Failure modes and effect analysis (FMEA) a personal case study culminating in an aborted transatlantic flight


I have just spent a very comfortable night in a Heathrow hotel, after a 5 hour round trip spent in the air somewhere between London and Boston.  Although eating airline food, watching a (not very good) movie, and having a doze mid-air might be one way to spend an afternoon in May, it would not be my first choice!
It was the culmination of a series of misadventures that, viewed positively, provide an interesting case study on ‘Failure Modes and Effect Analysis’ (FMEA), or indeed Risk Management.

Failure Modes Effect Analysis – origins and applications

Put simply, FMEA is a technique that enables a team to identify what might go wrong and develop appropriate mitigation plans based on the probability, severity and ease of detection of the various ‘failures’.  The 3 metrics are assigned numeric values which, when multiplied, produce a Risk Priority Number (RPN).  The mitigation plans are prioritised based on the RPN of each failure.

The technique originated in the US army, and spread from there into various industries, including manufacturers such as Toyota and is now part of the American Society for Quality’s tool-kit.

This blog is written from the perspective of Lean and Six Sigma practitioners who use FMEA to evaluate current processes, and also potential solutions to the issues needing improvement.

Project Management practitioners’ Risk Management approach is also a variant of FMEAs.

My FMEA case study

I was due to catch a 3:00 pm plane from Heathrow to take me to Boston for a business assignment.  The journey involved catching a 10 o’clock train to London from my home village in Cambridgeshire, the underground to Heathrow, and then the plane.  My train and plane tickets were booked and I allowed plenty of time.  What could go wrong?  How did I end up staying in a hotel in London instead?

  1. Getting to the station.  I had to take my daughter into Cambridge, usually a 40 minute round trip which would get me home by a little after 9:00 am, so lots of time to walk to the train station.  However, there were some roadworks in Cambridge so that at 8:50 am we were still a long way from our destination.  Luckily I found an alternative route, dropped her off and was home by 9:30 am and so at the station in good time.
  2. Getting to Heathrow.  The train was on time. I picked up an underground train going to Terminal 3 straightaway. Check –in was from just after 1:00 pm, by about 12:10 we had passed Hounslow.  I could relax.  Not so: a defective train at Hatton meant that we had to go back to Hounslow and catch a bus to the airport.  By 12:40 the number of passengers waiting for the bus, and the scarcity of the bus itself, made this look impossible.  Some fellow passengers and I caught a cab, reaching the Terminal by about 1:15 pm.  No problem.
  3. Getting onto the plane.  The lady at the check-in desk patiently pointed out that I should have filled in an ‘ESTA’, the online equivalent to the ‘green form’ that I’d regularly filled in on previous flights to the US, but my last one had been about 4 years ago.  So, off to the internet lounge to fill one in.  Took me a little while due to my by then slightly agitated state, but got it done, and got checked in and to the boarding gate still in reasonable time.
  4. Flying to Boston.  We didn’t make it!  2 ½ hours into our flight time, the captain announced that a mechanical fault had been detected, and we were going back to London.  Everyone kept calm, and so after 5 hours, we landed safely, queued for our luggage, queued for our passes to local hotels, and there I am now, waiting to go back to the airport for the replacement flight.

THE FMEA ANALYSIS AND POTENTIAL PREVENTATIVE MEASURES

  1.  Getting to the station.  We do the journey into Cambridge on a daily basis, and although it can be slow, especially if it’s raining, we still manage to get home by a little after 9:00 am. However, there had been some roadworks the previous evening and if still there, they could have caused problems, which they did.  So probability high, severity medium but detection high had I thought about it!  I could have prevented the delay by listening to the radio before setting off or simply taking a different route from the start.
  2. Getting to Heathrow.  Train problems are frequent!  So high probability, high severity, medium detection capability.  I checked the train live departure information on-line before setting off and everything was fine. Underground train performance is less predictable, however the information boards and announcements also indicated the Piccadilly line was running normally. I allowed an extra half-hour before the start of check-in, in effect 1 ½ hours before the close.
  3. Getting onto the plane.  Not knowing about the ‘ESTA’ was pure negligence on my part.  Especially as my son had booked a trip to the US quite recently, and had said something about it which I’d not paid attention to.  A lesson in checking requirements before flying anywhere as a matter of course, even if I’ve flown there many times before.  Perhaps if I’d booked my own tickets I would have spotted this…
  4. Flying to Boston.  I am sure there are statistics on the likelihood of something going wrong during a flight, though most of us probably would prefer not to know.  The severity will obviously vary depending on the nature of the problem.  Luckily the in-flight detection system worked.  The cost of this incident to the airline in accommodating us all in hotels and in arranging replacement flights is very high.  From a business point of view, and from their customers’ peace of mind, let us hope that they adopt a rigorous FMEA procedure of their own when preparing for each flight.

Closing thoughts

I hope you agree that this makes for an interesting FMEA case study.  I’ve certainly learnt some lessons from it.  I’ve gone on-line already to see if my ESTA is valied for today’s flight but can’t find it on the system – so will be going to the airline’s customer desk in good time to check on this and possibly re-do it.  Hopefully by this evening I will be in Boston.

Notes

Elisabeth Goodman is Owner and Principal Consultant at RiverRhee Consulting, enhancing team effectiveness through process improvement, knowledge and change management. Follow the links to find out about how Elisabeth Goodman and RiverRhee Consulting can help your team to work more effectively for greater productivity and improved team morale.

Read Elisabeth Goodman’s blog for more discussions on topics covered by this blog.

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3 responses to “Failure modes and effect analysis (FMEA) a personal case study culminating in an aborted transatlantic flight

  1. Elisabeth, an interesting story, and I hope you were 2nd time lucky. Your post immediately set me thinking – I’ve just read Susan Solomon’s book The Coldest March, a ‘scientific’ analysis of Scott’s fatal Antarctic expedition, and I can’t help wondering whether FMEA might help resolve some of the subjectivity about its tragic outcome.

    • elisabethgoodman

      Thanks John – and yes I am now safely in Boston. Good point about the potential applicability to Scott’s expedition.

  2. Pingback: Getting it right rather than ‘firefighting’…unless that’s your job! | Elisabeth Goodman's Blog

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