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David C. Crosby

Quality Insider

Words That Kill Quality and Spill Oil

If your boss says, “Don’t worry about it,” then worry.

Published: Monday, July 19, 2010 - 06:00

Ben Margugilio wrote a nice article for Quality Digest Daily outlining how failure mode and effects analysis (FMEA) and what might be called just good practices could have prevented the Gulf oil spill.

I believe the cause goes deeper than method, procedures, and even technical knowledge and skills. The real cause of the oil spill can be summed up in a few words—four words, in fact.

I can remember it as clear as can be—my first day on the job as a hydraulic tester of missile controls at a large aerospace company. When I took the job I knew nothing about hydraulics, but I could turn knobs, read gauges, and follow instructions (and I needed a job, badly). The first control valve I tested failed; the dome on top of the valve popped up and changed shape. I didn’t see anything about that in my instructions, so I asked my boss what to do about it. His instruction? “Don’t worry about it.” I was puzzled, but grabbed the next valve and kept on testing. Sadly, I’ve heard those words, “Don’t worry about it” many times since.

Every quality manager and inspector has had arguments that ended,“Don’t worry about it.” That means the good guy probably lost the argument. It also means that questionable product got shipped.

A few Sundays ago, I was watching 60 Minutes; maybe you saw it. The subject was the oil spill in the Gulf of Mexico. It was a first-person report from an employee who lived through the whole thing and narrowly escaped death. He fought his way out of the burning and exploding oil rig after he performed his emergency duties. While he was busy doing that, others—not so brave—left with the last lifeboat. With all the lifeboats gone, he ended up jumping into the oil-laden water some 90 feet below to save his life. He’s a lucky man, a very lucky man.

He went on to explain the problems. He walked through all the events that caused the explosion, the fire, the oil spill, and the death of 11 people. It boiled down to several mistakes that were made and the reaction to those mistakes. The critical mistakes involved the shut-off assembly located at the mouth of the well. This device was designed to do what its name implies: shut off the flow of oil in an emergency.

Long before the disaster happened, a technician made a mistake that resulted in a fire and destruction of one of two control panels located on the valve. This caused part of the device to overheat and damaged a seal. The seal, a large rubber ring designed to compress and seal the oil passage, was damaged by the heat. You know how rubber gets when it’s overheated—dried out and cracking.

The crew topside learned about the damage to the seal when bits and pieces of charred rubber started showing up in the fluid coming out of the well. When this obvious damage to the seal was reported, the instructions were, “Don’t worry about it.” That was the start of the disaster.

Later—as I understood it—a decision was made to remove the drill. The normal process is to pump what is called mud into the well as the drill is removed. It’s a complex process—done in baby steps—that I don’t understand. According to this gentleman, orders were given to ignore the proper mud routine and just pull out the drill. Another “don’t worry about it” moment. This apparently put more strain on the system and was the final straw. Motors started to run too fast, generator output was too high, gases started filling the air, and things started exploding.

There is an easy solution to the “don’t worry about it” problem, which is “worry about it.” Managers, supervisors, and workers must understand the importance of meeting the requirement and the risk—to their careers and the lives of others—if they don’t. It must be part of the culture. It’s called “attitude.”

Like everything else in business, the right attitude starts at the top. If a foreman or plant manager is judged by meeting shipping schedule, you’ll hear “don’t worry about it” quite often. The company's attitude is that shipping is more important than making it right. Sadly, in many manufacturing operations, once a defective product is shipped, it becomes someone else’s problem. It belongs to the quality department when it’s returned.

Every level of management must have a zero defects attitude—defects are not acceptable—and be trained to play by the rules. Sometimes it takes courage to do the right thing, but it's critical.

About that valve thing at my old job—it became part of an engineering test using air instead of oil. The valve failed again and blew a guy’s thumb off. That was the last time I accepted anything that didn’t conform 100 percent to the specifications. Many times I was told, “Don’t worry about it.” When I was a source inspector and had a problem, the answer was usually, “Don’t worry about it,” followed by, “Just ship it.” My answer was always, “If you like it, put your stamp on it.”

Maybe if the CEO of General Motors or Toyota or a hundred other companies had the correct attitude about quality, there wouldn’t be so many recalls. I wonder what GM's reaction to the 1.5 million recalled trucks was, or all the Toyota vehicles that have been recalled. I wonder what the attitude of the CEO of Enterprise car rental was who let the employees think it was OK to deliver a defective car to a customer, which caused the death of two young women. I wonder if these CEOs—like many plant managers—had a habit of saying, “Don’t worry about it,” and then blaming someone else for the problems.

Quality is serious stuff. Preventing defects is serious stuff. Quality management and inspection are important, but everyone in the company must play by the rules. Somebody at the top must insist that everyone plays by the rules. Someone at the top must have the right attitude. “Don’t worry about it” doesn’t work.


About The Author

David C. Crosby’s picture

David C. Crosby

Dave Crosby is president of The Crosby Company, a firm he created to develop and deliver software and training in the field of quality management. His SPC software was the first on the market for the personal computer. His books include, How To Get Your People to Do Things Right, Quality is Easy, How To Run a Zero Defects Program, and The Zero Defects Option.

Crosby served as corporate director of quality for RCA Corp., General Instruments Corp., and Portec Inc. He was awarded the “Outstanding Civilian Service Medal” by the U.S. Army for his work with the Army Zero Defects Program. His web site is www.zdoption.com.


Quality Gurus Violate Their Own Principles

The recent spate of articles in Quality Digest by pundits of quality and safety regarding the Gulf oil spill only prove that people are governed by their own self-interests. This is no more true than of the authors of these articles. Without exception each author has violated the first principle of root-cause investigation.

You keep your judgments regarding what may have happened to yourself until you have all the facts and have been able to analyze those facts against the knowledge and expertise of the individuals on the root-cause team and any specialists that the team may request assistance from to understand a particular aspect of an incident. Until you have exhausted every avenue for obtaining the full facts of an incident you don't go around speculating or pronouncing judgments regarding actions, motives, procedures, etc.

It is irresponsible journalism that Quality Digest would engage in the manner of self-centered reporting that it has in regard to the events surrounding the Gulf oil spill. What happened in the Gulf is far more complicated than anyone understands at this time. It is especially deplorable that those who claim to be experts actually engage in the kind of speculative discussion regarding what happened and why, when they are not even part of the root-cause investigation team!

This only highlights their own arrogance and demonstrates their fantastical belief that they can somehow see into these events and discern what happened so though they have some kind of crystal ball or ability to see through walls and read minds! Obviously, these individuals have learned nothing from the teachings of Deming and Juran. Thank you.

Richard S. Bradley, Jr.
CQE Systems, Inc.

of course you should worry

I agree totally. And since psychologists tell us that the majority of people need at least six repetitions of exposure to an idea before they internalize it; you might want to point out that this same mentality caused both of the shuttle disasters (don't worry about the booster O-rings in freezing weather or impacts on the insulating tiles). It was also the cause of several of the world's greatest maritime disasters, including the Titanic. It was at least a contributing factor in some of the military's greatest disasters as well. BP itself had a previous instance of this with the explosion of one of it's refineries here in the US. Sadly the list is nearly endless. While not every instance of complacency is disastrous or deadly they are all undesirable and unprofessional. It seems reasonable to say the same is true for those who routinely approve of such behavior.

Another sad case...

Not long ago, a famous film actor and his wife went on 60 minutes to discuss how their twins, as newborns, nearly died because they were given the wrong medicine. For their ailment, there was an adult version and an infant version of the correct drug. IIRC, the 2 medicines had different names but similar containers. The scary part was that the manufacturer's VP of Public Relations went on 60 minutes to say that they had no responsibility regarding the packaging design (acting to save her job and minimize legal risk). While this may be true, it is an astonishing failure of accountability - particularly since the variety of size and shapes that pills come in clearly indicates that mistake-proofing is common in drug design - and illustrates the lack of coordination among entities in a supply chain. As Mr. Crosby suggests, an FMEA would likely have driven the packaging change that would have functioned as a poka-yoke.