be.

And almost certainly could be, even though I'm 67 years old. Until recently, I never believed that was possible. For most of my adult life, I've accepted the incredibly durable myth that some people are born with special talents and gifts, and that the potential to truly excel in any given pursuit is largely determined by our genetic inheritance.

Anders Ericsson, arguably the world's leading researcher into high performance has been making the case that it's not inherited talent which determines how good we become at something, but rather how hard we're willing to work -- something he calls "deliberate practice." Numerous researchers now agree that 10,000 hours of such practice is the minimum necessary to achieve expertise in any complex domain.

That notion is wonderfully empowering. It suggests we have remarkable capacity to influence our own outcomes. But that's also daunting. One of Ericsson's central findings is that practice is not only the most important ingredient in achieving excellence, but also the most difficult and the least intrinsically enjoyable.

If you want to be really good at something, it's going to involve relentlessly pushing past your comfort zone, as well as frustration, struggle, setbacks and failures. That's true as long as you want to continue to improve, or even maintain a high level of excellence. The reward is that being really good at something you've earned through your own hard work can be immensely satisfying.

So how do you achieve excellence in an organization?

We have found that a structured approach to implementing change and continuous improvement into an organization are the keys to achieving business excellence. The goal of the Business Excellence Program is to improve the customer's loyalty to your organization.

You can't achieve true, life-long loyalty if you are continuously breaking commitments, delivering less than perfect quality, or having mis-communications.  You have to be trustworthy.

Through that improvement process, most organizations find that their net profits go up as well.  You might get so good that you can justify premium pricing over your competitor's offerings.

All of this starts by focusing attention on the strategic issues & bottlenecks in all aspects of the company’s operations - financial, customer, process, and human resources

There are 5 major elements to a Business Excellence Program:  I’ll cover them in detail with my next posting to this Blog.

Don Whitred   P.Eng. CQE CQA
Process Quality Associates Inc.

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Tuesday, July 23, 2013


Train Safety

Mississauga Train Derailment Nov. 1979
Is there an important historical link between the train derailment in Lac Megantic Quebec, and the similar train derailment in Mississauga Ontario 34 years earlier?

On Nov. 10, 1979 there was a trail derailment in Mississauga ON that involved transportation of dangerous goods, such as chlorine, propane, styrene, butane, propane, toluene, and other highly flammable materials.  It resulted in the largest evacuation in North America, six days in duration, but fortunately nobody was killed.

Mississauga Mayor Hazel McCallion said: 

 “If this had happened a half-mile farther down the track – either east or west – we would have seen thousands of people wiped out. It’s a miracle it happened here.”

This Mississauga accident sparked many investigations and recommendations about the safety of transporting dangerous goods.

For example:

Zoom forward 34 years to 2013 and a little farther down the track, and we have another derailment in Lac Megantic Quebec.  So far, I have heard no mention or comparison between Lac Megantic and Mississauga.  I wonder why?

In Lac Megantic's case, the derailment caused an explosion of light crude oil from shale oil deposits in Montana, set fire to the town, and is likely to have killed 50 people.

Should we remember Mississauga at this time?  Did we learn all we could from the Mississauga disaster 34 years before?

The railcars involved in Lac Megantic were DOT-111 railcars (a Department of Transport specifications), also known as CTC-111A cars.  These DOT-111 rail tankcar are the most numerous of all the different types of railroad tankcars, which represents over 80% of the tank cars in the North American fleet.  DOT-111 cars are relatively cheap to manufacture, and have minimum strength; certainly insufficient to withstand a derailment, so a spill is likely during a derailment.

Poor performance of DOT-111 tankcars in the past, especially during rail accidents, prompted the upgrading of the DOT-111 specifications in 2011, but the vast majority of the North American rail fleet, built before 2011, doesn't have to be upgraded to the new standard.  There is minimal maintenance performed on these railcars thereafter, as they often carry innocuous cargos such as vegetable oil.

The operating procedures for trains, the logic of the train crew abandoning a train, leaving the engine running while away from the train, and ensuring the braking system has minimal leakage and working air brakes all need to be reviewed.

However, we are in a Catch-22 in this area.

The Federal Regulations state the minimum requirements, but don't describe how the railroads should meet those requirements.  Each railroad can develop its own solution, as Montreal, Maine & Atlantic (MM&A) Railway did prior to the Lac Megantic incident.  The railway submits their proposed solution, it is reviewed by Federal bureaucrats, and filed away.  Nobody is able to examine the railroad's standards, as they are proprietary and confidential.

Did the railway exercise sufficient due diligence in developing its standard operating procedures?

Did the Federal bureaucrats conduct a sufficient review of the railroad's submissions before they approved them as adequate for meeting the Federal Regulations?

What is the public's right to know before an incident occurs, or after?

There are Risk Management techniques, such as FMEA (Failure Mode Effect Analysis), FTA (Fault Tree Analysis), PPA (Potential Problem Analysis), BPA (Business Process Analysis), and many others that could have been used to identify unacceptable risks well in advance.  Were any of these used in this case?  Many industries have standardized these risk management techniques as minimum mandatory requirements due to the risks and costs that will follow major accidents.

For transporting crude oil, railways have a much higher risk of a safety incident (eg. a spill, fire, explosion, injury, death, etc.) than a crude oil pipeline on the basis of barrel-km transported (ie. barrels of oil transported X kilometers traveled).  Therefore, doesn't it make sense for the railways to do everything possible (even Risk Management prevention efforts such as  FMEA, FTA, or other tools) so as to improve their safety record?

It is interesting that Bloomberg published an article on April 9th 2013 warning of rail disasters due to the huge increase in crude shipments by rail.  Crude by rail has increased due to the growing bottleneck in crude oil pipelines.

Association of American Railroads ("AAR"), the railroad lobbying group, rebutted this Bloomberg article on April 18th 2013.  After Lac Megantic occurred on July 6th, AAR added 2 more articles (here and here) with well chosen statistics that are intended to convince the public that crude by rail is safer than pipelines.  When the DOT-111 railcars became an issue, AAR supplemented their media spin with another article on July 18th, extolling the virtue of the new, improved specifications on the DOT-111 cars.  Too bad it was the old DOT-111 versions that Lac Megantic got to experience first hand.

How many times must we repeat these major disasters before we learn the necessary lessons?

Glenn Black P.Eng. CQE CQA
Process Quality Associates Inc.

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Saturday, July 20, 2013


Where do we begin?

With all the world before us, should we look outward, or start with the internal view of our ourselves through the lens of excellence?

Leading by example is often effective.

Perhaps we should start there.

How does an individual, like me, make excellence operational in my life?

Declaring the intention to myself, my family and friends, co-workers, and the world might be a place to start.  To do so can create significant expectations, perhaps more than what our capabilities and intentions can initially achieve.

Aristotle noted that we become something by doing it more and more. For example, somebody becomes brave by doing more and more brave things.  Eventually others will begin to recognize the difference in our behaviors,  and see a difference between us and most others.  Self-declaration is probably not worth the effort.  When others see the behaviors and decisions that show excellence, they will eventually declare our capabilities.  It would be arrogant and crass for us to self-declare our journey towards excellence.

So let's keep our plan for excellence private at first.  In time, others will discover our change for the better.

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Saturday, March 19, 2005


We're Off !

PQA has now joined the latest web fad (4 years after the starter's pistol went off!).

This blog is on Excellence.

Why Excellence?

I believe excellence touches everything on this planet.

Environmental excellence stops spills.

Manufacturing excellence stops job losses and prevents accident.

Excellence in hospitals prevents medication errors.

No matter where you are, or what you do, you are affected by excellence (or its lack thereof).

Paraphrasing Vince Lombardi,

"Excellence isn't everything. It's the only thing"

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