At 0910 the base helicopter arrived at the crash site. Captain Storer’s last communication was spent describing a spider crack forming on the cockpit glass then abruptly halts.
I called the pitch Can-A-Peas. It was the first project in my new position as the quality statistical weenie, I mean engineer. A perk at major corporations like this aerospace company was that you really got to move around the operation and spend a year or so in different departments of the organization. I started in inspection moved to quality data systems, budget systems, coordinate measurement, avionics quality and now statistical quality control.
I was waiting on the director of Quality and representatives from the Navy, our major customer, to covey my findings. I was excited to say the least, as mentioned, the title of my presentation was Can-of-Peas with a graphic of the same. The project however was sobering. Seems a couple of the company’s aircraft suddenly came apart at high altitudes killing the pilots and crashing the planes. My job was specific; I needed to determine if a drill bit could have nicked the glass during manufacturing of the canopy assembly. If so this could have weakened the glass and caused an implosion during high altitude high speed maneuvers. Since the canopy drilling operation utilized a fixture that determined the location of the holes, all I really needed to do was take a number of readings on where the location of the holes were, in relation to the glass when fitted.
To take the observation samples, we needed to look at some assembled canopies. To measure hole locations required several x-rays of different canopies and then measure the variance in the distance of the hole placement to the glass. This procedure was performed by a senior quality engineer and I received the measurements on a piece of paper. It was really just a matter of cranking the locations into an algorithm to get the variation and then running another computation to determine the probably of actually nicking the glass. Obviously my company was hoping that the probability was zero! On one side of the canopy the probably of nicks were zero. On the other side there was one of the hole locations that showed a probability of nicking. I knew the implications of the findings so I did what I felt anyone would do under the situation. I asked for verification of that holes measurement. I thought it was odd that my request was met with some consternation given the implications of the analysis but alas the locations were confirmed and here I sit with my presentation waiting for the meeting to begin. At the appointed time the Director of Quality’s assistant walked in to inform me that the meeting was canceled. When I inquired about rescheduling she said there was no need. The Navy had decided that it would be too expensive to retrofit the entire American fleet since most of the aircraft were on carriers in the pacific.
That was my first real taste of economic quality. Oh, I had been trained on the cost benefit analysis and been through all the algorithms of determining “Optimum Quality Costs” but this was the first time I realized the algorithms were not just numbers but represented lives. And the lives were valued at Zero.
I never got the opportunity to ask why the analysis wasn’t performed before production began. After all, it would have been a relatively easy change to the fixture to assure that the hole in question was out of nicking range of the glass. I’m almost certain the answer would have been, “we did”. Meaning it was checked during the computer aided design (CAD) phase and as part of a first article inspection procedure but apparently didn’t take into consideration the overall variability of setting the tool in place to locate the holes. This company had seen the emergence of the quality industry from its infancy. An industry rooted in exceptional craftsmanship and now one focused on reducing variability. However costs are the driving force in business and will always have the tendency to win out in a showdown with quality. After all, we need to remember we live in a capitalistic system where profits are king. That’s one reason it’s vital to eliminate those showdowns!
Some however, have acquiesced to them. Not long ago I was in the office of a Vice President of Quality at a major medical device company, he was not all concerned about the number of recalls and FDA letters his company had received the prior year. He said, “Actually our problem rate is not that bad. When you’re implanting devices in people at the rate of one every 6 minutes you have to expect a few problems.” His comment is not that far from the norm in business today. And like the prior experience, has its roots in the issue of economic quality. The belief when boiled down is essentially this: Doing things correctly is more expensive than doing things incorrectly and giving the impression that you’re trying your best to catch the things done wrong versus preventing them from happening in the first place.
I was fond of saying that the first social responsibility a company had was to make a profit. I always assumed it was with an understanding that the profit was made legally and ethically. I’m not sure my assumptions are in the majority today.
In the typical company the costs of fixing things and assuring things go right is between 20 and 40% of the costs of goods sold. You’d think that amount of wasted profits would move companies to solve the money drain but as it turns out it’s much more complicated than that. For instance, the earlier discussion on making things certain eliminates perceived “flexibility” and therefore is often viewed as an impediment to “getting the work out”. They call it the cost of doing business. I wonder what Captain Storer would say?