We all know the point of using a Quality Management System (QMS) is to clearly understand customer requirements, then manage internal processes (management, design, and production) so that they fulfill these requirements in an effective and efficient way. A QMS based on ISO 9001 also charges organizations with continual improvement of these processes.
A QMS History: When QMS Failures Go Viral
Most of us are fortunate. When the Quality Management System fails to function and important requirements are missed or processes run amuck, it doesn’t make the national news. Customers might be upset; management and employees both might be unhappy, but as bad as that is it is usually as far as it goes.
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For the unfortunate ones, a Total Quality Management (TQM) failure makes headlines.
Here, in no particular order, are our top 5 Famous Quality Management Failures:
Three Mile Island
While the country was having a strong debate about the safety of nuclear power in the late 70’s, in March 1979 the worst nuclear disaster in U.S. history at the 3 Mile Island reactor facility in eastern Pennsylvania sealed the deal. Proper controls that should have been developed as part of routine safety procedures were not in place (i.e. auxiliary coolant system valves were shut for maintenance while the reactor was operating, so a failure in the main coolant system resulted in no coolant). Then the situation was exacerbated by human error eventually attributed to the lack of proper training. The only nuclear power stations built since that day were the ones already under construction.
The promise of an advanced technology, orbiting telescope seemed almost endless – until someone tried to look through it. The images were only slightly better than Earth based telescopes, and very distant and faint objects (the very reason for having an orbiting telescope) could not be seen at all. It turned out that the most precisely ground mirror in history had been ground into the wrong shape. A congressional investigation revealed that during production negative testing results from multiple instruments were ignored, while the good readings from a flawed instrument were accepted. Additional billions were spent correcting the problem.
While they quickly recovered, Apple was on the verge of losing their dominance in the device market when it became clear that it was difficult to make a call using the much anticipated iPhone 4. Calls were dropped suddenly and frequently causing wide spread dissatisfaction with loyal customers who upgraded to the new version early on, while Apple continued to deny or minimize the problem. Independent tests revealed that touching the left side of the case at a certain spot interrupted the signal and dropped the call – not a great feature for a handheld device used primarily to make calls. As the issue continually made the news cycle, Apple eventually conducted a “voluntary” recall to correct the problem.
Just a few months after being completed, in early June of 1976 the earthen dam in Idaho collapsed and completely flooded about 6 miles of the Teton River canyon to devastating results. Not only were improper materials used in the construction, but the main outlet and spillway gates needed to relieve pressure were closed and blocked with sheet metal for painting. This maintenance was being done in the spring, even though it was not unexpected that during this time of year the reservoir created by the dam would fill to capacity – which it did.
While it would be easy to nominate the whole U.S. automobile industry in the 1970s, the Ford Pinto is most well-known and the worst disaster. Apparently the entire U.S. auto industry decided to spend the 1970s resting on their laurels of building great cars that people wanted during the sixties. Not only were many cars built during the seventies ugly and ill-conceived, they were also notoriously unreliable after as few as 40-50 thousand miles. The Pinto tops the list because its design flaws and questionable ethical decisions by top management made it dangerous as well.
Did This Need to Happen?
All of the above notorious quality management failures could probably have been prevented if the principles of a fully functioning quality management system were in place. Requirements like effective design reviews, design and process FMEAs, measurement based corrective action (including customer satisfaction) that are part of TQM and QMS could have changed quality history for these organizations.
While a QMS might not have to save your company from national humiliation, it might save customers and improve the value of internal efforts – the essentials for success in any business.
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