I would like to pass on some very positive feedback on the new look. While many magazines tout “new and improved” features, graphics and content, it looks like this change adds substantive content, accessibility and usability. The change, from my perspective, embraces the true meaning of quality progress.
Congratulations on a job well done and implementing an improved process and product improvement! It befits a quality organization and magazine to get it right the first time.
Electronic Systems Sector
We received many letters, e-mails and phone calls about the QP redesign, most of which were complimentary about the new look and website. In the spirit of continuous improvement, a few individuals also suggested enhancements we could make. We will continue to collect and address this valuable feedback and make changes and adjustments accordingly.
Thanks to those who took the time to contact us and to everyone for reading.
Soft dollars can stick
I just read the Expert Answers article in the January 2008 QP (p. 10), which posed the question about senior management desiring projects with bottom-line savings versus soft dollar savings. The answer focused on the soft savings from process step reduction, but I think this missed the issue.
I lead the lean Six Sigma program for our hospital, and soft versus hard savings is a common topic. For example, we recently embarked on a 5S project to improve nursing supply rooms.
Not counting any savings from improved inventory, this project could save each nurse five minutes of time per eight hour shift. If 300 nurses work a shift each day, this would result in 25 nursing hours saved each day or 9,125 hours per year. If the average nurse earns $25/hour, the savings would be $228,125 per year.
Before we rush off to do the project, our CFO will say, “We are not going to send each nurse home five minutes early each day, so there will be no actual reduction in salaries.” Therefore, this project will generate only “soft dollar” savings.
This viewpoint accompanies many quality improvement projects in healthcare settings, which tend not to use cost allocation financial systems more commonly found in manufacturing.
At the end of the day, we are still doing this project, but the savings will not count toward my department’s contribution to “hard dollar” savings. While I do understand and appreciate the viewpoint of finance, in this case it is also an important project for internal customers—our bedside nurses.
Saint Vincent Health System
The article “Conflict and Complexity” by H. William Dettmer (January 2008, p. 22) reminded me of an old Dilbert cartoon. In it, the CEO states, “Quality is our top priority.” A question is asked: “Is it more important than safety?” The answer from the pointy-haired CEO: “I forgot about that one.”
The logical thinking process, had it been in existence, would not necessarily have prevented the Challenger disaster without a change in the mind-set of leadership. It appears that Morton Thiokol Corp. and NASA top management made launch decisions that outweighed considerations for the safety of the Challenger crew.
Aristotle said, “It is possible to fail in many ways … while to succeed is possible in only one way.” Independent of the quality program or process used, unforeseen situations appear. We are not always perfect designers. But when the leaders have the proper attitude and emotional attachment with respect to doing the right thing, it is likely that safety issues related to injury or death can be reduced to very low-probability events.
According to Jeff Forrest in his paper, “The Challenger Shuttle Disaster,” it seems at least two opportunities existed for greatly reducing the probability of failure:
- O-ring problems had been observed months before the launch. They did not appear to have been investigated, and appropriate changes had not been made.
- The temperature at launch was well below the Thiokol recommendation of 53 degrees. Thiokol designed the O-ring seals and supposedly knew their limitations. NASA management browbeat Thiokol into agreeing to the launch.
It was stated that the height of the assembled boosters precluded a vertical assembly that better approximated actual conditions for launch. If so, it can be concluded that the horizontal assembly was not sufficiently tested to ensure it would function properly in real-world conditions. Engineering designs are usually tested under simulated and actual use conditions.
Performance objectives, including safety, are not achieved without proper testing. Problems can become visible after a design is released. The logical process, while useful, will not necessarily avoid all critical safety problems. The fundamentals of providing quality must still be used: test, find and remove failure modes, continuously collect field performance data, analyze and make necessary changes
Levin raises some excellent points, particularly about the decision process among top management. The idea of decision making on a conference call with 35 participants is ludicrous. It reminds me of the old saying, “Teamwork is essential—it allows you to blame someone else.”
The launch decision management process, from the first shuttle launch in 1979 through Mission 51-L, is a ripe issue for a completely separate discussion about organizational leadership and groupthink. And the Rogers Commission Report clearly identified this as a contributing cause.
But, as Levin suggests with his Aristotle quotation, there are multiple contributing causes for a single outcome. The logical thinking process assumes it might not be possible, or even advisable, to try to eliminate all contributing causes. Elimination of one might be sufficient to break the chain of causality. In the Challenger case, one of those contributors was a faulty, Band-Aided design established in the mid-1970s.
Had that design not been embraced as the only way to address the challenge of vertical versus horizontal assembly, the issue of launch time air temperature and its effect on the integrity of O-ring sealing probably would never have been an issue. Titan-IIIs launched in similar conditions for years, with the same booster design, and the Titan-III was NASA’s most reliable booster.
So the issue is not whether there were multiple causes of the accident. The question centers on the interdependent nature of the relationship among them. The faulty management decision process that occurred later depended on the earlier faulty booster design to produce the result. And which is easier to change, an engineering design or human group behavior?
Use of the logical thinking process does not guarantee success. I hope my article did not imply as much. But in the absence of any other logical problem-solving approach, it can turn the odds of success in your favor. Other analysis tools, had they been available (and used), might have done the same.
If the booster design engineers had the ability to apply an evaporating cloud and TRIZ to their engineering challenge in 1976, the odds are extremely low that a top management launch decision (based on O-ring compromise) would have been necessary. Perhaps some other aspect of safety would have required a group decision (ceramic tiles come to mind), but not the issue of O-ring failure to seal, which was the cause-in-fact of the accident.
H. William Dettmer