The first part of Deming’s System of Profound Knowledge is appreciation of a system.
I will make a case for PT. Kereta Api Indonesia/KAI (Indonesian Railways) as last week since there was another crashed involving two trains with 34 fatalities(!). And this was not the first time…
I don’t have any intention to say the problem in KAI is simple. It’s not; should it were simple, it would be solved years ago.
Yet, an appreciation of the system will help the management to improve it. Especially to blame any crash as a human error will not only ineffective, but also can be dangerous because does not touch the root cause.
The crucial part in understanding the system is to know who are the CUSTOMER(S). Then, what are their NEEDS? See below picture.
From PT. KAI website it was mentioned that the company have 4 main pillars: safety, timeliness, services and convenient. Yet, only timeliness have the measurement and performance tracking (only shown fore 2007-2008) in the form of “average lateness” and “average punctuality %).
In my opinion, KAI first and foremost must find out the voice of customers for SAFETY; what customers need. I believe this should be ZERO accident or zero fatality. That the vision, for example.
For each of performance parameter, KAI should have an operational definition (for example what are the parameters for SAFETY) and track the performance daily.
For instance, they could be: # accidents, # incidents, time between accident, etc.
Next step, track them daily and build a control chart to see if the system is stable or there is a special cause. Is the system capable, means it is within the customer requirement? (Will continue in the next post on Understanding Variation).
I believe all of the thinking on the system, customers need and control chart will lead the management to find a way to achieve the customers expectation.
Understanding the whole system will also help to understand the complexity if there is conflicting objectives (e.g. safety vs. cost) or any problem from the input and suppliers.
In summary, through a mindset like this, we can start a continuous improvement.