THIOKOL PROPULSION

At Risk Behavior
People Systems - Culture
Mike Henry
September 25, 2002
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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
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Understanding At Risk Behavior

Concern on numerous unrelated process/people

incidents in the past 12 months
At risk behaviors examples
Not working to paper (or without paper), taking shortcuts
Not tethering
Not wearing PPE
Continuing to work when confused or distracted
Working short handed
Working when unusually tired or stressed
Not bothering to perform adequate walk downs, pre-ops,
checklists, etc.
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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
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General Observations

At risk behavior contributes to most incidents

At risk behavior is the result of:
Poor communication
Unclear roles/responsibilities
Lack of specific experience/training
Confusing procedures
Schedule pressure (self-imposed or system)
Poor preparation/planning
Poor decisions
Bad habits
Peer pressure pride self esteem
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General Observations

At risk behavior, unfortunately, tends to be more in line

with human nature
Easier, more convenient, more comfortable, faster than the
safe/pre-described method
Reinforced by work culture
Rarely results in negative consequences powerful enough to
discourage
Provides more self-satisfaction when completed successfully
than following all the rules
Becomes unnoticeable over time (complacency)
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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
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General Observations

Leadership not always engaged with people issues

Distractions
Physical fatigue/illness/biological clocks
Mental repetitious work
Emotional personal problems
Environmental over 100 in summer
Attitudes/state of mind
Burned out lost feeling of contributing
Negative layoffs/shifts/boss
Caring no one listens, so why bother
Fear of embarrassment
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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
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Summary
Summing up root cause of issues
Lack of clear customer-supplier relationship from topbottom

Lack of timely systems to learn and correct problems

Lose interest to listen and involve operations/inspections

Inadvertently reward wrong behavior

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
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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

Will make people:

Feel better about their contributions
Give them confidence to use the system to help them
Help keep them engaged at the right level
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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
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How to Make it Happen

How to achieve recommendations and meet challenges
Integrated Product Team (IPT) activity (using Integrated Product and
Process Development (IPPD) methodology)
Relationships
Help chain
Knowledge sharing
Work Center Change Review Boards (CRB) Program Configuration Control
Board (CCB) improvements
Recognize floor as customer
Involve operations
Meet in manufacturing area whenever appropriate
Staff meetings on floor
Propulsion Enterprise System (PES) implementation (Toyota business
system)
Strengthen PPIA and PFMEA
Corrective action effectiveness IPT involvement/on floor/real time, and
Corrective Action Board (CAB) reviews
Establish measurements to assess improvement
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At Risk Behavior IPT Breadth and Depth

Program Team
Suppliers Integration NASA

(Operators/Inspectors)
Hardware
Processing

Capturing IPT
Knowledge

Design Intent
(DE/ME/QE)