In this blog we will discuss five events which, in our opinion, represent the greatest Quality Management System related failures ever recorded. These failures had, and in some cases continue to have, massive consequences, including loss of life and financial ruin , for the companies and organisations involved. Hopefully, by the end of the blog, you should also have a good understanding of why having a Quality Management System in place and adhering to its processes is crucially important.
1986 Challenger Space Shuttle Explosion
January 28th 1986 will be forever remembered as one of the most devastating days in the history of space exploration. The Space Shuttle, Challenger, exploded just 73 seconds after lift-off, killing all seven crew members aboard. It is thought that this tragic event may have been avoided if expert Quality advice had been observed.,
On the day before Challenger's launch, a group of engineers from a NASA sub-contractor, Morton Thiokol, attempted to delay the space mission over safety concerns. A meeting took place between the two parties where the Morton Thiokol engineers warned that the low temperature forecast for the next day potentially constituted unacceptable launch conditions and, given what both NASA and Morton already knew from previous findings, could prevent crucial ‘O’ rings from forming a seal in critical field joints in the solid rocket booster. However, part way though the meeting during a recess, Morton Thiokol’s engineers concerns were overruled, and leadership changed their position, declaring any evidence of failure of the ‘O’ rings was inconclusive, and giving their recommendation to proceed with the launch.
This decision ultimately led to the deaths of the seven crew members, costing NASA’s reputation and the United States Government an estimated $3.2 billion. In the months that followed the tragedy, multiple investigations were commissioned and reports submitted, with conclusions pointing to pressure to increase the rate of flights negatively impacting Quality Control, amongst other factors.
2010 Deepwater Horizon Drilling Rig Explosion
On April 20th 2010 in the Gulf of Mexico, a blowout on the Deepwater Horizon drilling rig operating for British Petroleum, caused an explosion and fire, leading to the one of the largest human-made environmental disasters in history and directly causing the deaths of at least 11 people as well as at least 17 injuries. In some reports, the cause of the explosion was ultimately attributed to the poor design and safety, and quality protocols on the rig. It is reported that a failure to adequately cement the base of the 18,000 foot deep well, the failure of several valve systems and failure to carry out several key safety and maintenance checks played a key role in the disaster. .
Over the course of more than 5 years and multiple lawsuits, BP was eventually found guilty of gross negligence, and reached an $18.7bn settlement with the US government and others. By January 2018, it was estimated that the disaster had cost as much $145.93bn.
Three Mile Island
On March 28th, 1979, the Three Mile Island nuclear power plant suffered a malfunction to primary and secondary systems that caused the temperature of the nuclear reactor coolant to rise substantially. This led to a series of automatic safety trips engaging, and the reactor shut down after pressures reached maximum safety limits. However, emergency systems designed to relieve these pressures failed to engage correctly, and engineers failed to notice warning signs, later reports pointing to inadequate training and design flaws leaving them ill-prepared.
Stuck valves began to leak reactor coolant water to the reactor coolant drain tank, causing the emergency cooling pumps to automatically go into operation. Even with the failure of multiple systems, if conditions and warnings had been trained for and interpreted correctly, the emergency cooling pumps could have stopped the crisis, but the plant workers present lacked the crucial training for such an event and disaster spiraled further out of control, leading to a partial meltdown of the Unit 2 reactor. The Three Mile Island incident may have been avoided if better quality checks, training and controls were implemented.
TOYOTA'S Recall of Vehicles Due to Unintended Acceleration
In 2009, Toyota issued an emergency recall of 9 million vehicles after some drivers began experiencing unintended acceleration, costing the lives of 52 people and injuring a further 38. After recalling the vehicles, it would take some time to find the reason why the Toyota cars would accelerate and not stop, with some reports stating that even after applying the handbrake the car would continue.
Two years later on February 8th, 2011 the National Highway Traffic Safety Administration (NHTSA) and NASA would conclude in their findings that there were no electronic defects found anywhere in the Toyota vehicles ,both agreeing that the unintended acceleration was due to driver error and was no fault of Toyota.
However on October 24th, 2013 a court jury ruled against Toyota after being shown evidence that demonstrated that the unintended acceleration was caused by a deficiencies in the Electronic Throttle System (ETCS). As a result of Toyota being found responsible, they entered into settlement agreements, suffering financial losses of around $5.5 billion.
Chernobyl Disaster
The Chernobyl nuclear disaster on the 26th April 1986 in the former Soviet Union is considered the worst nuclear disaster in history both in terms of cost and casualties. A flawed reactor design, operated by inadequately trained staff Led to the Chernobyl power station meltdown and explosion, affecting much of the surrounding settlements in Ukraine and Belarus.
The disaster was brought about by a series of human errors and design failures during a safety test on the steam turbine of reactor four. Whilst carrying out preparations for the test, the power output unexpectedly dropped to near-zero. The plant operators found themselves unable to restore the power level specified by the test program, and this risk this posed was not made evident in their instructions, so they proceeded.
Upon completing the test, the operators attempted to trigger a reactor shutdown as planned. However, the combination of operator error and critical design shortcomings had left the reactor primed to explode. An uncontrolled nuclear chain reaction began, releasing enormous amounts of energy inside the reactor and leading to a chain reaction of explosions and radioactive material being spewed into the atmosphere.
The Chernobyl disaster is one of history’s most terrible quality failures, directly causing the deaths of at least 31 people and many others in the vicinity suffering from adverse health effects due to radiation.
Conclusion
The five disasters and Quality Management System failures above showcase extreme cases where steps designed for safety were circumvented, or shortcuts taken when training staff leading to disasters that could potentially have been avoided.
Quality Management System Failures Prevention
- Design and Process FEMAs
- Effective design reviews
- Measurement-based corrective action
- Customer Satisfaction
This demonstrates the benefit to every business of a well-maintained and implemented quality management system from anything such as improving your product quality, increasing efficiency in production, maintaining safety and in the most extreme cases saving lives. All of these benefits can also help to increase the profitability of work activities.
How can we help your business thrive with a Quality Management System?
A well-maintained and implemented Quality Management System can benefit your business in a variety of ways from improving your product quality, increasing efficiency in production, maintaining safety and, in the most extreme cases, saving lives. All of these benefits can also help to increase the profitability of work activities and reduce waste.
How can we help your business thrive with a Quality Management System?
If you need help with quality assurance, QMSRegs can provide over 70 templates that you can purchase and download today to help improve your Quality Management Systems.
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