Workforce Training is Not a Quality Management System

By Jon Miller Updated on May 15th, 2017

There are many reasons to love the Boeing Company. They are a pillar of the community, a significant local employer, an innovator in bringing lean to the aircraft industry as well as to local non-profits, and they enable global consulting and training businesses like ours through the safe and reliable medium of air travel. As if that were not enough, they occasionally provide rich fodder for one point lessons on lean manufacturing.

The November 4, 2008 article in The Seattle Times titles Boeing finds problems with 787 fastener installation reports yet another challenge to the on-time delivery of the Boeing 787 Dreamliner and a peek into the dysfunction of Boeing’s new product introduction process. From the article:

In the middle of the Machinists strike, Boeing inspectors in Everett discovered a new and serious problem with the manufacture of the first 787 Dreamliners.

“For lack of a nail” indeed. It turns out that about 3% of the fasteners installed on the five test airplanes being built at the Everett plant were installed incorrectly. These 5 airplanes are now rework, a great waste. In addition, these same errors have been found upstream at suppliers. What was wrong?

“We are finding that the specification for installation of the fasteners wasn’t as clear as it could have been and so it was misinterpreted by folks doing the installation,” said Boeing spokeswoman Mary Hanson.

Quoting one of our consultants who spent 10 years as the quality assurance manager at Toyota Motor Manufacturing Kentucky: “Brilliant! Quality Key Points in the Standardized Work were not clear!”

At which point in the process here was this nonconformity found? According to the Seattle Times article:

Hanson said the issue was first detected about two weeks ago during an inspection of the “static test” airframe in Everett, an early production airplane that undergoes prolonged stress tests in a large fixture inside the factory. Subsequent inspections found the same problem on the four 787s under final assembly, three of which were due to be flight test airplanes.

How expensive is it to discover this problem at final test, as opposed to let’s say, at the source? Perhaps 10,000 times. Now Boeing will have to tear apart, rebuild and retest those 5 airplanes. A proper inspection at the source every takt time would have caught this error months ago at negligible cost.

Perhaps it was corporate PR talking points not representative of the reality of Boeing’s quality management system or perhaps it was what the journalist chose to write. But the words of Boeing spokesperson Mary Hanson were discouraging:

“We’re going to strengthen our quality management system,” said Hanson. “We have already prepared additional training on the installation process that is now being deployed through the factory to our workforce. And we’ve also sent it to our partners and they are deploying it to all of their workforce as well.”

“Train the workers” is nearly always the first response to deep quality problems, but nearly never the true root cause countermeasure. Workforce training is not a quality management system. What is? We’ll here’s a start:

1. Study past failures through 5 why root cause analysis to determine failure modes
2. Identify quality key points and document them in the standardized work
3. Instruct workers in standardized work and follow up
4. Perform quality assurance through in-process checks, successive checks and final quality audits
5. Find mistakes early and learn from problem discovered and amendment or clarify those quality key points in the standardized work

We don’t usually do this, but I feel a civic duty: Dear Boeing Company, please CALL US. We’ll teach you how to put those quality points in the standardized work and how to strengthen your quality management system. I’m not flying a 787 until you do.

  1. Chris Nicholls

    November 5, 2008 - 1:24 am

    Dear Jon
    I was drawn to this blog entry by your remark “for lack of a nail” because I just watched yet another in a long line of documentary programmes about Titantic. In this one they sighted a number of actions, consequences or causes that lead to the “unsinkable” sinking in the North Atlantic 96 years ago.
    The thing that intrigued me was the discovery that the wrong type of rivet had been fitted in critical areas of the hull which subsequently failed on collision with the iceburg.
    The designer’s specified two main types of rivet in the construction of the hull. The modern steel rivets that could only be attached using a riveting machine and the old fashioned wrought iron rivet that could be attached manually. In certain restricted areas of the ship they could only physically use manually attached rivets. However they had discovered that some of the inferior wrought iron rivets had been fitted wrongly, in fact where steel ones should have been. In addition the purchasing people had decided to buy a cheaper grade of wrought iron to save cost. Although these cheaper rivets when fitted in the intended places would have been OK, when fitted wrongly in the place of the steel ones they would fail.
    So the Titantic was sunk for want of a nail, or anyway the correct nail at least.
    I guess Harland and Wolf should have foolproofed this design and process.
    Best Regards

  2. Priyavrat Thareja

    November 11, 2008 - 6:53 am

    A nail (or a rivet) is a strategic thing. It is (or becomes) strategic when it is Not subjected to a systemic approach. Same is the treatment deserved by a Quality Management System.
    I am reminded of having written a stanza in verse on nail ( it is old story but a new style):
    For the Err of a Nail, a (horse) shoe was Lost,
    For the want of a shoe a horse was Lost,
    For the want of a horse a soldier was Lost,
    For the want of a soldier a section was Lost,
    For the want of a section an army was Lost,
    For the want of an army a battle was Lost,
    For the want of a battle a war was Lost,
    For the want of a war a Nation was Lost,
    Priyavrat Thareja

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