Main Stream Product Quality
Ryan Connolly
Jason Guhsé
Jed McCann
Rich Steffens
Do you think you’re safe?
2763 vehicle
related quality
recalls since
January 2000
Are Vehicles Safe?
• Mitsubishi admits to covering up quality - recalls 1 million
vehicles (8/22/00)
• Kawasaki - Motocross Motorcycles, rear brakes can fail,
may result in death (18,000 units) (1/2001)
• Kawasaki – 2000 Ninja Motorcycles leak fuel – may cause
fire – 7785 units. (2/16/2001)
• Isuzu Trooper 2000-2001 – Fuel leaks upon front impact
may cause fire. (18,462 units)
• Mercedes E-Class 1997 – Side air bag deploys without
crash. (16,255 units)
More Vehicles...
• BMW R1200C – Back support bracket can break allowing
passanger to fall. (1,636). (1/23/2001)
• Saturn – Fuel System Vent Valve – may leak, can cause
fire. 6092 units (1/23/2001)
• Honda – Off Road Motor Cycles – Handle bars separate
from bike. 22,000 units (11/22/2000)
• Honda – ATV’s – Faulty front suspension bracket, causes
crash, may result in death, 126,000 units. (11/13/2000)
Consumer Products?
• DeWalt – Battery Charger, does not turn
off after charging, battery explodes, may
cause fire or burn, 1.7 Million
• AmeriGas Propane Tanks - leak
unexpectedly and risk fire and explosion.
• Water Heaters - fail to vent carbon
monoxide - (320 units) may cause death
• Gun Locks - Open without a key
(400,000 units)
• Black & Decker 12” miter saw - bolts
loosen, cause blade to come off - “risk of
laceration” (6400 units)
Children’s Products?
• Graco - Highchair legs come out and fall to ground.
860,000 Highchairs (2/2001)
• Simmons - 68,600 baby cribs, mattress can collape, may
cause suffocation.
• Children’s bikes - pedals are too low, they hit the ground,
may cause injuries, (1400) units (1/2001)
Food
Quality?
• Tyson Foods recalls 2.3 million pounds of chicken (not
fully cooked - in precooked packaging) 2/21/01
• Cargill Turkey – 16.7 million pounds of turkey and
chicken – Listeria. (12/14/2001)
• Cargill Turkey – 10 more tons of Turkey – Listeria
contamination. (1/3/2001)
• Schreiber Foods – Colby Cheese – Listeria. 6 months
production / over 22 brand names.
• Safeway Drinking water- unfit for consumption - filth.
30,200 cases. (2/8/2001)
Mini - Case Study #1
• You are the R&D
Manager - A possible
design flaw has been
brought to your attention
• The design problem
affects an entire fleet of
products.
• Supplier insists that the
– The issue appears to be with
design is flawed.
an out-sourced component.
• Correction per unit is very
– The issue is a potential
costly.
safety issue.
• This unit already has the
best safety record on the
market.
The Boeing 737: Is It Safe To Fly?
737 Airframe Data
•
•
•
•
First introduced to service in 1967.
3,111 Airframes in service worldwide.
Cost per Airframe: $38-$64 million
The 737s have carried the equivalent of the
world's population - about 6.1 billion
passengers.
The Problem: Rudder PCU
• Power Control Unit (PCU)
– Only aircraft using non-redundant control
system
– If system becomes stuck, uncommanded rudder
movement may ensue
– Severe upset (rollover) may occur
– Most likely to happen during take-off and
approach
The Result: Disaster
• 1991: United Airlines Flight 585
– All 25 people onboard killed
• 1994: USAir Flight 427
– All 132 people onboard killed
• Four more crashes still under investigation:
–
–
–
–
Aug ‘99 in Argentina
April ’99 in Turkey
1998 in Peru
1997 in Indonesia
More Incidents...
• The National Transportation Safety Board
(NTSB) lists 112 “rudder events” on Boeing
737 flights in the past two decades.
• “The 737 series airplanes… remain
susceptible to rudder system malfunctions
that could be catastrophic.”
– 9-13-99 NTSB report on Boeing 737 Rudder Malfunctions
Did Boeing Know about this
problem?
• 1969: Bertea Corp.* patents a solution to
the jamming problem
– Result: No buyers were interested
• 1982: Bertea again patents an anti-jamming
patent
– Result: Still no buyers.
*Bertea Corp. contracted with Boeing to mass-produce 737 rudder valves
in the late 1960’s.
• “One failure... Occurs when the valve
becomes stuck or jammed. This may be the
result of contaminants… warpage, thermal
expansion or contraction of the elements of
(the valve) or numerous other reasons.”
– 1969 Bertea corp. Patent on anti-jamming mechanism.
Boeing’s Response
•Boeing initially stood behind the Design
of the 737 Rudder Control System.
•In 1998 the company issued an upgraded
rudder valve in all US 737’s and many
Foreign models.
•However, the FAA was not satisfied with
Boeing’s solution to the Rudder Control
problem.
The NTSB’s Response
• “While the Boeing 737 is one of the safest
airplanes in the world, the Engineering Test and
Evaluation Board (ETEB) found that:
– The 737 rudder system is susceptible to numerous
failures and jams;
– The 737 “Resistricted or Jammed Emergency
Procedure” is difficult to use and flight crews are not
adequately trained in its use;
– Maintenance inspections used to address undetected
failures are insufficient.
The NTSB’s Response (cont.)
• Issued Alpha Safety Alert Bulletin 2000-7
– Overviews the safety issues of the 737
– Describes to pilots how to overcome
uncommanded rudder movement
– Outlines the corrective action Boeing must
follow to eliminate the Rudder Control problem
The FAA’s Reaction
• December 1, 1999: Federal Aviation
Administration commences special audit of
Boeing Company following recent quality
issues.
The Airlines’ Reactions
• USAirways: Boeing Co. withheld flight test data
on the twin-engine 737 jet that could have
prevented the crash of the airline’s Flight 427.
• If the airline had known of the aerodynamic data,
it could have changed its flying procedures before
the crash.
– “I would have expected the 427 crew to have
successfully been able to fly out of the situation”
-James Gibbs, USAir flight manager.
The Public’s Reaction
• The widow of Timothy McCoy has already
received $62 million in damages from her
husband’s death on Flight 427.
• McCoy’s attorneys are trying to prove
“willful and wanton” conduct of both
Boeing and Parker-Hannifan (manufacturer
of the Rudder Mechanism) for concealing
design defects.
Boeing’s Final Fix
• Near Term:
– “Restricted or Jammed” rudder procedure will be
simplified (Oct 2000)
– Improved jammed rudder training will be incorporated
into 737 training programs (Nov 2000)
– Changes to airline maintenance programs will be made
to limit exposure of undetected failures (First Quarter
2001)
– Flight crews and maintenance personnel will be trained
to recognize the symptoms of rudder malfunctions
(First Quarter, 2001)
The Final Fix (cont.)
• In the long-term:
– “The Boeing 737 rudder control system will be
redesigned to increase redundancy and enhance
protection against undetected failures. One goal of the
redesign is to eliminate the need for a jammed rudder
procedure. Initial design changes should be defined by
July 2001 with a target FAA certification date in mid2003. The redesign should be finalized by July 2002
with implementation on the 737 production line by
2003. A complete retrofit of the United States 737 fleet
should be completed by 2006.”
The Cost of Quality
• The cost of the new PCU: $50,000 to
$60,000
• Total number of airframes affected: 3,111
• Total Estimated Cost of Redesign:
$155,550,000 to $186,660,000
Was this a Quality Issue?
• Quality Control does not just apply to
production! Quality in Design must also be
enforced.
• We can produce a product conforming to 6sigma quality, but if the design produces a
product that doesn’t work (or endangers
lives), it cannot be considered a “quality”
product.
Translation:
• Boeing ignored the Rudder Control problem for
30 years, until the FAA stepped in.
• Boeing argued that there was no problem.
Reluctantly, the issued an upgrade valve to fix the
problem
• 737’s still had rudder problems. Boeing still said
there was no problem.
• The FAA ordered a FULL redesign of the PCU
• Boeing now advertises this redesign as an
“enhancement”
The New Design:
Mini - Case Study #2
• You are the VP of
Quality - A problem
has been brought to
your attention
• Supplier has long-term
relationship with you.
– Their 1st product was
on your 1st product.
– The issue appears to be • Supplier was recently
purchased by a foreign
with an out-sourced
company.
component.
– The issue is a potential • Supplier insists that no
problem exists.
safety issue.
• Same component is used
– Improper Disclosure
could land company in
across 5 major companies.
court.
Firestone
Tires
Tread
Shedding
Production Quality Issues
• Worker strike - 1,400 replacement workers (inexperienced)
• Financial Incentives to release poor quality tires - hides
poor quality
• Bad plant conditions- high humidity causes corrosion
• Poor understanding between management and inspectors
• High production rate: backup at inspection
• Unique process: pelletized rubber
Did Firestone Know About the
Problem?
• 1996: Internal durability testing showed
potential defects.
• Manufacturing procedure changed, but no
further testing was done.
• Proper design-test-fix cycle was not
followed.
Ford Enters the Picture...
• Firestone refuses to issue a recall notice
• Ford begins tire replacement without
Firestone’s consent
• Ford continues to press Firestone for
recall… Threaten to issue a recall with or
without Firestone’s agreement
• Firestone buckles under Ford’s pressure and
recall begins (Aug. 9, 2000)
Fallout
• Ford closes 3 manufacturing plants for
several days to provide needed replacement
tires to the public.
– A One-day closure costs $24 million in profit
per plant.
• Began in Saudi Arabia, moved to Thailand,
Malaysia, Venezuela, then to the US.
Firestone
• GM, Nissan, Toyota, Subaru, and Ford used the same
Firestone Wilderness AT Tires.
• Firestone is currently replacing 100,000 tires installed
on the Nissan Altima due to a design defect.
• Firestone is owned by Bridgestone Japan.
• GM announced 2/22/01 to drop Firestone and switch to
Bridgestone….
• Toyota pledges to support Bridgestone.
• Ford is now switching to Michelin and Goodyear Tires
to replace Firestone.
Discussion?
Summary
• Ensuring Quality is not an Easy Task!
• As outsourcing grows, who becomes liable?
– “The buck will stop entirely at the company
whose name is on the grill”
• When does a design flaw become critical?
– What cost do you put on human life?
• Processing Chicken vs. Making Airframes:
What’s the difference?
How safe would we be
if YOU were in
charge?