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MD-11 Team —
We learned root cause analysis can be as simple as repeatedly asking, "Why?"

Safety is first and foremost in how we operate our business. Between 1997 and 2013, FedEx Express experienced multiple MD-11 aircraft accidents — and senior leaders knew that another accident could put the safety of the crew and fleet, as well as the ability of FedEx to serve its customers, at risk.

The MD-11 airplanes are a critical part of the lift needed to serve customers, but with the current safety metrics, the entire fleet was in danger of being grounded or having operations restricted. A team of FedEx pilots, instructors, check airmen, chief pilots, safety experts, and data collectors assembled to improve MD-11 landing safety.

To understand why the accidents happened, the team collected data about how the airplanes performed during landing. Based on the data collected on critical aircraft operational metrics, such as unstable approaches and hard landings, the team recommended to Flight Operations that specialized training should be conducted for FedEx MD-11 pilots.

By using the Five Whys during root cause analysis, the team uncovered the unique requirements of flying the MD-11 and the additional safety techniques its pilots must know. Pilots who went through the training course took the instruction to heart.

Inside the cockpit, pilots utilized this new training to change the way they flew the airplane, which made a measurable difference in landing safety:

The Results

0

accidents

0

hard landings

34

reduction in unstable approaches

3-5 million

minimum saved in hull loss avoidance

4-5 million

minimum saved in tail strike avoidance

With complex airplanes, the typical solution to problems is to add another "black box" and leverage additional computer technology. The MD-11 team's results prove that making relatively simple QDM-driven process changes can have a dramatic effect, even without expensive technology solutions. That's the power of QDM — finding the right solution to solve a problem.

QAT Member Inspired by Quality Driven Management
Throughout his experiences with QDM, FedEx pilot Steve Harden has found one of the most important things to consider: "The people who have to use the solution are the ones who should create it." That's why this QDM team was led by pilots — they were the main working group who had to use whatever solution was developed.

However, given the far-reaching impact of the MD-11 project, many other groups across multiple levels of leadership and working groups at FedEx Express needed to weigh in on the solution. Steve says, "Part of the team's success was due to the fact that any working group affected by the solution was part of creating the solution. QDM is a scientific way of bringing diverse teams together to solve problems."

For people who may feel overwhelmed by QDM, he recommends starting with the tools that you are most familiar with, rather than trying to apply all of the QDM principles and tools to every project. The simple approach is often the best approach.

Whether it's in his work or daily life, Steve always starts with the Five Whys: "If you see something that's not working, go through a series of asking yourself "why" at least four or five times in order to get to the root cause and solve the problem, instead of addressing the symptom."