Words That Kill Quality and Spill Oil

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

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.

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Comments

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.

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.
President
CQE Systems, Inc.
www.cqesys.com