The phrase ‘elephant in the living room’ refers to a major problem that everybody knows is there, but nobody wants to acknowledge. Acknowledging and defining the problem is, of course, the first part of any closed-loop corrective action process. ‘Problem notification’ and ‘problem identification’ are the first two steps in the Automotive Industry Action Group’s Effective Problem Solving for Practitioners process.
General Motors seems to have forgotten this.
It is, meanwhile, difficult to figure out how anybody can perform a failure mode and effects analysis (FMEA) when he or she is discouraged from using words like ‘critical,’ ‘serious,’ ‘safety,’ and ‘safety-related.’ These were four of the 69 words that General Motors’ employees were told to avoid. Others, such as ‘rolling sarcophagi’ and ‘malicious,’ are admittedly not necessary for scientific risk assessments.
An ignition switch failure that not only shuts down the engine, but also disables the vehicle’s power steering and air bags, is emphatically critical, serious, and safety-related. This qualifies the failure as a 10 severity on a 1–10 scale in a FMEA. Anything with a severity of 10 requires attention regardless of low (i.e., good) ratings for chance of occurrence and chance of detection. The fact that no fewer than 13 fatalities resulted from ignition switch failures underscores the consequences of the automaker’s refusal to acknowledge a problem.
Admonitions to ‘be careful’ also fall far short of modern standards for consumer and workplace safety. During the early 20th century, countless factories warned their employees against putting limbs into presses. Countless factories added procedures for workers to signal each other when they used the presses, and countless hands and fingers were nonetheless crushed or severed. In his book, Ford: Men and Methods (Doubleday, Doran and Co., 1931), author Edwin Norwood points out that Henry Ford implemented the safety principle, ‘Can’t rather than don’t.’ This means, ‘In so far as it is practicable it is not a case of ‘Don’t,’ but the installation of devices that stand for ‘Can’t.’
General Motors, however, relied on ‘Don’t rather than can’t.’ In December 2005, GM sent a bulletin stating ‘…the defect can occur when ‘the driver is short and has a large and/or heavy keychain… the customer should be advised of this potential and should… [remove] unessential items from their keychain.’’ This relates to inadequate spring tension that allows vibration or jostling of the keychain to shut down the engine. Another reference describes the switch detent plunger, and its operation, in detail. A heavy keychain is a foreseeable use of the ignition switch, and shutdown due to vibration or jostling should simply not be possible.
According to the International Registry of Certified Auditors, ISO 9001:2015 will require risk-based thinking (as opposed to risk management), and is likely to specify ‘Actions to address risks and opportunities.’ An organization cannot plan for a risk it does not acknowledge.
This article was previous published in Quality Digest Magazine.
Bio:
William A. Levinson, P.E., is the principal of Levinson Productivity Systems P.C. He is an ASQ Fellow, a certified quality engineer, quality auditor, quality manager, reliability engineer, and Six Sigma Black Belt. Levinson is the author of Henry Ford’s Lean Vision: Enduring Principles from the First Ford Motor Plant (Productivity Press, 2002). He holds degrees in chemistry and chemical engineering from Penn State and Cornell Universities, and night school degrees in business administration and applied statistics from Union College.