Guest Post: GM Ignition Switch Recall vs. Sunroof Recall: An ISO 9001 Case Study

Today I am pleased to be able share a guest post sponsored by one of our sponsors 9001 Academy. This post compares two product recalls in terms of a quality management system.

Product recalls are something we have become used to in our society. As I argued in my article Does a QMS ensure 100% quality?, product recalls do not mean that there is a complete failure of the quality management system. In fact, the existence of requirements for a process to deal with non-conforming products is evidence that the ISO 9001 standard expects that an organization will need to deal with products that do not meet requirements; however, this process can either work well or be flawed. This article looks at two recent examples of the non-conforming product process as it deals with product recalls in the automotive industry.

What is needed in a non-conforming product process?

First, let’s look quickly at the requirements for a non-conforming material process, in particular, the requirements of what needs to be done to deal with a non-conformance when one is identified. In Section 8.3, the ISO 9001 standard requires that the organization take action to deal with an identified non-conforming product in one of four ways:

1.    Take actions to eliminate the non-conformance

2.    Authorize use with acceptance from the customer when needed (intended for non-conformances that do not hinder the operation of the product or service)

3.    Take action to preclude original use (scrap or use as “seconds” where this is acceptable)

4.    Take action to eliminate the effects of the non-conformity when it is detected after delivery, or when use of the product has started

It is requirement 4 that could trigger a product recall if a repair needed to be made to the delivered product. The next two examples demonstrate where this failed to happen quickly enough, and when it has happened in a timely manner.

For more information on the process for non-conforming material, see this blog post on Five Steps for ISO 9001 Nonconforming Products and this blog post on Understanding dispositions for ISO 9001 nonconforming product.

GM ignition switch defects: When the process failed

In February 2014, General Motors (GM) instituted a recall of 2.6 million vehicles worldwide for a problem with defective ignition switches. The defect with this product is that the ignition switch can slip out of the “on” position while driving, which can lead to the car stalling and the air bags turning off. As of October 2014, this has caused 27 deaths and many more injuries, leading to compensation claims against the company along with the expense of the recall itself.

News reports state that GM has acknowledged that it knew about the faulty ignition switches in several of its small cars for over a decade before the recall was initiated. It is clear that in this case, the decision on taking action on non-conformities that were already delivered was not timely.

GM sunroof recall: When the process works

Just over a year later, in March 2015, GM issued a recall for Chevrolet Malibu models due to overly sensitive controls. This followed a recall of Cadillac ATS models in February 2014 for the same issue. The controls in question would cause the sunroof to close with only a slight touch of the controls. According to the company, it does not take much force on the controls for the power sunroof button to make the sunroof close, which could pose a safety hazard such as fingers being caught in the closing unit.

In this case, there are currently no known injuries from the defect, nor has GM received any customer complaints, but still the recall was issued to address the problem. Clearly, the process to address non-conforming products has addressed delivered product as it is intended to do.

Make sure you address all non-conforming products or services

The key point is that a process for non-conforming products needs to address all products or services when your company identifies a problem. Sometimes it is easy to forget that products or services that are already delivered need to be included when you are making your decisions on how to address a problem. In many cases, there may be no action needed for a product or service already delivered, but the decision on these products and services that are already in the hands of your customers needs to be made and properly recorded. You owe it to your customers to consider them in your dispositions, and customer satisfaction is a key reason to have a quality management system in place.

About the Author:

Mark Hammar is a Product Assurance Manager and freelance author. Positions include working in all aspects of Product Assurance, including Supplier Quality Engineer, Quality Engineer, Product Assurance Program Manager, and Quality System Auditor. He is certified with the American Society of Quality as a Certified Manager of Quality and Organizational Excellence. His goal is to work more in Quality Management including supervision and people management.

Lean Quote: Power of Many

On Fridays I will post a Lean related Quote. Throughout our lifetimes many people touch our lives and leave us with words of wisdom. These can both be a source of new learning and also a point to pause and reflect upon lessons we have learned. Within Lean active learning is an important aspect on this journey because without learning we can not improve.

"Many hands make light work." — John Heywood

A common saying we have all heard about teamwork that means the more people that do a job, the easier the job for each person.  This is true in Lean.

Continuous improvement is about small changes on a daily basis to make your job easier.  Small step-by-step improvements are more effective over time than occasional kaizen bursts, and have a significantly greater impact on the organization culture - creating an environment of involvement and improvement.

Lean is meant to involve the whole company. It is not intended to be put into action in only one area. It is a management philosophy which should include every part of your organization. This helps promote the concept that everyone in the company is part of the team. True Lean manufacturing needs the involvement of everyone coming into contact with the company’s product and its customer.

Improvement should be ongoing and employees should be a critical part of that process so there is not fear of change but a willingness to embrace it because it’s a part of the everyday process in the organization. As employees begin to demonstrate a willingness to assimilate change into their daily routine, they develop a commitment to the change, a willingness to stick to the plan of action.  The change actually becomes integrated into the work environment, and employees begin to feel a sense of satisfaction in accomplishment.  They readily see the payoffs associated with the change.  They enjoy, and may even take credit for, their participation in the process.  Employees can view their efforts to bring about change with personal respect and pride. The change becomes a part of their routine, and any lingering concerns vanish.

In Lean we strive for a culture in which everyone in the company makes small improvements to their work environment everyday.  Many organizations start with large activities with titles like Kaizen or improvement events.  This is necessary in the beginning to create the conditions for change.  You need to teach people how and why to improve.  The Kaizened area then serves as a powerful example for the rest of the organization to learn from.  But as we strive for "True North" we want to create an environment where continuous improvement occurs regularly as part of the work.

 

Daily Lean Tips Edition #78 (1171 - 1185)

For my Facebook fans you already know about this great feature. But for those of you that are not connected to A Lean Journey on Facebook or Twitter I post daily a feature I call Lean Tips.  It is meant to be advice, things I learned from experience, and some knowledge tidbits about Lean to help you along your journey.  Another great reason to like A Lean Journey on Facebook.

Click this link for A Lean Journey's Facebook Page Notes Feed.

Here is the next addition of tips from the Facebook page:

Lean Tip #1171 - Take Your Time When Doing a VSM

There is a lot to think about when undertaking value stream mapping for the first time so be sure not to rush – create a check list of items that should be included in the map and cross them off as you go along – check out Value stream mapping guide for more information on how to run a VSM program.

Lean Tip #1172 - Don’t be Shy – Visit the Workplace When Mapping

A key element of Value stream mapping is accuracy – an incorrect VSM can lead to wrong conclusions being drawn and can waste valuable time of improvement teams. Spend time at the workplace to ensure that what you map is accurate.

Lean Tip #1173 – Validate Your Map

When you think you’ve got your map complete – validate it with your stakeholders – ensure its representative of what actually happens – use this to iron out any problems with the map. Don’t take this stage for granted – get it wrong and you can find your improvement suggestions shot down in flames as stakeholders rubbish your map!

Lean Tip #1174 - Ask Lots of Questions

Don’t be afraid to ask! – To document the process ensure the team asks stakeholders what happens, why it happens, what are the inputs – what are the results – remember – a value stream mapping program is a data and information gathering exercise.

Lean Tip #1175 – Don’t Do the Current State Map and Future State Map at the Same Time.

Don’t be tempted to produce the “current state” and “future state” maps at the same time – we can all see improvements but capture them (perhaps in a list) and go back to producing your “current state” map. Remember that you may not have the whole picture until the “current state” is complete.

Lean Tip #1176 – Making Mistakes is Part of Improvement

Help employees realize that making mistakes is an acceptable part of becoming Lean. The mantra should be: “Let’s try it. The worst that can happen is we’re wrong.” As this approach is sinking in, help employees understand that unstable systems that allow variation cause most mistakes. Employees are doing their best. If something goes wrong, the idea is to determine the root cause and fix that, not criticize the worker. Understand errors more; punish less. Focus on the tools of mistake-proofing, standard work, poka-yoke, and elf-check to prevent mistakes.

Lean Tip #1177 – Perfection is Not an Impossible Target

If people are told that perfection is the goal, but that it is impossible, they will rightly think that management has not quite thought this one through. They will mistrust much of what else is said. Instead, people should be told that perfection is the goal and we simply don’t know enough at the moment to reach it.

Lean Tip #1178 – Encourage Keeping The Goal Always In Sight

Distractions and setbacks are bound to happen. To prevent them from thwarting your efforts, remind employees (and yourself) of the vision on a regular basis. Have employees consistently survey if what they are doing throughout their work day is moving them towards that desired destination, and if not, re-evaluate their efforts to get back on track. Encourage positive steps taken in the right direction and recognize individuals for making them.

Lean Tip #1179 - Leadership is a Service and Not a Destination.

Sometimes people seek a position of leadership for the position itself. They may desire the power or the acclaim that goes with the position. However, a leader that seeks to serve rather than to be served will always be more effective.

Lean Tip #1180 – Leaders Must Empower Excellence

Look around you sometime with this in mind - people are trying their best to do an excellent job at something. That something may or may not be what you "grade performance" on, but nevertheless, people feel better and accomplish more when their leaders take the time to not only notice, but encourage and empower them to be excellent in what they strive toward. Empowering excellence is different than expecting or demanding it because it starts with the ambitions of the led, rather than the leader.

Lean Tip #1181 – Lean Leaders First Envision Success

Leaders know that every problem has an answer; it just needs to be found. Worrying about the problem gets you nowhere, while working towards the answer will get you everywhere. Leaders control their attitude and focus on results.

Lean Tip #1182 – Lean Leaders Get the Facts

Leaders collect all the facts about the problem because they know that some problems are not as big as they seem. Fact-finding is an analytical, rather than an emotional task, so it is useful in other ways, too. When a follower comes to a leader with a problem, a good leader will start asking questions and gather the facts, rather than engage in an emotional discussion.  Fact-finding is a process and you may have to dig deep to get to the real problem. Leaders are great at asking the right fact-finding questions. They’re also adept at listening to the answers and “hearing” any sub-text that could illuminate the situation.

Lean Tip #1183 – Lean Leaders Follow Through

Effective leaders don’t just implement the solution and turn away. They follow through with making sure necessary team members are also doing their part (if required). And they ask everyone involved how they think the “solution” is working out now that it’s actually being used.

Lean Tip #1184 – Lean Leaders Don’t Just Know How to Solve Problems; They Know How to Find Them

Great leaders can detect smoke, rather than simply trying to fight raging fires. That’s the type of leader you should groom your employees to be. And it’s critical they have a good rapport with their team to encourage them to share bad news, red flags, or concerns with them quickly!

Lean Tip #1185 – Lean Leaders Continually Self-Evaluate

Leaders pick a solution and implement it. They may start with a quick-fix solution and follow up with a more long-lasting fix, but they decide what needs to be done…and they do it. Leaders constantly assess whether the process is going well, if the solutions being discussed make sense, and if they are doing everything they can to solve the issue.

The Role of Communication In Lean

Communication is the glue that binds an organization together but you can’t assume that several announcements and a note on the notice board is sufficient to get the story out.

However, when employees feel connected to the company mission or feel their work is contributing to a goal that is greater than profits, they feel like their work has purpose. A sense of meaning is priceless and costs nothing for an employer to cultivate.

Good communication is vital. Reasons for change must be explained beforehand. Clear communication is the best investment, since resistance is often due to misinterpretations, half-truths, and rumors that recede the change. Easy to understand written and verbal communication should reach all layers of the company.

Communication is a key ingredient for empowerment. Give every employee equal and direct access to information. Many companies have developed a trickle-down style of communication that alienates those employees who may not be "in the loop."

Let them in on what is going on within the company as well as how their jobs contribute to the big picture. When you keep you employees informed they tend to feel a greater sense of worth. Keep communication hopeful and truthful – do not be afraid to share bad news, instead be more strategic about how you deliver it. The more informed employees are and the more communication is open, honest, direct and complete, the more likely employees are to feel empowered and connected to the daily operations and overall goals of their company.

Open communication is at the center of Lean and Respect for People. Employees need to know what is expected of them and how they’re performing. Visual displays such as scoreboards, scheduling charts, team communication boards, and recognition displays all help to keep information flowing between employees, departments and upper management.

Developing advanced communication skills begins with simple interactions. Communication skills can be practiced every day in settings that range from the social to the professional. New skills take time to refine, but each time you use your communication skills, you open yourself to opportunities and future partnerships.

Lean Quote: Courage to Start, Courage to Succeed

On Fridays I will post a Lean related Quote. Throughout our lifetimes many people touch our lives and leave us with words of wisdom. These can both be a source of new learning and also a point to pause and reflect upon lessons we have learned. Within Lean active learning is an important aspect on this journey because without learning we can not improve.

"If you have the courage to begin, you have the courage to succeed." — David Viscott

When things are difficult, unknown, and perhaps unattainable we may turn the other direction. We must find the inner strength to overcome these perceived barriers. History has proven time after time that the power of a thought is the beginning for actions that will alter the future positively. Understanding this, and having the courage to keep going even in the face of all obstacles, allows us to accomplish anything we want.

Courage means trusting yourself to overcome your fears and doing what you are afraid to do. Courage increases conviction and inspires others to confront their fears.

It takes courage to be a change agent, to rise up and lead the way when others are filled with fear. It takes courage to walk in a different direction when others walk along a contrasting path. Most important, it takes courage to drive persistence to overcome resistance…to find comfort outside your comfort zone when the promise of reward is ambiguous.

If courage is the fuel that gets the engine going, commitment is the will to keep filling the tank, to see things through no matter how dire the situation may seem. Not that the will to see things through is simple at all. It requires attention to detail, passion for the craft of making change, and a zealous, unwavering dedication to achieving an outcome, no matter what the odds, risks, obstacles and challenges along the way.

I have learned is that the entire workforce wins when everyone shows up to work each day with more courage.  With less fear and more courage, workers take on harder projects, deal better with change and speak up more willingly about important issues. In short, courageous workers try more, trust more and tell more. As a business leader and entrepreneur, your job is to put courage inside of people— to encourage them.

 

The Language of Lean is Visual

A Visual Factory is the language of the Lean production system. Without it we can’t see the wastes in our factory, which are the greatest source of potential improvements in customer service and business performance. Visuals ensure that what is supposed to happen happens on time, every time by everyone involved.

Visual Factory (or Visual Management) refers to a lean tool that results in more than just a pretty workplace. 5S is the foundation for Visual Factory specifically in the areas of cleanliness, order, and discipline, but it doesn’t stop there. However, true Visual Factory goes beyond a clean, well organized factory; it’s a company-wide “nervous system” that allows all employees to understand how they affect the factory’s overall performance.

A Visual Factory provides a clear and common understanding of goals and measures of the business. With this information employees are able to align their actions and decisions with the overall strategic direction of the company. It is also an open window to factory performance, and it provides the same unbiased information to everyone, whether owner, manager, operator, or visitor.

The goal in Visual Factory is to create a “status at a glance” in the workplace. This refers to an operating environment where anyone can enter the workplace and:

See the current situation (Self-explaining)

See the work process (Self-ordering)

See if you are ahead, behind or on schedule (Self-regulating) and

See when there is an abnormality (Self-improving)

Visual Factory techniques can be used in a variety of ways. This offers an unlimited number of opportunities creating a significant variation in the actual application of Visual Factory.

There is irrefutable evidence that a “shared vision” is critical to the success of today’s businesses. Visual Factory communicates the “shared vision” along with an understanding of how each individual should contribute toward that success.

In the game of baseball why do fans repeatedly look at the scoreboard when the action is clearly on the field? The scoreboard answers important questions about the status of the game. It tells us how our team is doing in relation to the goal, to win the game! Visual Factory is the scoreboard for our business.

Lean Roundup #71 – April, 2015

A selection of highlighted blog posts from Lean bloggers from the month of April, 2015.  You can also view the previous monthly Lean Roundups here.

The Relationship Between Trust and Lean – Andy Carlino and Jamie Flinchbaugh explore the relationship between lean and trust.

Go to the Gemba to Learn to Learn – Michael Balle says the lean practice of going to the gemba and learning how to master lean principles highlights very different potential starting points to improve the business.

The Lean Formula – Gregg Stocker shares a lean formula that can be used to drive transformation of an organization.

The Kata of Leader Development – Mark Rosenthal discusses leadership development with Toyota Kata from a Navy Captains experience on the USS Santa Fe.

Towards a Culture Free of Fear, Embrace Surprise – Jon Miller talks about leaders admitting when they are wrong to create a culture where mistakes are okay.

Exploring Leadership – Bob Emiliani discusses leadership and says that leadership processes are a means to improvement.

A Simple Approach to Aligning Values - Bill Kirkwood  advocates common ground for the following value categories: personal, organizational and Lean values.

Reprise – What is Kaizen Spirit? – Pascal Dennis shares three things that comprise Kaizen spirit.

Showered With Creativity – Steve Kane says overburdening chokes the mind and inhibits improvement.

What is Lean? -  Vivienne Fagrell explains Lean and says it just may be the most elegant solution.

Why Would These Workplace Slogans Be Offensive to Employees? – Mark Graban discusses the respect of employees in the workplace by management.

Unreasonability – Bruce Hamilon shares an example of Muri from experience on the waste of unclear directions.

Beware the Lean Expert – Gregg Stocker discusses the need for continuous learning and humility is a pre-requisite.

What Is The Metric For People Development? There Isn't One – Michael Baudin says there is no metric-- or even set of metrics -- that can reasonably summarize people development, but it is nonetheless tangible and observable.

To Achieve Success Focus on Improving the System Not On Individual Performance – John Hunter shares some ideas on creating a management system that focuses on long term continual improvement.

Flaws In Lean – Bob Emiliani shares the flaws of progressive management but says some improvement is better than no improvement.

Do We Trust our People to make Lean Improvements? – Paul Akers answers this question with training employees like crazy and using expertise of Lean leads and implementers.

Reprise -The Paradox of Standards – Pascal Dennis explains how standard work is not rigid but rather sets you free.