Operational "Integrity" - lessons from the AFSO 21 Frontlines Published Sept. 10, 2008 By Dr. Ronald C. "Ron" Ritter Special Assistant for AF Smart Operations WASHINGTON (AFPN) -- The U.S. Air Force faces intense operational demands and resource challenges that sit at the heart of the role that Air Force Smart Operations, or AFSO, plays in improving mission performance. We all understand the need to strengthen fighting capability, recapitalize, increase financial efficiency and most importantly, save Airmen's time. In recent days, there has been an important call to renew our focus and our commitment to the integrity of critical missions. While the visibility is on nuclear surety, this really applies to all operations. At the end of the day everything we do lies in the path of combat operations. Inside the Air Force, assuring high operational integrity is a core competency that is fundamental to conducting current war-on-terror operations, our long-term national security posture. It is important to step back and take a hard look at how we in the Air Force, and any other large organization, really drive operational integrity. First off, "integrity" is about absolute mission reliability with a zero-tolerance for readiness failure, security of operations and the best possible personnel safety -- understanding the inherent risk of combat operations. The very heart of this is performance by "normal" Airmen, not super-heroes on their best day of work ever. This is about consistently high performance work done by real people who are tired, in the dark and the rain, with a new guy on the team. While different in many respects, we have counterparts outside the Department of Defense with valuable parallels and practical insights. Nuclear power generation, pharmaceutical manufacturing, commercial aviation, petroleum refinery operations, even commercial banking and automobile production all deal with this challenge. The implications of process failure include catastrophic loss of life, undermined citizen confidence and debilitating impacts to the economy and our way of life. As one example, a refinery explosion in Southern California threatens the lives of thousands of employees and citizens, risks national energy supplies and operations in the adjacent Port of Long Beach, through which passes more than 50 percent of U.S. foreign trade. All mission-critical operators, including those in the Air Force, base integrity on certain fundamental, well known and time-tested principles: -- Clearly defined standard operating procedures -- tech orders, AFIs, etc. -- System redundancy -- Rigorous inspections and audit with independent oversight -- Organizational alignment with specific "lanes" and responsibility -- Accountable leadership With these as the foundation, "process improvement" is the workhorse of driving operational integrity forward. Modern organizations actively pursue a multi-layer strategy to constantly strengthen work processes to the point that they cannot fail. The objective is intrinsically fail-safe, or "error-proofed" operations, to the point where normal people can execute these reliably day after day after day. Inspection and audits move from front-line to last-line of defense. "Lean" principles are firmly grounded in operational integrity. One of the core pillars of the Toyota Production System is "Jidoka" or error-proofing. The principle translates as giving every machine and human process built-in intelligence to identify failure risk and then prevent defects. There are other specific tools and methods like 6S, Value Stream Mapping, Visual Management, Total Productive Maintenance and perhaps most importantly, Standard Work. In his 1926 book on operational efficiency Today and Tomorrow, Henry Ford clearly drove this home. "We cannot afford to leave any process to human judgment," he said. Mr. Ford also strongly dictated the role of continuous process improvement in integrity. If you think of "standardization" as the best that you know today, but which is to be improved tomorrow, you get somewhere. But if you think of standards as confining, then progress stops. When operations do deviate from performance standards, and they will, there are powerful tools like the "8 step" root-cause problem solving model, "5-Why Analysis" and advanced analytical methods like "Process Failure Modes and Effects Analysis" that Lean organizations use to get back on target. It is often noted that the distinctive feature of ultra-high performance organizations is not that they do not have problems. It is that they are relentless about transparency, root cause analysis and standardizing long-term countermeasures. They have problems, but they are visible and quickly solved. As we move forward with AFSO, we should be confident and aggressive in looking at ways to further strengthen the integrity of Air Force operations. Every time commanders initiate AFSO action they should press teams to show how they have driven integrity and set up long term metrics to keep the process on track. In the last several weeks alone, we have seen powerful examples of this in the Air Force and in our industry AFSO partners. Air Combat Command officials recently ran an AFSO event looking at F-15 Eagle inspections as part of the regular maintenance cycle. The team combined existing tech orders and front-line input of mechanics to develop more visual standard work instructions. These are straightforward sheets with photographs, arrows indicating key task points and markers emphasizing safety and quality control points. The team then ran a controlled experiment on a known aircraft. Using traditional tech orders, a 7-Level maintainer with more than 15 years experience completed the inspection in 2 ½ hours. They then took a 3-Level, "not-fully trained" maintainer and asked him to do the same inspection, but with the new visual standard work. All 21 write-ups were correctly identified in 45 minutes. That is incredible testament to the power of good visual standard work. The smile on the airman's face was priceless. We have now enabled a less-experienced Airman to successfully complete mission critical tasks, in less than half the time, which allows us to invest the deep experience of the 7-Level Airman into more demanding work and/or coaching of our younger Airmen. As a part of every AFSO course for general officers, senior executive service civilians and command chiefs, we invest a day in industry site visits. General Roger Brady, commander of U.S. Air Forces in Europe; Maj. Gen. Marc E. Rogers, vice commander of USAFE; and other senior leaders spent a day with Porsche AG. Porsche is an interesting example for us to learn from. They survived a near-death crisis in 1990-91 and today build world leading high-performance cars like the 550hp 911 GT3. These are life-critical machines, produced in a highly regulated industry, using advanced technology and materials, for a customer base that is notoriously demanding. Like us, they are also highly dependent on outside contractors -- in their case, suppliers are responsible for more than 70 percent of the car's systems by value. Walking through the engineering and assembly operations in Stuttgart Germany, you can see their intense focus on process integrity. They have clear, highly organized workspaces, total transparency on operation status and a rigorous system for identifying and fixing process failure. Assembly-line workers at all levels are authorized and expected to call "line stop" for entire production process by pulling an "Andon" cord if they detect any failure or risk in the work. Consider giving any Airman the responsibility to shut down flight line operations. This Andon triggers an immediate escalation procedure for short term containment and resolution, right down on the shop-floor by production workers, engineering, purchasing and any other process owner. Porsche uses a thorough, root-cause-problem solving framework to develop long-term solutions. Identified problems are then visually documented and posted in high-visibility areas. In one case, an entire wall of failure points with lessons-learned was posted right on the assembly line. They also make extensive use of error-proofing devices such as a light-curtain control device that would not allow the technicians to install the wrong parts on the safety critical brake systems. Any attempt to put a European spec part on a U.S. vehicle would immediately shut down the work cell. Another dramatic example comes from Virginia Mason Hospital, one of our AFSO partners in Seattle. Following a fatal accident in the hospital, VM has been on a seven-year journey to implement the "Toyota Production System" in all aspects of their hospital operations. One particularly powerful element is their "Patient Safety Alert System." Like Porsche, if any hospital employee observes a non-standard, unsafe condition, he or she can immediately call "line stop" with a PSA. This triggers an immediate "knock it off" and assessment. All PSA events are tracked and subjected to root-cause analysis within days. VM staff members also have rededicated themselves to thorough Standard Work. All doctors and providers are required to perform operations to the "standard," ensuring consistency of care for the patient. As a result, their overall visibility of process failure has increased dramatically, but the absolute number of mistakes, injuries or worse has declined dramatically. A recent visit to the 31st Fighter Wing at Aviano AB, Italy, surfaced more powerful examples. Airmen in the F-16 Fighting Falcon egress shop implemented improved layout, 6S, visual status indicators of the work and, as at ACC, visual standard work. Under the old system, every ejection seat would reach the final 7-level inspection with multiple write-ups, rework and delays. Fast forward the new system. The last 23 seats have seen zero late-maintenance completions and more "fully mission capable" aircraft days. We need to keep the final inspection on such a critical system, but these Airmen have built a much more robust process that should make every pilot more confident in the jet. In the 31st FW's gun shop, front-line Airmen have completed detailed industrial engineering to improve overhaul performance. They took a critical look at all maintenance steps, timed each element of the work to get a much more specific look at the process of F-16 gun overhaul in that exact shop by these Airmen. This analysis allowed them, completely within existing TOs, to put the work into a sequential "assembly-disassembly" work-cell that divides the tasks between Airmen. Realistic standard times made it possible to define much more accurate manning and cycle-time targets for the work and, most impressively, shift these to match different rates of gun overhaul demand. The result of this brass-tacks stopwatch engineering is a carefully designed work-cell with divided tasks and standard times. You can just see the reliability, and this had the additional benefit of freeing up people and making it much easier to take on junior Airmen. Finally, in the 31st Medical Group, process improvement has a strong foothold. A one-stop process to accomplish all Active-duty medical and dental requirements in under two hours saved 24,000 man-hours per year and reduced errors. It is also "green," saving more than 22,000 miles of travel per year. The same process is now used to eliminate discrepancies in pre-deployment processing. In the surgical arena, a 6S project for C-sections has eliminated searching for emergent medications and equipment through the use of an anesthesia shadow box. At a glance anyone knows that everything is available. Back in 2005, medical group staff members incorporated the "stop" mentality to patient safety. "Incident" reports are embraced as a positive indicator for it helps focus on broken processes. Other examples using patient-carried medication lists in OB/GYN to reconcile electronic records, reductions in code-blue response time by more than 50 percent and use of computer-design capability to reduce porcelain crown fabrication from 14 days to 1. These improvements save lives, improve quality of care, increase readiness and free up the time of our doctors, nurses and technicians. As with any high performance organization, the No. 1 objective always must be mission performance. Absolutely central to this is operational integrity, reliability, consistency, safety and security. AFSO originally was chartered to explicitly drive integrity with the foundational Five Desired Effects: 1. Improve productivity of our people, our most valuable asset 2. Increase reliability and availability of critical assets 3. Enhance agility and responsiveness 4. Maintain and increase safety of operations 5. Increase energy efficiency Even in cases where the "only" benefit of AFSO work is manpower or dollar savings, we still see a strong integrity benefit. Airmen and financial resources freed up in one area are available to re-invest in strengthening operations in other areas. We should all take heart in these and many more examples where operational integrity is increased through the innovation of Airmen worldwide. (Maj. Gen. Marc E. Rogers contributed to this article) Comment on this story (comments may be published on Air Force Link) View the comments/letters page