We are surrounded by quality failures that are appallingly costly in rupees lost, opportunities foregone and grief incurred. Our lives are full of mundane personal failures. Consider the occasions when we spend ten minutes standing in the wrong queue, when we need to pay an additional service charge because we forgot to pay a bill on time, when we are late for an appointment, or when the boss returns our work for correction. In all these cases personal quality control has failed because of a lack of a systematic way of doing things right the first time.
Apart from personal failures, the suppliers we deal with often disappoint us with their quality failures. For example, the credit card company that double charges our expenses or the electrician who drills a crack in our wall. We become victims of quality failure when our new bedroom furniture arrives with the wrong polish, the bottle of mineral water refuses to open or we have to wait two hours to see a doctor to be admitted to a hospital. Equally a victim is the airline passenger who has to wait in a queue to screen his checked-in luggage, then wait in another queue to check-in, then stand in a crowded hall, then stand in more queues to screen hand luggage, check-in at the gate, undergo security formalities, wait for the coach, enter the aircraft, and finally (manage to) squeeze into a tiny seat with the possibility of going hungry.
Fear of major disasters and near disasters has also raised product quality to a position of prominence in the public mind. On the night of 2-3 December 1984, 40 tons of methyl isocyanate, hydrogen cyanide, mono-methyl amine and other lethal gases began spewing from Union Carbide’s pesticide factory in Bhopal. Nobody outside the factory was warned because the safety siren was turned off. Not until the gas was upon them in their beds, searing their eyes, filling their mouths and lungs, did the communities of Bhopal know of their danger. Over half a million people were exposed to the deadly cocktail. The gases burned the tissues of the eyes and lungs, crossed into the bloodstream and damaged almost every system in the body. Nobody knows how many died but over the next few days more than 7,000 death shrouds were sold in Bhopal.
On the night of the disaster, water (that was used for washing the lines) entered the tank containing methyl isocyanate through leaking valves. The refrigeration unit, which should have kept the methyl isocyanate close to zero degrees centigrade, had been shut off by the company officials to save on electricity bills. The entrance of water in the tank, full of methyl isocyanate at ambient temperature, triggered off an exothermic runaway reaction and, consequently, released the lethal gas mixture.
The Bhopal disaster had ingredients of:
- failure of product
- failure of process
- failure of system
- failure of management
- failure of individuals.
In other words, the Bhopal disaster was a total quality failure.
On 28 January, 1986 the spectacular explosion of the space shuttle Challenger with the loss of all its crew seemed like a freak, random accident. In fact, it had the classic pattern of a specific failure arising out of a flawed system that could have produced a failure in many ways. The presidential commission that investigated the Challenger tragedy focused, as most such bodies do, on the immediate cause: the O-rings on one of the booster engines that allowed gases to escape through a joint in the booster. The launch occurred after a night of frost, on a day colder than that for any other shuttle launch. Therefore, the rubber O-rings had lost their resilience and failed to set a tight seal at the joint.
The commission found that the original design of the seal was flawed. They discovered that engineers at Morton Thiokol, which built the booster, and those at Marshall Space Flight Center, which was responsible for the booster and main engines, had for years warned of flaws in the performance of the seals. On previous launches, especially in cold weather, the O-rings were eroded by burns and marked with soot. But top management never listened to the warnings. NASA acted like a manufacturer such as an auto plant, with management demanding that it “push metal” out of the door - and fix whatever problems might show up, later. NASA was under pressure from Washington and the media to send more shuttle missions into space, but NASA had no way of fixing the shuttle’s problem “later”. The engineers knew the Challenger should not fly right after a freeze, but NASA management did not get the message.
On the night of 31 October, 2000, at least 80 persons were killed in the crash of Singapore Airlines flight SQ 006 at Taipei’s Chiang Kai Shek Airport. The Boeing 747-400 was enroute from Taipei to Los Angeles with over 150 passengers and 20 crew members on board. The aircraft crashed on the runway during take off at 11:18 pm. The pilot, C K Foong, a Malaysian, had 11,235 flying hours experience. He had two Singaporean co-pilots on board. The passengers were from 18 different countries.
The three pilots were detained in Taiwan since their Boeing 747-400 jumbo jet had mistakenly tried to take off on a closed runway during a severe storm. The plane had slammed into construction equipment and burst into flames. Crash investigators did not conclude that pilot error had caused the accident. The black box cockpit recorder indicated that the pilot had thought that he was on the correct runway.
These three examples of disasters highlight the interdependence of quality and safety. They demonstrate the possible effects of the failure of quality systems. They underline the grief caused by unreliable processes. In short, we live behind quality dikes.
In his classic, “Leadership for Quality”, Dr J M Juran explains:
“Industrialization confers many benefits on society, but it also makes society dependent on the continuing performance and good behaviour of a huge array of technological goods and services. This is the phenomenon of ‘life behind the quality dikes’ - a form of securing benefits but living dangerously. Like the Dutch who have reclaimed so much land from the sea, we secure the benefits of technology. However, we need protective dikes in the form of good quality to shield society against service interruptions and to guard against disasters”.
CREDITS: Suresh Lulla, Founder & Mentor, Qimpro Consultants Pvt. Ltd.