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The Top 5 Quality
          Management System
           Failures of All Time


www.cebos.com
Purpose of Quality Management Systems
    Clearly understand customer requirements

    Manage internal processes to fulfill requirements
    in an effective & efficient manner
•   Management
•   Design
•   Production


    Continuous improvement of processes
•   Quality Management System (QMS) based on ISO 9001




Page 2
QMS History: When QMS Failures Go Viral
    Most QMS failures have unfortunate implications,
    but do not make national news
•   Requirements missed
•   Processes don’t work
•   Customers upset
•   Employees/management unhappy

         But sometimes an unfortunate Total Quality
         Management (TQM) failure makes headlines
                     Such as these top 5 “Famous Quality
                     Management Failures” in no particular order…




Page 3
3 Mile Island
  Strong debate in the
  late 70’s about safety
  of nuclear power

  Worst nuclear disaster
  in U.S. history –                Photo source: britannica.com


  March 1979
• Proper controls not in place
                                       Only new nuclear
• Human error attributed to lack       power stations built
  of proper training                   since were those
                                       already under
                                       construction

Page 4
Hubbell Telescope
  Orbiting telescope
  utilizing advanced
  technology
  Distant and faint
  objects – could not be
  seen                            Photo source: nasa.gov


  Mirror had been
                                     Additional billions of $
  ground into wrong
                                     were spent to correct
  shape
• Negative testing results from
                                     the problem
  multiple instruments were
  ignored


Page 5
iPhone 4
  Apple was on verge of
  losing dominance in
  device market
  Difficult to make calls
  with iPhone 4
• Dropped calls                     Photo source: mobilehuntz.com
• Widespread dissatisfaction with
  early adopter loyal customers        “Voluntary” recall was
• Denial/minimization of problem
  by Apple
                                       conducted to correct
                                       the problem
  Independent tests
  identified issue


Page 6
Teton Dam
  Only months after
  completion, dam
  collapsed - June 1976
• 6 miles of Teton River canyon
  were flooded
  Improper materials
                                  Photo source: web.mst.edu
  used
  Maintenance was
  done during spring
  when likely reservoir
  would fill to capacity


Page 7
Ford Pinto
  U.S. auto industry built
  ill-conceived and
  unreliable cars during
  the 70’s
• Many were considered ugly
• 40-50,000 miles was not          Photo source: cargurus.com

  unusual for major breakdowns

  Pinto tops list
• Design flaws
• Questionable ethics decisions
  by top management resulting in
  dangerous vehicle


Page 8
Did This Need to Happen?
  All of these notorious failures could most likely have
  been prevented if principles of a quality
  management system were in place
• Effective design reviews
• Design and process FEMAs
• Measurement-based corrective action (including customer satisfaction)



  QMS has potential to save customers & improve
  the value of internal efforts…
            …the essentials for business success



Page 9
Thank You
                                                           Phone: 810.534.2222
                                                         E-mail: info@cebos.com




www.cebos.com   Images used with permission from Microsoft.

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The Top 5 Quality Management System Failures of All Time

  • 1. The Top 5 Quality Management System Failures of All Time www.cebos.com
  • 2. Purpose of Quality Management Systems Clearly understand customer requirements Manage internal processes to fulfill requirements in an effective & efficient manner • Management • Design • Production Continuous improvement of processes • Quality Management System (QMS) based on ISO 9001 Page 2
  • 3. QMS History: When QMS Failures Go Viral Most QMS failures have unfortunate implications, but do not make national news • Requirements missed • Processes don’t work • Customers upset • Employees/management unhappy But sometimes an unfortunate Total Quality Management (TQM) failure makes headlines Such as these top 5 “Famous Quality Management Failures” in no particular order… Page 3
  • 4. 3 Mile Island Strong debate in the late 70’s about safety of nuclear power Worst nuclear disaster in U.S. history – Photo source: britannica.com March 1979 • Proper controls not in place Only new nuclear • Human error attributed to lack power stations built of proper training since were those already under construction Page 4
  • 5. Hubbell Telescope Orbiting telescope utilizing advanced technology Distant and faint objects – could not be seen Photo source: nasa.gov Mirror had been Additional billions of $ ground into wrong were spent to correct shape • Negative testing results from the problem multiple instruments were ignored Page 5
  • 6. iPhone 4 Apple was on verge of losing dominance in device market Difficult to make calls with iPhone 4 • Dropped calls Photo source: mobilehuntz.com • Widespread dissatisfaction with early adopter loyal customers “Voluntary” recall was • Denial/minimization of problem by Apple conducted to correct the problem Independent tests identified issue Page 6
  • 7. Teton Dam Only months after completion, dam collapsed - June 1976 • 6 miles of Teton River canyon were flooded Improper materials Photo source: web.mst.edu used Maintenance was done during spring when likely reservoir would fill to capacity Page 7
  • 8. Ford Pinto U.S. auto industry built ill-conceived and unreliable cars during the 70’s • Many were considered ugly • 40-50,000 miles was not Photo source: cargurus.com unusual for major breakdowns Pinto tops list • Design flaws • Questionable ethics decisions by top management resulting in dangerous vehicle Page 8
  • 9. Did This Need to Happen? All of these notorious failures could most likely have been prevented if principles of a quality management system were in place • Effective design reviews • Design and process FEMAs • Measurement-based corrective action (including customer satisfaction) QMS has potential to save customers & improve the value of internal efforts… …the essentials for business success Page 9
  • 10. Thank You Phone: 810.534.2222 E-mail: info@cebos.com www.cebos.com Images used with permission from Microsoft.