MAGIQ

Chapter 1: Introduction

When I was just five years old, I became fascinated by the princess’s amazing talent for finding hidden beans among a stack of mattresses. Inspired by her exceptional abilities, I eagerly attempted to emulate her. I would play games of hide-and-seek with beans, hoping to uncover them with the same ease and finesse. However, despite my best efforts, I couldn’t match her remarkable skill. It became apparent that her unique talent was not easily replicated.

Years later, as I matured, I came to a profound realization that my childhood fascination with hidden beans was a story about quality. The beans symbolized elusive gaps within our processes, challenging to detect. The princess’s remarkable talent became a metaphor for the pursuit of excellence, emphasizing the importance of uncovering hidden truths that elevate our endeavors to new heights. This ignited my passion for exploring how to identify and address critical gaps in our journey toward achieving true quality.

Example 1: NASA’s Challenger Disaster In 1986, the space shuttle Challenger exploded shortly after launch, resulting in the tragic loss of all seven crew members. Investigation revealed that a faulty O-ring seal in one of the solid rocket boosters was the primary cause. Concerns were raised by engineers about the O-ring’s vulnerability to low temperatures before the launch. Despite these known risks, alerts were tragically ignored, leading to a devastating outcome. 

Example 2: Takata’s Faulty Airbags Takata, a prominent automotive parts supplier, experienced a significant recall crisis due to defective airbags. These airbags had the potential to explode upon deployment, causing injuries and fatalities. Internal documents and test results indicated potential issues with the airbag inflators, including the release of sharp metal fragments into the vehicle cabin. Unfortunately, these warnings were not adequately addressed, resulting in a widespread safety problem and the recall of millions of vehicles equipped with Takata airbags.

Example 3: Samsung’s Galaxy Note 7 Recall In 2016, Samsung faced a major crisis when reports emerged of Galaxy Note 7 smartphones catching fire and exploding. Subsequent investigations traced the issue to a design flaw in the battery, which led to a worldwide recall of the product.

What do these failures have in common? Despite being among the most successful in the world, these companies experienced catastrophic failures due to overlooking the importance of quality. They chose to address the flaws only after the damage was done, incurring massive costs and causing harm. However, with foresight and a commitment to quality, these failures could have been prevented, saving resources and reputations. This serves as a crucial lesson for all organizations, emphasizing the significance of proactive quality measures to avoid such devastating outcomes.

“Complex systems almost always fail in complex ways.” This insightful quote from the Challenger report, later echoed in the Horizon Gulf of Mexico oil spill investigation report, reminds us that failures in complex systems are rarely caused by a single factor. It’s important to understand that even if your product or process is not considered complex, it can still be susceptible to potential problems. Complexity exists in various systems, including the human brain and organizational structures, and failures result from intricate human decision-making and communication. As an individual, you play a vital role in this complex system, and it’s crucial to grasp this concept to effectively prevent and address failures.

When you look closely, you’ll see that these failures didn’t happen overnight. They were like a chain of falling dominos. Each little issue, if ignored, added up and led to a big mess. It’s like when you set up a row of dominos and one falls, knocking down the next one, and it keeps going until they all fall. That’s how these failures happened—they were a bunch of little things piling up and causing a disaster.

What if it happens to you? All it takes is a handful of mistakes that will evolve into catastrophic failure. This is why you need the MAGIQ framework—a powerful tool to help you prevent and address failures proactively. The MAGIQ framework consists of five key steps: Mind Your VAG, Articulate Your JOLT, Generate Solutions or Grasp Blind Spots, Implement Lesson Learn, and Qllaborate. This framework will guide you in navigating the complexities of quality management and empower you to take proactive measures to achieve excellence.

Chapter 2: Mind Your VAG 

The first few days of my first job were a milestone in my professional journey, and I was excited to make a positive impact. That’s until a particularly tactless manager commented directly to my face, that in the past, during market downturns, the company had let go of the entire quality team. There was even an unsettling implication that in the next downturn, I could potentially face the same fate. This statement, made so early on, deeply confused and unsettled me. 

How could something as critical as quality, which I had come to believe was vital for success, be treated as expendable? It perplexed me and raised profound questions about the true value of quality and the inconsistency in its understanding, especially in challenging times. This paradox defies logical reasoning and begs for a deeper exploration.

On one hand, there is widespread recognition of the critical role that quality plays in ensuring the excellence and long-term sustainability of any organization. Extensive studies and empirical evidence have consistently demonstrated that companies that prioritize and maintain a strong focus on quality outperform their competitors. 

On the other hand, when faced with challenging times, quality often takes a backseat, and it becomes vulnerable to being sacrificed in the pursuit of short-term financial gains. This decision to prioritize immediate results over enduring quality seems counterintuitive, yet it happens far too often.

Takata’s decision to prioritize cost-saving over safety in its airbag manufacturing is a tragic example of compromising quality for financial gain. By using ammonium nitrate propellant, a risky element known to be sensitive to temperature changes, Takata knowingly put lives at risk. This choice, aimed at saving a mere 30% or a few dollars per airbag, resulted in 34 confirmed deaths and over 400 injuries worldwide.

We often encounter organizations that make grand promises about prioritizing safety and quality, presenting themselves as paragons of these values. However, when we examine their day-to-day operations, we are confronted with a disconcerting reality. The products or services they provide do not live up to their claims, leaving us questioning the authenticity of their promises. This disconnect between words and actions is known as the Value-Action Gap (VAG), a prevalent issue that undermines trust between organizations and their customers.

If you find yourself answering “yes” to any of the following statements, there is a possibility that the Value-Action Gap exists within your organization:

• Your organization rewards individuals who don’t adhere to the organization’s guidelines or take shortcuts.
• The quality team in your organization is understaffed or lacks sufficient funding for activities related to maintaining and improving quality.
• Essential verification steps are sometimes skipped to meet tight shipment deadlines or revenue targets.
• When a discrepancy or quality issue is raised, it is not always given the necessary priority and attention for timely resolution.

Despite the VP of Takata’s statement that safety is a fundamental part of the company’s identity and operations, the subsequent actions taken by Takata did not align with this claim, ultimately leading to negative consequences.

• For Takata, safety is more than an obligation; it is the core of who we are and what we do.’ 

The Deepwater Horizon oil spill serves as a striking example of the disconnect between safety rhetoric and actual outcomes. Despite the CEO’s declaration of safety as a top priority after assuming leadership in 2007, BP experienced a devastating disaster three years later. Criticism suggests that the company’s safety philosophy focused excessively on minor incidents like spilled coffee, neglecting the more critical issue of preventing drilling disasters. Furthermore, BP’s approach to safety management emphasized individual worker safety rather than adequately addressing process safety, which contributed to the tragic incident.

The GM faulty ignition switch failure revealed a concerning phenomenon known as the “GM nod,” where managers at General Motors would nod and agree with proposed plans of action but fail to take the necessary steps to address critical issues. This lack of follow-through and inaction had severe consequences, jeopardizing lives and leading to a major safety failure in the company’s ignition switches.

The Boeing 737 MAX crisis serves as a stark reminder of the dangers that arise when profit is prioritized over safety in the aviation industry. The rushed development process, coupled with flawed software and insufficient pilot training, led to tragic crashes and the loss of numerous lives. This crisis brought to light the critical importance of robust safety measures, transparent communication, and a culture that encourages the reporting and addressing of safety concerns. The aftermath of the crisis sparked a significant reevaluation of aircraft certification processes and a push for stronger safety standards across the industry. The Boeing 737 MAX crisis stands as a clear example of the Value-Action Gap, where the actions taken by a company did not align with its stated commitment to safety, resulting in devastating consequences.

If you think VAG is only a problem for big corporations and high-profile crises, think again! This issue can happen in organizations of all sizes and types, and the consequences can be just as devastating – even if they don’t make headlines. While we hear about big companies because of their failures, smaller companies might not be investigated as much. 

The truth is that every organization must adhere to the values they claim to hold, no matter its size. Whether a corporation or a small business, a VAG can harm the organization and its stakeholders.

Certain industries, like healthcare, are particularly sensitive to the risk of the Value-Action Gap because they directly impact public health, safety, and well-being. In the healthcare industry, the FDA which is the U.S. Food and Drug Administration, plays a crucial role in ensuring compliance with regulations. The FDA issues warning letters, which are official notifications highlighting specific violations and requesting corrective action. These warning letters are publicly available and cover various violations, such as inadequate quality control systems, improper handling of adverse events, non-compliance with acceptable manufacturing practices, or failure to submit required reports. These violations indicate a disconnect between what organizations claim and how they operate.

“The difference between what we do and what we are capable of doing would suffice to solve most of the world’s problems.” 

This powerful quote from Mahatma Gandhi reminds us that our potential to make a positive impact on the world is vast. It emphasizes the importance of utilizing our full capabilities to address global challenges and create meaningful change. Gandhi believed that individuals possess incredible power and can significantly contribute to solving the world’s problems if they harness their true potential.

The Value-Action Gap (VAG) is not limited to organizations alone; it also impacts individuals who proclaim certain values or behaviors but fail to act accordingly when it truly matters. This serves as a powerful reminder that actions speak louder than words. While it may be effortless to make grand promises, it is the consistent follow-through that distinguishes successful companies and individuals from their competitors. Upholding values through consistent actions is key to building trust and credibility.

As I progressed in my professional journey, I frequently encountered the statement from executives that “Quality is everyone’s responsibility.” While this concept sounded great in theory, I found that in practice, the reality was quite different. When I requested support to uphold quality standards, I discovered that many individuals within the organization were unaware that quality was their responsibility, it wasn’t budgeted for, it wasn’t a part of their goals, they didn’t have time for it, or simply didn’t care. This disconnect between the stated value and the actions of individuals within the organization highlights the existence of the Value-Action Gap and the challenges associated with ensuring a collective commitment to quality.

more examples:

NASA’s failure to act on safety warnings resulted in the loss of the space shuttle Columbia crew. 

Merck’s marketing of a dangerous drug as safe showed a disregard for patient well-being. 

The Peanut Corporation of America ignored contamination and shipped dangerous products. 

The Rana Plaza tragedy highlighted the fashion industry’s unseen VAG. 

Chapter 3: Articulate Your JOLT  

Simply knowing the gaps is not enough to ensure the safety and quality of your organization. There have been numerous cases where risks were recognized but not addressed, resulting in harm and failure. Therefore, acknowledging gaps is merely the first step; Taking action and driving your organization toward improvement is what truly matters.

examples 

Knowing about risk does not guarantee that the organization will take action to address it. Unfortunately, Boeing, Takata, and NASA are not alone in their failure to deal with risks. Countless other organizations from various industries have ignored warnings and failed to take action, with disastrous consequences.  

Almost every failure in safety or quality follows a pattern. It starts as a risk, and if not properly managed, it becomes a failure. Risk management is not a new concept. Every culture throughout history has emphasized the importance of thinking before acting. It has been used for generations to prevent accidents and mistakes. Famous proverbs or parables have been written about it to demonstrate that the presence of risk does not mean that failures have to happen.

Ideally, people would have identified, addressed, and avoided many fatalities discussed in this book. In retrospect, a majority, if not all, of these fatalities point to a fundamental flaw in how organizations manage risks. Despite early warning signs and concerns about possible risks, organizations often ignore them until it’s too late. 

The Boeing 737 MAX crashes underscore the criticality of heeding warning signs. Before the 2018 and 2019 accidents, alarming indications of safety issues were evident in the aircraft. Notably, a 2016 email exchange between a test pilot and an employee unveiled problems with the Maneuvering Characteristics Augmentation System. Despite whistleblowers sounding the alarm to the Federal Aviation Agency, no action was taken. This emphasizes the imperative of acknowledging and addressing warnings promptly to avert devastating outcomes.

The Fukushima Daiichi nuclear disaster is a cautionary tale of ignoring red flags. In 2011, a massive earthquake and tsunami caused a total power loss at the plant. It led to a catastrophic meltdown of multiple reactors and a hydrogen explosion that caused widespread damage. An investigation by the Japanese government showed that both the company and the government knew of the dangers but didn’t take any steps to prevent the disaster. 

• Takata’s story is a reminder of the dangers of ignoring warning signs. The company used ammonium nitrate, a highly volatile chemical, in its airbags, creating a risk of explosion. The engineers at Takata were initially concerned about using ammonium nitrate, and other experts in the industry considered it too dangerous. Competitors of Takata even approached their clients to warn them about the dangers of using this chemical in an airbag. Despite the above, Takata was confident in their engineering and manufacturing expertise, believing it could resolve any quality issues. Sadly, the airbags in some of Takata’s vehicles exploded, causing metal pieces to rip apart and harm drivers and passengers.

• The story of the Hubble Space Telescope is a lesson in the importance of listening to warnings. In the 80s, NASA contracted a company to fabricate the mirrors for the Hubble using an expensive measurement jig. However, a retired engineer appointed as an independent technical advisor raised concerns about the reliance on the accuracy of the jig and suggested implementing a verification test. Despite these warnings, team members and management at NASA disregarded the potential risks and did not take action. After the launch of the Hubble into space, NASA found that the images were blurry due to a misalignment in the jig, leading to a costly and time-consuming mission to repair the telescope.
• The NASA Challenger disaster is a powerful reminder of the importance of paying attention to warning signs. The Challenger exploded 73 seconds into its flight on January 28, 1986, killing everyone on board. The cause was a problem with the O-rings. The O-ring seals were not designed to handle the cold temperatures as on the launch day. The low temperature made the O-rings brittle and led to fuel leakage and explosion. The O-ring manufacturer warned NASA about the dangers of ice on the launchpad. These warnings were ignored, leading to the tragedy. 

The question is, why do people within organizations ignore the warning signs? 

The science behind every human action: The Pain and Pleasure Principale 

The pain and pleasure principle is a well-researched concept in psychology and neuroscience. It suggests that our emotions strongly influence our decision-making. We tend to make choices based on the emotional outcomes they may bring, whether they are positive or negative. This principle applies to everyone, regardless of their job or position, because it is a fundamental aspect of human nature and how we make decisions.

In the world of decision-making within organizations, the same principle holds. When an organization considers a risk to be of low priority, the perceived “pain” of not addressing that risk may not appear immediate or significant when compared to other urgent matters. The organization might believe that investing resources to mitigate a risk that may or may not materialize would be more painful. However, ignoring the risk can ultimately result in considerable pain down the line, including lower customer satisfaction, increased defects and complaints, and reduced competitiveness.

On the other hand, the potential “pleasure” of addressing the risk and improving quality, customer satisfaction, reputation, and profitability may not be perceived as appealing when considering the required efforts.

You can use the pain and pleasure principle to influence people’s behavior and decisions to pursue quality and safety. By highlighting the negative consequences of not addressing potential risks or improving product or service quality (pain), the principle can motivate people to take action to prevent them. On the other hand, showcasing the potential benefits of making improvements (pleasure) can also drive people to take action.

The intensity of pain or pleasure directly shapes our decision-making process. When the potential outcomes carry severe consequences, the associated pain becomes a powerful motivator to take preventive action. Likewise, when the potential benefits are significant, the allure of pleasure drives us toward pursuing those outcomes. In essence, the greater the intensity of pain or pleasure, the stronger its influence on our decisions. Understanding this dynamic helps us grasp why certain choices are made and how they are driven by the intensity of the associated pain or pleasure.

Add here examples for a wake and strong pain statements. 

In this line of thought, quantifying the consequences of continuing in the same mode without solving the problem or addressing a risk is a better remedy for influencing management to move in the right direction. It would be much easier to drive people toward the right decision if we knew accurately what a failure would look like and the implications for the individuals involved. Clearing the smokescreen, converting a blurred risk into a quantified cost, will allow us to influence the organization’s decision-makers to reconsider their approach and place quality higher in their priorities in terms of actions and not just words. 

In the same way, vague promises about a better future may not be enough to motivate change and improvement. When you want to influence people’s behavior and decisions, ensure that the potential pleasures and benefits are substantial. By clearly demonstrating the positive outcomes of making improvements, people are more likely to be motivated to pursue them. Return On Investment (ROI) represents a positive outcome or benefit from an investment, whether financial, time, or other resources. In making decisions, senior leadership considers all potential benefits and rewards of their projects and weighs them against the costs. In this sense, a positive ROI is a form of pleasure that motivates decision-makers to pursue the project. 

To get people’s commitment to quality, you need to describe what will happen if the organization will NOT take action. Make it clear that the problem will not simply disappear, allowing the organization to realize the cost of not resolving it. Cost is not only financial. It also reflects customer pain, damage to brand image, lack of productivity, etc. 

However, measuring the ROI of certain investments, such as those related to safety and quality, can be challenging. Measuring what failures you have prevented is often not an accurate metric. As an alternative, you should apply the other ROI, this time as Return On Ignorance, and consider what will happen if you do not invest in quality. Instead of asking what we would gain from investing in quality (pleasure), amplify the consequences of continuing in the same mode and ask what would happen if we did not improve (pain). 

JOLT provides a framework to quantify the real-world impact of a risk. With JOLT, you can articulate the associated pain to stakeholders in a way that inspires them to take action. 

If you associate the term JOLT with unpleasant shock or surprise, which will alter people’s behavior, priority, or way of thinking – you are right! JOLT occurs when a product creates a new problem for the user instead of solving an existing one. As you might have guessed by now, JOLT is also an acronym. It described the granular elements in quantifying how much a failure costs for the company and its customers. 

Jeopardize the 4S of Well-being

Customers are the first ones in line to pay for a failure. They pay with their health, their time, goals, and comfort. Unfortunately, sometimes they lose their life or the life of their dearest. As it stands, the first letter in this acronym refers to customer pain. Your failure might jeopardize the customer’s well-being in 4 ways: Safety, Success, State-of-mind, and surroundings (a.k.a environmental effects). There are too many examples of products and processes that failed to achieve their original intent and caused injury to the consumer. 

• The Takata airbag crisis is one of the largest and deadliest automotive safety recalls. These airbags, designed to protect drivers and passengers, ended up causing harm and taking lives due to the use of defective inflators. The airbags exploded with tremendous force and sprayed metal shards into drivers and passengers. At least 27 people have died worldwide while hundreds more have suffered injuries, many of them left with physical and emotional scars. Moreover, the recall affected millions of vehicle owners who were hesitant and afraid to use their cars for apparent reasons. Also, let’s not forget the mental state of the individuals who had no choice but to drive their vehicles and grapple with fear and uncertainty every time they got behind the wheel. 

Operational liabilities Costs 

Every failure carries with it operational obligations. It’s not just the direct and immediate recall and repair expenses but also indirect costs associated with the efforts spent recovering from an error instead of focusing on future growth. Organizations must divert resources from future growth and innovation toward recovery from failure. It can put the organization at a disadvantage compared to competitors and hinder its ability to remain competitive and achieve its long-term goals.

• Takata, for example, had to recall and provide new airbags to more than 100 million cars globally, resulting in cost estimates as high as $9 billion.
• The General Motors recall cost, due to the faulty ignition switch, reached over $5.3 billion in expenses. Additionally, General Motors had to establish an extensive communication system to ensure that consumers knew about the potential hazard and how to prevent it. It included a call center of 50 employees and utilizing blogs, social media, and letters to send out recall messages. The recall was related to potential engine shutdown due to the weight of key rings on the switch, and it was crucial that the company’s customers were informed and knew how to prevent it.
• The investigation into the exploding Samsung Note7 required over 700 R&D engineers who thoroughly tested 200,000 devices and 30,000 individual batteries to replicate the failures and identify the root cause. 
• The Challenger disaster significantly impacted NASA’s aerospace and defense partners. Following the tragedy, it took over two years for flights to resume after a thorough investigation, redesigned systems, and various measures implemented. The accident also resulted in the cancellation of several programs. The aftermath of the disaster was a shock to the industry, and its effects were far-reaching.

Litigation Costs   

Litigation costs can arise if individuals or organizations seek compensation for damages caused by a product defect, design flaw, or other safety or quality issue. These are the expenses related to resolving legal disputes, including lawsuits and other claims. These costs may include attorney fees, court costs, settlements, and other expenses. These costs can be substantial and adversely affect a company’s financial performance, especially in the case of large-scale recalls or failures.

• The financial burden of the Takata airbag crisis was made worse by the criminal charges brought against the company and its executives. On January 13, 2017, the US government charged three Takata executives with wrongdoing relating to the exploding airbags. The company agreed to plead guilty and pay a settlement of $1 billion.

Trustworthiness collision

A trustworthiness collision occurs when a company experiences a significant loss of trust from its shareholders or consumers because of a safety or quality failure. It can have a long-term impact on the company’s financial stability, as consumers may choose to do business with other companies, and shareholders may lose confidence in the company’s ability to manage risk and make sound decisions. It can be challenging to rebuild trust after losing it, as it takes time and significant resources. In addition, the reputational damage can lead to reduced sales, higher marketing costs, and increased litigation costs, further burdening the company’s finances.

• The loss of confidence in Takata’s ability to produce safe airbags affected automobile brands, which source replacement airbags from other companies. This trustworthiness collision impacted Takata’s ability to do business in the future and caused long-term damage to the company’s reputation and stability.
• The Challenger disaster significantly affected the public’s perception of NASA and the US space program. The disaster was widely covered in the media and has been the subject of numerous books, documentaries, and discussions, including a Netflix documentary. The loss of life and the technical failure of the Challenger shuttle shook the public’s trust in NASA’s ability to send astronauts into space safely. It took the agency years to regain public confidence and resume regular space missions. 

The impact of these failures extends beyond just the companies involved and can have long-lasting effects on individuals working for or associated with those companies. According to a 2016 research study by the Harvard Business Review, executives with scandal-tainted companies on their résumés face reduced salaries compared to their peers, even if they had no involvement in the scandal or left the company before the issue arose. On average, these executives receive nearly 4% less pay than their peers, which can accumulate significantly over their lifetime. 

The JOLT formula is a practical tool to help you estimate the impact of a failure, not only in retrospect. The JOLT formula goes beyond just listing potential risks and offers a deep understanding and consideration of a failure’s potential impact. This approach aligns with the pain and pleasure principle, where people are more motivated to take action when they see the possible pain of a failure rather than just being told about potential risks. By quantifying the potential costs and consequences, the JOLT formula helps to drive prioritization in a more meaningful and impactful way. By incorporating JOLT into decision-making processes, companies can estimate when a failure might cross the line from an operational asset to an unrecoverable liability and proactively manage risks. 

Not all businesses are alike; different business models have varying risks. There is a possibility that while reading these lines, you consider your risks as less significant. It may be that your product won’t harm the user or the environment in any manner described. 

Specifically, you should focus on those elements in JOLT most relevant to your circumstances. For example, a malfunction in your product or service might impact your customer success. It won’t matter if your client is an individual or a business. Wasting time, effort, or money is an obstacle to their goals. Dissatisfied customers can affect you considerably, even if for part of the JOLT model. Therefore, you have to know your risks. You have to call their names and look at them with eyes wide open. JOLT them fairly, so it will be easier to fix them. 

Chapter 4: Grasp Your BLIND SPOT 

A blind spot is an area of the business that gets overlooked. A blind spot unnoticed for too long can snowball into failures and quickly take you off the growth track. Everyone has blindspots, typically more than one, and your organization is no exception. In the pursuit of safety and quality, it is crucial to be aware of your blind spots. Blind spots are areas or aspects that are not easily visible or recognized but can have a significant impact on the overall performance and success of your organization. They are often overlooked or ignored, leading to unforeseen risks and failures.

B – Behavioral Blind Spots: Uncover hidden patterns and biases that hinder progress. 

• Lack of urgency to fix a problem
• Communication gap 

L – Leadership Blind Spots: Empower leaders to challenge their assumptions and expand their perspectives. Our framework offers cutting-edge techniques to enhance leadership effectiveness and drive organizational growth.

I – Information Blind Spots: Eliminate information gaps and maximize data-driven decision-making. 

• Training. 

N – Neglected Blind Spots: Shine a light on overlooked areas that may pose significant risks. Our framework helps you identify and address neglected blind spots, ensuring comprehensive risk management.

D – Diversity Blind Spots: Embrace the power of diversity and inclusivity. Our framework promotes diverse perspectives and cultivates an environment where blind spots stemming from homogeneous thinking are eradicated.

S – Strategic Blind Spots: Align your strategy with your vision by identifying strategic blind spots. Our framework provides methodologies to assess your strategy, uncover potential gaps, and develop robust plans for success.

P – Perception Blind Spots: Understand how perception shapes reality. 

• sugarcoating

O – Operational Blind Spots: Streamline operations and optimize efficiency.

• test not simulate opeation conditions

T – Technological Blind Spots: Embrace innovation while managing the risks associated with technological advancements. Our framework helps you stay ahead of the curve by identifying and mitigating technological blind spots.

S – Social Blind Spots: 

Cultivate strong relationships with stakeholders and adapt to societal changes. Our framework provides insights into social blind spots, enabling organizations to connect authentically with their communities.

Honda ignored signs of airbag problems at Takata. The problem was identified by a Swedish airbag maker who warned General Motors that Takata airbags are unsafe and potentially dangerous. Patent application state the compound is vulnerable to temperature changes. A Supply chain / Staffing / Human factor 

Identifying and addressing blind spots requires a proactive approach. It involves looking beyond what is readily apparent and questioning assumptions, processes, and practices that may be hiding potential risks. It also involves seeking diverse perspectives and feedback from employees, customers, and other stakeholders to uncover hidden issues.

To grasp your blind spot effectively, you need to encourage a culture of openness and continuous improvement within your organization. Here are some key steps to help you in this process:

A – Act with urgency

Supply Chain Rigor / System

I information 

Communication 

Many owners or leaders in businesses seem to believe that everyone involved fully understands the vision and direction in which the company is moving. The truth is in many instances this is not the case. The vision for a business must be communicated clearly and consistently to ensure that everyone understands and is on board. What if the team members do not have a clear view of where the company is headed? Let’s create a visual – it would be like having cars on a one-way street driving without headlights, a recipe for disaster or a blind spot.

• Foster a culture of psychological safety: Create an environment where employees feel comfortable speaking up, sharing their concerns, and challenging existing practices without fear of retribution. Psychological safety encourages open dialogue and helps uncover blind spots that may otherwise remain hidden.
  • Add example 
• Encourage diverse perspectives: Actively seek input from individuals with different backgrounds, experiences, and expertise. Diverse perspectives can provide valuable insights and uncover blind spots that a homogenous group might overlook. This can be done through diverse hiring practices, cross-functional teams, or seeking external feedback.

Implement robust feedback mechanisms: Establish channels for employees, customers, and other stakeholders to provide feedback on safety and quality issues. Encourage reporting of near misses, incidents, and concerns, and ensure that feedback is acted upon promptly. This helps uncover blind spots that may not be apparent through routine inspections or audits.

Conduct thorough risk assessments: Regularly evaluate and assess potential risks across all aspects of your organization, including processes, products, services, and systems. This includes considering both internal and external factors that may impact safety and quality. Look beyond immediate risks and consider long-term implications as well.

Promote cross-functional collaboration: Encourage collaboration and communication across different departments and teams within your organization. Cross-functional collaboration helps break down silos and ensures that blind spots are identified and addressed from a holistic perspective.

Seek external expertise: Engage external consultants, auditors, or experts to conduct independent assessments and audits of your organization’s safety and quality practices. External perspectives can provide valuable insights and uncover blind spots that may be difficult to recognize internally.

Encourage questioning and challenging assumptions: Create a culture where questioning and challenging assumptions are welcomed and encouraged. Encourage employees to challenge the status quo, propose alternative solutions, and seek evidence-based justifications for existing practices. This helps uncover blind spots that may be rooted in outdated or flawed assumptions.

Continuously review and adapt: Regularly review and reassess your organization’s practices, processes, and systems. Blind spots can evolve over time, so it’s important to continuously adapt and improve your approach to identifying and addressing them.

By following these steps and embracing a proactive approach, you can better grasp your blind spots and minimize the risks and failures associated with them. Remember, uncovering blind spots is an ongoing process that requires commitment and vigilance. It is a crucial step in ensuring the safety

Chapter 5: Implement lesson learned

“Those who don’t know history are destined to repeat it.” Edmund Burke “Those who cannot remember the past are condemned to repeat it.“ George Santayana “What has been will be again, what has been done will be done again; there is nothing new under the sun. “ Ecclesiastes 1:9

Learn from the most famous quality failures in history, etched in blood and pain, Failures from the last few tenths of years that resulted in catastrophic consequences taught us valuable lessons. In theory, leaders from around the globe should embrace these lessons, taking advantage of the free tuition that others paid with blood and tears. In reality, many companies fail to learn from their own mistakes, let alone from the mistakes of others. Unfortunately, companies and their leaders tend to overlook the opportunity to learn from others’ mistakes. It usually happens because people falsely assume that such failures cannot occur at their watch. After all, they are better leaders, have better systems, or come from a different industry, so their product cannot ever do awful things like endangering user safety or harming the environment. Yet, there is a great deal of commonality between your organization and all of these described here, probably more than you would like to believe. As you read on, you will find that beyond these failures, there are minor deviations that accumulate over time. Your organization likely has the same issues.

Many companies fail to learn from their mistakes, let alone from those of others. Often, these organizations falsely believe that the same problems will not hit them, especially if they are in a different industry sector. Or that they can handle them successfully or differently. 

CAIB found disturbing parallels remaining at the time of the Columbia incident from the challenger events. CAIB determined that NASA had not learned from the lessons of Challenger

BP- Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation. As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success. The tested barrier nevertheless failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.

Embrace a learning mindset: Cultivate a culture of continuous learning and improvement. Encourage employees to seek opportunities for professional development, share lessons learned, and engage in ongoing training and education. By embracing a learning mindset, you create an environment that is receptive to identifying and addressing blind spots.

Utilize technology and data: Leverage technology and data to identify patterns, trends, and anomalies that may indicate potential blind spots. Implement systems and tools that enable proactive monitoring, early detection of risks, and data-driven decision-making. Analyze data regularly to uncover potential blind spots and take appropriate actions.

practice of learning from errors had to change 

2. Establish ways to learn from failure throughout the organization, not just in operations. At Honda, as at most manufacturers, detecting mistakes is linked to continuous improvement on the factory floor. Other parts of the company — including IT, supplier relations, strategic planning, corporate communications, and accounting — have had less exposure to that “lean management” tradition (as it is sometimes called). Few companies are prepared to uncover and manage systemic problems in these continually shifting functions, especially when they are more far-flung and unwieldy than at a production plant.

As detailed in this section of the Report, DeGiorgio’s failure to disclose this critical information had very significant consequences going forward. GM investigators struggled to identify the root cause of the Ignition Switch problem for years, in part because they could not explain why, if the Ignition Switch was mechanically the same in all model years, incidents ceased occurring in MY 2008. As set forth below, while the decision to change the Ignition Switch, without changing the part number, violated GM’s policies, GM also failed to have in place an oversight system suffici ent to ensure such decisions were reviewed and the correct decisions made. 

Appendix List of cases

Challenger 

2021 Texas Power Grid Failure

2019 Conception Dive Boat Maritime Disaster

2019 Philadelphia refinery explosion and fire 

2019 British Airways flight BA3271 landed on a different airport 

2019 Notre Dame fire  

2018 Massachusetts Gas explosions  

2018 The Camp Fire

2018 New York helicopter crash 

2018 Amazon Echo

2018 New York Limozine crash 

2017 Grenfell Tower fire

2013 Costa 

2006 Mississippi oilfield explosion 

2001 Milwaukee Brewers bug blue fell 

2000 London Millennium Footbridge

1980 Lake Peigneur

Three Mile Island Accident

Recommendations are only words on paper until they are acted on

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Chapter 1: Introduction

• Introduce the purpose and scope of the book
• Explain the importance of quality for business leaders
• Provide an overview of the MAGIQ framework and its benefits

Chapter 2: Mind Your VAG (Value-Action Gap) and Lesson Learned

• Explain the concept of VAG and its significance in quality management
• Discuss specific lessons learned from VAG-related failures and how to avoid them
• Guide readers through the exercise of mapping interfaces and assessing value and action ranks, integrating lessons learned from quality failures

Chapter 3: Articulate Your JOLT (Jeopardizing user well-being, Operational costs, Litigation, Trustworthiness) and Lesson Learned

• Discuss the importance of understanding the potential costs of actions
• Explore specific lessons learned from JOLT-related incidents and their impact on quality
• Provide practical examples and exercises to help readers articulate their own JOLT, incorporating lessons learned from quality failures

Chapter 4: Generate Solutions or Grasp Blind Spots and Lessons Learned

• Encourage readers to think innovatively and identify blind spots in quality management
• Present lessons learned from past blind spots and how they were addressed, including examples from quality failures
• Offer case studies and examples that demonstrate effective problem-solving approaches and lessons learned from quality failures

Chapter 5: Implement Lesson Learn and Lesson Learned

• Guide readers through the process of analyzing past failures and successes
• Discuss lessons learned from previous implementation efforts and how to overcome challenges, including insights from quality failures
• Emphasize the importance of continuous learning and improvement, sharing specific lessons learned from implementation experiences and quality failures

Chapter 6: Qllaborate and Lesson Learned

• Highlight the power of collaboration in achieving quality goals
• Share lessons learned from successful collaborations and pitfalls to avoid, including insights gained from quality failures
• Provide strategies and lessons learned for effective collaboration and leveraging collective strengths, drawing from quality failure examples

Chapter 7: Conclusion

• Summarize the key points and takeaways from the book, including overarching lessons learned from quality failures
• Encourage readers to apply the MAGIQ framework and lessons learned in their contexts
• Reinforce the importance of continuous learning, improvement, and collaboration in mastering exceptional quality results

This revised outline maintains the integration of lessons learned from quality failures while ensuring a focused and interconnected structure for the book. Let me know your thoughts on this updated outline, and if there are any further adjustments or additions you’d like to make.

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1. Ford Pinto Fuel Tank Design (1970s): The Ford Pinto’s fuel tank design was found to be flawed, resulting in a higher risk of fuel leakage and fires in rear-end collisions. The company was aware of the issue during the development process but chose not to recall or modify the vehicles due to cost concerns. This case exemplifies the ethical implications of prioritizing cost over customer safety.
2. Chernobyl Nuclear Disaster (1986): The Chernobyl disaster in Ukraine was caused by a combination of design flaws, inadequate training, and violation of safety protocols. The catastrophic explosion and subsequent release of radioactive material resulted in immediate deaths and long-term health and environmental consequences. This incident underscores the importance of stringent quality controls and adherence to safety protocols in the nuclear industry.

To avoid these failures, there’s something called the Plan-Do-Check-Act (PDCA) cycle. It’s like a continuous improvement cycle that helps you keep an eye on quality. It’s simple: you make a plan, you do it, you check if it’s working, and then you make adjustments if needed.

Let me break it down for you. In the planning stage, you ask yourself questions like: What do we want to achieve with our quality? What do we need to do to get there? And how can we avoid problems before they happen?

Then comes the doing stage. You need to make sure that what you planned actually happens. Are people trained and ready to do their jobs well? Are they following the quality standards?

Next, is the checking stage. Here, you need to monitor and measure how things are going. Are you keeping track of important things and checking if they meet the quality standards? And are you involving your employees in this process so that they know what to look out for?

Finally, the acting stage. This is where you take action based on what you’ve learned. If something isn’t going as planned, you need to make adjustments. And don’t forget to learn from your mistakes and share those lessons with everyone.

But here’s the thing—even big organizations like NASA can miss out on important steps in the PDCA cycle. Take the Hubble Telescope, for example. They discovered that the lens was misaligned only after they launched it into space. If they had checked it properly during manufacturing, they could have fixed the problem before it became a disaster. It’s a classic case of missing out on the “Check” stage.

By embracing the PDCA cycle and making it a part of your work, you can make sure that quality is always on your mind. You can identify problems early on, set clear goals, follow robust processes, keep an eye on performance, and take action when needed. It’s a disciplined approach to quality that will help you deliver products and services that meet or exceed customer expectations.

The choice is yours. Will you let your organization be vulnerable to failures and customer complaints? Or will you embrace the importance of quality and integrate the PDCA cycle into your work?

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OLD:

We often come across organizations that make lofty promises about prioritizing safety and quality, presenting themselves as paragons of these values. However, when we delve into their day-to-day operations, we often find a disconcerting reality. The products or services they provide do not live up to their claims, leaving us to question the authenticity of their promises.

This disconnect between words and actions is known as the Value-Action Gap (VAG). It is a prevalent issue that transcends industries and sectors, undermining the trust between organizations and their customers. The VAG arises when organizations fail to follow through on their commitments when faced with real-world challenges and pressures.

As consumers, we have likely witnessed instances where companies neglect essential verification steps, penalize employees for raising concerns, or underinvest in training and technology. We may have observed misaligned incentives, weak quality control systems, or the outsourcing of critical functions without proper vetting. These actions prioritize short-term gains over safety and quality, resulting in inferior products or services that can potentially cause harm.

Deepwater Horizon oil spill: Safety words that fell short in the face of a disaster The Deepwater Horizon oil spill was an environmental catastrophe that devastated the Gulf of Mexico, causing lasting damage to marine life and coastal communities. Even more tragic is the fact that this could have been prevented. The CEO of British Petroleum had a safety philosophy that focused too much on minor issues, such as spilled coffee, and not enough on the potential for drilling disasters. Eventually, several safety gaps were left unaddressed and critical components of the oil rig were not adequately inspected, ultimately leading to the Deepwater Horizon oil spill. This tragic event is a stark example of the VAG in action, where mere words and good intentions failed to prevent a disaster. 

GM faulty ignition switch failure: The GM Nod: Nod of agreement, lack of action The GM faulty ignition switch failure was a serious safety issue that affected millions of General Motors (GM) vehicles. The problem was a defective ignition switch that could cause the engine to shut off while driving, disabling power steering, power brakes, and airbags. In this case, the company had known about the ignition switch defect for at least a decade but failed to take meaningful action to address it. A report on the investigation revealed a practice called the GM nod. After nodding their heads in agreement with a proposed action plan, managers left the room without doing anything. It sends a message that the manager does not prioritize safety despite their verbal agreement. 

NASA’s failure to act on safety warnings leads to disaster The loss of the space shuttle Columbia crew in 2003 was a tragic example of VAG within NASA. Despite its commitment to safety, it failed to take adequate action to address known safety risks related to the shuttle thermal protection system, despite warnings from engineers. This devastating outcome is a stark reminder of the significance of aligning values with actions. 

Merck: Marketing a dangerous drug as safe An additional example of VAG from the medical/drug industry is the case of the pharmaceutical company Merck. In the early 2000s, the company marketed its drug Vioxx as a safe and effective treatment for arthritis. However, internal studies conducted by the company had shown that the drug would increase the risk of heart attacks and strokes. Despite this knowledge and the proclaimed commitment to patient safety, they continued to market the drug as safe and effective, prioritizing profits over patient safety. 

Peanut Corporation of America: Ignoring contamination, shipping danger Imagine opening a jar of your favorite peanut butter and taking a big, satisfying spoonful – only to end up sick and hospitalized with Salmonella poisoning. It was an unfortunate reality for many people during the 2008 Peanut Corporation of America crisis. The VAG is that their practices did not reflect its emphasis on food safety and quality. Despite receiving multiple positive test results for Salmonella in their products, they chose to falsify records and ship the contaminated products anyway. This reckless behavior ultimately led to one of the largest food recalls in U.S. history. 

The Rana Plaza Tragedy: Fashion Industry’s Unseen VAG In 2013, the collapse of the Rana Plaza building in Bangladesh killed more than 1,100 garment workers and injured thousands more. The tragedy exposed a VAG among leading clothing brands that had outsourced production to factories with poor working conditions, despite public commitments to ethical sourcing and labor practices. 

Boeing’s 737 MAX Crisis: Profit Over Safety Boeing, a leading global aircraft manufacturer, faced a major crisis after two fatal crashes involving their 737 MAX aircraft. Boeing’s commitment to safety came into question as it became clear that the company had rushed the aircraft development to compete with rival Airbus, downplaying safety concerns along the way. The crisis damaged Boeing’s reputation and resulted in significant financial losses, illustrating the consequences of the VAG in the aviation industry.

The issuance of FDA letters in the pharmaceutical industry exposes the Value-Action Gap (VAG) between stated commitments to safety and quality and actual practices observed during inspections. These letters highlight violations of regulations and serve as valuable lessons, emphasizing the need for robust quality control systems, effective adverse event reporting, transparency, and accountability. By studying FDA letters, organizations can bridge the VAG, align their words and actions, and prioritize safety and quality in pharmaceutical manufacturing and distribution.

The Value-Action Gap is not just a problem of the past; it is still very much relevant today. The disconnect between organizations’ self-assessments and customer perceptions is evident in surveys and studies. The trust gap between public expectations and institutional performance highlights the ongoing issue of the VAG. It affects organizations of all sizes and types, and the consequences can be equally significant.

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Add the Talmud phrase. 

Even the world’s largest and most successful companies have failed due to poor quality, so what kind of quality should we expect from the rest?

A long list of other companies goes through crises because of a lack of proper quality systems or processes. 

Perhaps your product will never cause any harm to users or endanger their safety. However, if you learn from the mistakes and heartache made by others, you can avoid any potential mishaps. 

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i also have a story about a executive to used to tell me that quality is everyone responsbaility, but everyone didnt knew it or measured on that. will it fit to the book? which chpater?

40 years later, while walking through the office hallway, “management” stopped by to tell me that after thinking about it, they had concluded quality should be defined by its absence!

Everyone says that quality is important. All the time probably say it as well and I know you believe it, quaity is important, but not as much important as time to market, right?

These are just a few examples of quality failures due to time-to-market shortcuts. it’s very important to bring value to stakeholders. Not to miss the trend. But why on the epdxenspes of quality?

here is why 

Organizations, like people, are evolving over time, and developing their attitude to quality, 

Then for a couple of years, I heard: what is the worst that can happen? Only quality, right? tell it to people that lost their loved ones, their eyes, legs or other critical organs, tell it to the customer that missed their targets, theor well-being due ot yur quaity failure, tell it to board, when they will ask why there is a reduction in sales  

It’s easier to apologize for a product quality failure than not to ship the product at all. I really liked this one, Will you be pleased to get the new refrigerator that you’re ordered, on time, but not working? really? not? so why it legit to treat your customer?

this leaves us in the original question. if quality is important…?

Will you take 99% quality? sure you will. But will you go o airplane with 1% chance to crash? will you buy a car that has 1% chance to kill you?

one more thing about Takata, that managed to make their airbags to efficient killing machines, that throw…. they knew, along the way they know their customer knew as well, but hey, there was cost saving opportunity here. 

Cost saving is really important, it is. but do you really saving? if you take into account the potential issues, the time to handle them, the efforts, the repair, xxx have you really managed to save?

Mattel example, Chinese suppliers. 

You will get the bonus and the praise. Just watch out, not to get criminal charge on the way. 

but what to do? you can do plenty, without investing 

• how mamy of your employees will say that they ctively contribute to improve quality of products and processes as parts of their daily routine?
• the coke test
• do you have a meaninful quality targets to each of managers and emplyee? not the one that calls to meet the spec, the leading one, show me what you do 
• Key learning, leraning