Michael Brajac Michael Brajac Consulting Presentation to Toronto Section ASQ February 2015 Learning From Failure Learning From Failure Creates psychological anchors that reinforce learning Asking What went wrong is more insightful than What went right ID: 445426
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Learning from Failure: Quality Lessons from 2014-the Year of the Recall
Michael Brajac
Michael Brajac Consulting
Presentation to Toronto Section ASQ February 2015Slide2
Learning From Failure!Slide3
Learning From Failure
Creates psychological anchors that reinforce learning
Asking “What went wrong?” is more insightful than “What went right?”
Need a “clinically detached” approach--admit the failure, learn from the failure, don’t repeat the failure
We need more of this kind of discussion in the Quality ProfessionSlide4
The GM Ignition Switch Is the Automotive Equivalent of the Space Shuttle Disasters
GM Recalls
52 confirmed deaths GM ignition switch
No understanding of the risk or sequence of events that can lead to loss of power—customer convenience issue
House and Senate Investigations
Numerous lawsuits
Little understanding of the “systems aspect” of the ignition/air bag interface
2
Challenger Disaster
7 Astronauts killed
Risk greatly underestimatedExtensive cross functional investigationRogers CommissionNeither NASA nor Thiokol understand mechanism of joint sealing action1
The Presidential Commission on the Space Shuttle Challenger Accident Report, June 6, 1986, p. 120, p. 148
Valukas Report, pp. 33, 44Slide5
Space Shuttle Challenger Data “O-ring Failure”
Source: Datavis.caSlide6Slide7
Rogers Commission (sample of members)
William P. Rogers, (Chairman), former secretary of state
Neil A. Armstrong (Vice Chairman) Retired Astronaut
Richard P. Feynman, 1965 Nobel Prize in Physics
Robert B. Hotz, Editor Aviation Week and Space Technology
Donald J. Kutyna, Air Force General, ICBM Background
Sally K. Ride, astronaut, first American woman in space
Charles E. Yeager, retired Air Force general,
Source: WikipediaSlide8
Source: GMIgnitionCompensation.comSlide9
GM Ignition Switch
Picture credit: JonesWard.comSlide10
Understanding Your CustomerSlide11
Is There Only One Way to Solve a Problem?
Red X
1
Team engaged Sept 6, 2012
2
Key component of Red X—BOBs and WOWs looking at the extremes
Team tasked with “What Changed from 2007 to 2008
Crashed vehicles are supposedly “quarantined” as evidence
Red X Engineer assigned to project essentially walks away from the project when he is denied access to the crashed vehiclesProject declared “stuck”—outside experts retained—reach the same conclusion in 2013 that Trooper Young and Indiana University reached in 2007
Valukas Report, p. 186-188
Red X is a Service Mark registered to the Shainin ConsultantsSlide12
The Changed Detent Plunger
Photo credit: McSwain Engineering, GM’s Hit and Run: How a lawyer, mechanic and engineer blew open the worst auto scandal in history.
www.pando.com/2014/10/18Slide13
Lessons Learned
There was ample opportunity for other leverage—all non deployments were prior to 2008.
Don’t assume anything! Simple contrast—model year to model year—utilizing a group comparison would have shown right away the switch was different
Admit when you are “lost in the data” and ask for help
A fresh outside look can help return the proper focus
If you don’t do your own due diligence, someone else will do it for youSlide14
ISO 9001:2000
Fundamental error made—part change no part number change
No oversight system for Documentation—a well implemented and managed quality system could have been that
system
1
Organization wide adherence to these standards could have created a a more compliant culture with respect to documentation requirements
Quality standards not discussed in any detail in Valukas Report
1. Page 33 Valukas ReportSlide15
Leadership Is Crucial in Establishing Culture
Ignition Switch Issue
Not seen as customer safety issue—you can still steer and brake
No one is sure what their role is
Senior engineering leadership transition—champion
energize the team
Issue X (Old GM)
Team formed— “you guys are together until this is solved”
Team experienced issue first hand on a
highwayTen customer vehicles bought back on the spotEveryone knows their role—cross-functional team approach critical in resolving the issue
Valukas Report p. 178Slide16
Robust Design Failure Example 1—Heat in Electrical Modules
NHTS Campaign Number 14V26100
Models Under Recall
Certain MY 2004-2008 Chevrolet Aveo vehicles with daytime running lights (DRL)
equipped
Problem:
In the affected vehicles, there may be heat generated within the DRL module located in the center console in the instrument panel, which could melt the DRL module.
Consequence:If the DRL module melts due to the heat generation, it could cause a vehicle fire
Source: Autoblog.comSlide17
Robust Design Failure Example 2
Source: Autoblog.com
Picture Credit: Frugalityisfree.com
Certain model year 2014 CTS vehicles manufactured June 2013 to February 2014.
If vehicle is turned off, with wiper functionality left on, and battery dies, when vehicle is jump started, wipers will not workSlide18
Robust Design
First introduced to North American manufacturing in the mid 80’s
When done right, it is very effective “building in” quality to a product
Training trends--brief web based courses and tutorials
Tendency to design to a test
Clean sheet Robust Design techniques could have prevented at least some of the recalls
Understanding customer usage is keySlide19
Supplier Interaction and Management
Supplier’s actions can impact business further up the chain
Not enough to have culture of safety only at the OEM
Document Management—PPAP package never located
Design responsibilitySlide20
A “Fundamental Failure”
Engineering leadership—missing in action
Failure to recognize systems aspects of the vehicle
Chief Counsel—lack of
o
versight
Quality Organization—no escalation—where was the cross-functional approach with Engineering?Slide21
Concluding Remarks
One cannot hide anything
Initial sample sizes may have been small—impact was huge
Circumstances of crashes added a degree of confounding
Clinical look-- solely at the vehicle—did it perform as expected?
“5 whys” could have provided insight
Information Silos--No one person seemed to understand how the whole system worked, information not shared cross-functionally
“Says Who?” -- “tribal knowledge and practices”-- nothing
documented