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 issue appears to be with

an out-sourced component.

– The issue is a potential safety issue.

• The design problem affects an entire fleet of products.

• Supplier insists that the design is flawed.

• Correction per unit is very costly.

• 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 mid-2003. 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 6-sigma 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– The issue appears to be with an

out-sourced component.– The issue is a potential safety

issue.– Improper Disclosure could land

company in court.

• Supplier has long-term relationship with you.– Their 1st product was on

your 1st product.

• Supplier was recently purchased by a foreign company.

• Supplier insists that no problem exists.

• Same component is used across 5 major companies.

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?