Quality management systems will not work without engaged personnel.

It was just a few bolts. What could possibly go wrong?

In industry, but especially in the electronics industry, nothing has changed more over the past several decades than the concept and implementation of quality management. In the early 1980s it was inspect, inspect and inspect again. In the late 1980s and through much of the 1990s, the concept of Total Quality Management, or TQM, became the rage. Manage the process and involve all the shop floor employees and stakeholders and better quality will result – requiring less inspection.

During the 1990s and continuing into the new millennium, TQM became overshadowed by Six Sigma. Applying Six Sigma, including certifying employees as green or black belts, enabled greatly improved quality. To be Six Sigma meant 3.4 (or less) defects per 1 million parts. Achieving this level was impressive for sure.

During the first decade of this millennium, things seemed to go full circle. While focused on achieving Six Sigma, customers began to require (read: demand) suppliers to perform first article inspections (FAIs) before shipping product. Over the years, many colleagues in the printed circuit board fabrication community have commented that the number of FAIs they do has grown exponentially and the requirement is binary: all or none – regardless of the complexity of part or end-application.

I know in my company I often comment that industry might make more money if we all charge for the paper and give away the product! While that is an overstatement driven by frustration from filling out reams of paperwork, and seeing few customers actually following the basic AS9102 format and instead modifying it by adding what seems important to them, you cannot deny the process is time-consuming and costly.

All that said, in my experience even the best process management and most sophisticated statistical controls, all correctly applied and meticulously documented, all miss the two most common instances poor quality occurs.

One instance is when a manufacturing facility is operating with little work, it more often than not leads to quality suffering. Likewise, the other instance is when a plant is running overcapacity, with customers screaming to get product. In the rush to perform and under heavy pressure to deliver, quality usually suffers.

With too little work, people slow down and try to stretch what they are doing to fill time. Employees also begin to let their minds wander, so steps may be skipped, or may forget where they are in the process and believe they have completed a task thoroughly when in fact they have not.

With too much work, a different combination of events may occur, including excessive use of overtime, and borrowing people from different departments who are not familiar with a particular process that they have been asked to help with. And then there is the focus by all on just meeting shipments with often the implied message of “I don’t want to hear about problems.”

So, it was only a few bolts, what possibly could go wrong? Well in January, passengers on Alaska Airlines Flight 1282 found out, and in a hurry! “A few” bolts missing or improperly installed gave way and an emergency exit blew off the plane while flying at 16,000 ft. Now, a Boeing 737 Max must have close to two million bolts and screws, so the plane, statistically, still met Six Sigma. I can imagine how many trees were killed by Boeing and all the collective suppliers to produce the thousands, if not millions, of FAI reports. And assembly employees at Boeing are involved with quality circles, teams and reviews to assure product quality is achieved. So, all the evolution of quality management was well implemented in the assembly of the 737 Max. And yet ...

It appears that the most current and sophisticated quality management tools all failed in this situation. Why? I am sure the National Transportation Safety Board, along with scores of engineers at Boeing, will identify a root cause and will put appropriate protocols in place to prevent the problem from recurring. As the 737 Max has since experienced production delays and paused production, however, and that leads to customer demands to take delivery of planes they have ordered as soon as possible, the pressure mounts on management as well as production employees to work as fast as possible to make delivery, including running overcapacity to increase the number of planes shipped to meet demand and reduce backlog.

Quality can be measured in many ways. Statistics can be helpful, as can reasonable and effective documentation, but don’t forget the human factor! When the regular cadence of a manufacturing facility is altered by either high demand or extremely low demand, quality may suffer. Those are the times when management cannot take quality systems for granted but needs to become more involved to keep employees engaged, focused and not so pressured that errors are made because of fatigue. Perhaps the message to share is: It was only a few parts. What could possibly go wrong?