Deaths and disasters attributable to ISO 9000
GumDrop
deaths and major accidents in which ISO 9000 was cited as a contributing factor.
I've been working in Australia, where there are two significant incidents: one a
demolition by explosive (spectators were too close and a child was killed by
flying debris), the other a fire on a navy vessel caused by a wrongly-specified
fuel hose which burst (three sailors were killed). In both cases the purchasing
organisation required that the supplier by ISO-accredited, and relied on the
accreditation as proof of competence.
I was wondering if anyone knows of any similar incidents elsewhere in the world.
Please note that this is not remotely a criticism of ISO 9000 itself. In both
the incidents mentioned it was the interpretation of what ISO means that was
faulty.
Matti Vuori
news:k0Z0a.42955$jM5.1...@newsfeeds.bigpond.com:
> Please note that this is not remotely a criticism of ISO 9000 itself.
> In both the incidents mentioned it was the interpretation of what ISO
> means that was faulty.
Then why do you ask about "Deaths and disasters attributable to ISO 9000"
and not "Deaths and disasters attributable to misunderstanding the nature
of standards for quality assurance systems"?
--
Matti Vuori, <http://sivut.koti.soon.fi/mvuori/index-e.htm>
leto...@nospam.net
>"GumDrop" <Wh...@dumpmail.com> wrote in
>news:k0Z0a.42955$jM5.1...@newsfeeds.bigpond.com:
>> Please note that this is not remotely a criticism of ISO 9000 itself.
>> In both the incidents mentioned it was the interpretation of what ISO
>> means that was faulty.
>Then why do you ask about "Deaths and disasters attributable to ISO 9000"
>and not "Deaths and disasters attributable to misunderstanding the nature of
>standards for quality assurance systems"?
Because he probably is referring to the false belief by some that ISO means
"things are being taken care of." There is such a thing as complacency
factor.
Now everyone believes that ISO even means quality. All it really means is
that someone has documented how things are done or should be done, and it
satisfied the inspectors. In an honest, objective sense ISO xxxx means
nothing more. There is hope that it means something -- that the product is
better then it would be without ISO, but that doesn't make it so.
--
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leto...@together.net
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GumDrop
>
> Then why do you ask about "Deaths and disasters attributable to ISO 9000"
> and not "Deaths and disasters attributable to misunderstanding the nature
> of standards for quality assurance systems"?
>
What I'm looking for are instances where ISO 9000 has been specifically
mentioned as a causal factor in any sense. In the two instances mentioned there
were formal enquiries, the findings of which made reference to ISO 9000. These
did not blame the standard in any sense; but they did find a connection between
what went wrong and the fact of ISO being (mis-)used.
R&O
"GumDrop" ha scritto nel messaggio
> I'm currently researching some downsides of the quality movement,
specifically
> deaths and major accidents in which ISO 9000 was cited as a contributing
factor.
Dear all,
in Italy there is a law to fulfil an obligation for the
building-yard that the builder it's under ISO 9001 certification. Now,
pheraps the CEE to annul this law. For me the problem is not the
certification but the certificator, the consultant and the, of-course, the
builder property.
In any case I think that if you woul like build, ship, house,
factory or other, under the best technics, best raw materials, best engineer
or technician, it isn't a Law or ISO problem but only a money' problem!
Fausto Oggionni
from Italy
Mark Browne
sounds like an expedition into new territory leading to a flood of lawsuits.
Even studies in the interest of a harmless graduate paper can spark the
flame. If you produce a paper and get some popular press you are sowing the
seeds of future misery in the quality field. Somewhere there is a lawyer
that is having trouble meeting his bills; he is looking for a new way to
drum up some cash. It does not take a rocket scientist to imagine the class
of "faulty implementation of the ISO standards." One of the things that
infuriate me is the trick of leading a panel of juries to confusing the tool
with it's faulty application - ending with the punishment of the producers
of the tool. I have been on the receiving end of this sort of thing once and
have become very wary. We would all have to worry about being sued because
we have ISO certification.
This is the reason I have never gone for my "professional engineer" license.
It attracts lawsuits!
To evaluate the request lets substitute another useful tool like a
life-jacket and try it again:
"I'm currently researching some downsides of floatation gear, specifically
deaths and major accidents in which life-jackets were cited as a
contributing factor."
Hmmm, I don't think I want any part of this. Around every disaster there
will be companies with money and an ISO certification. I can see the shark
fins in the water now.
Mark Browne
"GumDrop" <Wh...@dumpmail.com> wrote in message
news:2sj1a.43708$jM5.1...@newsfeeds.bigpond.com...
GumDrop
pursued because some lawyer might construe your results as grounds for
litigation? Surely not. That's promoting ignorance because you're frightened of
the knowledge. My contempt for much that lawyers do is on par with yours; but to
turn tail and hide is the wrong response.
I think your reference to the life jacket makes MY point rather than yours.
Research somewhat like mine has led to significant improvements in jacket design
over the years (don't use kapok because if the covering is damaged it gets wet
and you sink; design the straps to prevent strangulation, arrange the floats to
keep your face out of the water, etc) Those improvements were the result of
research that included very detailed examination of instances where life jackets
"were cited as a contributing factor".
If we become afraid to ask questions when bad things happen, we're doomed to
repeat our mistakes.
GumDrop
> You don't need stories about disasters. Analyze ISO9000 itself
> and look for areas that need improvement. You are confusing the
> quality of the standard with the quality of its implementation.
>
For heavens sake, confusion between the quality of the standard and the quality
of its implementation IS the research topic. As I said at the outset, the
project is absolutely not a criticism of the standard. I am looking for real
world instances where somebody asserted (for whatever reason) a connection of
any sort between the ISO 9000 and a disaster.
Mark Browne
knowledge.
I have a few objections to the tone of the original post. My instant dislike
to the first post was the "have you stopped beating your wife yet" nature of
the assertion. Read the title of this thread. You are pairing disasters with
ISO 9000, not the incorrect application of the standard. I acknowledge that
you stated that this was not your purpose in the body of the post, but a
similar provocative title on a research paper will have much the same
effect.
My next problem is the phrasing of your question that I rephrased. Nothing
can withstand that sort of structure. I am not sure that it adds much to the
understanding of an issue - it seeks to reduce a complex situation to a
sound bite. Pick any common tool found at a disaster site and plug it into
the: "I'm currently researching some downside of *class*, specifically
deaths and major accidents in which *exemplar* were cited as a contributing
factor." You now state that more should be known about this tool. Fine. Then
I would expect you to be looking at aspects or usage of the tool. Best
practices perhaps. Not a sweeping evaluation about usage of the entire class
of tools.
From these considerations I don't trust you to provide a responsible and
useful paper.
The scientific method is commonly stated as making a hypothesis, using this
to make predictions, and finding examples of this prediction to prove the
original hypothesis. Of late, more emphasis in placed on finding an example
of a data point to *disprove* a hypothesis. The longer it stands against
concerted efforts the more likely it is to be true. A single observation can
bring an entire model crashing to the ground. The soft sciences don't fit
well with the newer model, one of the reasons for the "soft science"
grouping.
Turning back to the ISO and disasters question. It would take a very
rigorous analysis to show how these points have any sort of meaning at all.
This type of question can't be proved or disproved; in any disaster there
are many contributing factors. With sufficient data points you might be able
to work up a multivariate analysis. Anything less is meaningless fluff. It
takes much skill and training to produce anything useful with this sort of
thing, and just as much training to understand the findings. Look at the
long problems with the acceptance of evolution as an example - it takes
considerable intellectual prowess to chase down the underpinnings of the
explanations. Many people never do learn enough to even understand the
explanation. These sort of fine points never bothered a trial lawyer; a few
supporting sound bites from a scientific sounding paper with an easy to
understand title will do the job. Hence my concern.
Perhaps a better choice for research is - what semantic loading do poorly
understood topics acquire in the collective public mind?
Mark Browne
"GumDrop" <Wh...@dumpmail.com> wrote in message
news:0Py1a.44083$jM5.1...@newsfeeds.bigpond.com...
GumDrop
I'm sorry you don't like the question; but my brief is what I shall stick to.
Thank you for the comments anyway, and thanks to all who emailed me with
incidents. Given the tone of debate in the forum, I can understand why you chose
to avoid posting.
But I must say, I am stunned by the defensive of these responses. Doth protest
too much, methinks.
John
wrote:
The problem is research is rarely carried out as a completely
impartial act of analysis and conclusion. Somewhere along the line
someone will have an axe to grind, especially those who are may be
sponsoring the work.
Mark's points are well made, the words that are used are extremely
important bearing in mind the power they may well end up having. Far
from adding to the wealth of knowledge, sloppy writing could well
detract from the point the research is trying to make, as it seems to
have done in this simple thread.
It is not a case of being defensive but being precise in your
communication.
John
S. Daum
Sorry - I can't remember the source of this...
"John" <di...@hitmail.con> wrote in message
news:bd8f4vktn23tjsv24...@4ax.com...
Claude
How can ISO be cited as contributing to any of these accidents? ISO requires
that you provide a system for..etc etc. ISO does =NOT= tell you what
specifications you should establish as a distance for your observers to be
from an explosion. Nor does it guarantee that someone won't specify the
wrong fuel hose.
For Christ's sake, I wish people would stop expecting these systems to solve
all their worldly problems or look at them as insurance policies against
mistakes and violations of common sense.
Fit and adapt the system to meet the practicalities of your business or
operation rather than fitting and adapting your business to the system. Do
What Makes Good Business Sense!!!!!!!
End of Rant.
Claude
I agree with you and share the same worries.
However, looking at the original post as an example. Remove the elements of
ISO. Could the disasters have occurred? I think the answer is YES. Did
someone misinterpret ISO? Maybe. So what? It is totally irrelevant and so is
this line of research. It is completely bogus! You cannot argue that ISO is
at fault. If someone applies it or intepets it improperly then that is akin
to someone misinterpeting an MSDS sheet or a safety procedure. The procedure
may be ambiguous, but the fact that one is in place is where ISO comes in.
It doesn't guarantee that the procedure is correct and unambiguous does it?
"Mark Browne" <mbr...@attbi.com> wrote in message
news:OYt1a.43011$SD6.2614@sccrnsc03...
leto...@nospam.net
>End of Rant.
You're missing the connection he was aiming at; think in terms of people
making an "assumption" that is something is ISO certified it ought to be
enough.
--
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leto...@together.net
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Claude
Letoured"@"nospam can you read this????
"Jim Higgins" <UseAddr...@pandora.orbl.org> wrote in message
news:ndnd4vs1e8h0ltudg...@4ax.com...
> On Mon, 10 Feb 2003 07:35:56 +1100, in
> <0Py1a.44083$jM5.1...@newsfeeds.bigpond.com>, "GumDrop"
Claude
<leto...@nospam.net> wrote in message
news:3e4a4f57$2$yrgbherq$mr2...@news.together.net...
Claude
of those who have the knowledge of the subject?
"GumDrop" <Wh...@dumpmail.com> wrote in message
news:pjE1a.44258$jM5.1...@newsfeeds.bigpond.com...
leto...@nospam.net
You are missing the point. There is such a thing as "complacent behavior"
because of reliance on a system. You don't seem to get that. Its the point
the original poster had in mind.
--
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leto...@together.net
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Claude
independent of any system. It has nothing to do with ISO, it has nothing to
do with anything but the complacency itself which can and will occur under
any condition. READ his post again. He is suggesting that ISO contributed
to some extent. I am suggesting that that statement is ludicrous. People
are complacent because they are people, not because they have fantastic
expectations of some system. The last thing we need is someone wihtout
imagination getting a PhD because his research suggests that people are more
complacent with ISO in place. Complacency can be shown to increase
proportionally with the amount of incident-free exposure to a given risk.
Does that mean the risk is less? These accidents happened because people
made mistakes, didn't specify the right things. This would occur with or
without a system in place. The fact that a system was in place may have made
people more complacent, but complacency is the root cause and should be the
focus of the research.
<leto...@nospam.net> wrote in message
news:3e4bd623$3$yrgbherq$mr2...@news.together.net...
leto...@nospam.net
>I didn't miss that point. My point is that complacent behaviour is
>independent of any system. It has nothing to do with ISO, it has nothing to
>do with anything but the complacency itself which can and will occur under
>any condition. READ his post again. He is suggesting that ISO contributed to
>some extent. I am suggesting that that statement is ludicrous.
Well I'm sure ISO could and has contributed to failures -- complacent
behaviour is not independent of any system. If ISO or any quality system is
worth anything, its because its has become part of the corporate culture. If
you have even seen the inner day-to-day workings of some organizations and how
they actually think and make decisions, you would know that things like he
suggested can and do happen. Hell, we've had airliners almost run out of fuel
because well trained people relied on an alarm or someone else in the crew to
pay attention -- and they didn't for 5 minutes.
The same thing happens with reliance on a paper system that should catch
errors. The final point is that a system is only as good as the people using
it. If you have hired a collection of idiots, you are going to get idiotic
behavior at some point -- and the program may not check it in time.
Now I'm not interested in splitting hairs or playing semantics with you. --
I've seen the very behavior he suggests in action -- in organizations like GE,
and others of similar stature. So don't tell me it doesn't happen.
--
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leto...@together.net
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Claude
You said:
"The same thing happens with reliance on a paper system that should catch
errors. *The final point is that a system is only as good as the people
using
it.* If you have hired a collection of idiots, you are going to get
idiotic
behavior at some point -- and the program may not check it in time. "
<leto...@nospam.net> wrote in message
news:3e4cd42b$3$yrgbherq$mr2...@news.together.net...
> In <b2he68$5c8$1...@news1.mountaincable.net>, on 02/13/03
> at 07:44 PM, "Claude" <Claude...@quickpic.net> said:
Much appreciated!
Splitting hairs, LOL, gimme a break!!!
Mark Browne
analysis is to also find out how many disasters have been averted by
selecting an ISO supplier from the list of possible suppliers.
Of course, the claim will follow - That's too hard, it can't be done!
Mark Browne
"Claude" <Claude...@quickpic.net> wrote in message
news:b2iolp$9sr$1...@news1.mountaincable.net...
John Duffus
been more circumspect in his language. As far as I can see he has not
alleged any connection or is intent on proving one where none exists, but
merely noted some interesting facts and is planning an investigation that
may benefit the public interest. He has not outlined the entire scope of the
investigation so there is no justification for some of the assumptions and
irrational allegations that have been made. It is particularly silly to draw
the conclusion that because some research does not have pure motives all
research is suspect. However he can take comfort in the fact that when your
opponents are wrong-headed in some things they are likely to be
wrong-headed in general.
I took GumDrop's query as one bearing on the general question as to whether
buyers are justified in relying to any extent on ISO certification as an
indication of a supplier's competence. He chooses to emphasize the possible
serious consequence to life and limb. That doesn't exclude more general
conclusions that might be drawn from the same data about the detrimental
effect on quality.
He is not taking a shot in the dark. There is plenty of evidence that buyers
place reliance on the fact of a supplier's certification. There are also
lots of reasons to believe that many certified companies do not live up to
the requirements of the standard. This is not the generally held view of the
public at the moment but it will be if the present conditions persist.
Quality practitioners should be interested in maintaining the integrity of
the system, not attacking those raising legitimate questions. This is
exactly how the accounting shenanigans of large companies escaped attention
for so long.
My own opinion is that the auditing process is ineffective. A certificate is
something like a driver's license. Only the most egregiously incompetent are
denied one. You only have to glance at the miniscule numbers of certificates
that are revoked for noncompliance to form the strong suspicion that the
standard of compliance can't possibly be that high. From my own experience I
would estimate that less than half of those holding certificates would do so
under a reasonably strict auditing regime. It becomes legitimate to consider
the mishaps that can occur in any company only after it has passed a
realistic basic test for competence.
John Duffus
"Claude" <Claude...@quickpic.net> wrote in message
news:b2caot$9b3$1...@news1.mountaincable.net...
Claude
audit and that is very difficult to do if they must find a great amount of
fault in the systems they audit. I have witnessed audits that, if done with
a bit more scrutiny and objectivity, really would have found that the
systems were just not up to snuff and registration not granted. But auditors
take the approach that they need to work with the company to help them
mature the system. I guess for some, it is a bit like saying: "well at least
they are trying, they have put some effort into developing and implementing
a system, so why tell them they did a shitty job and will not get
accrediation"
But this is to me an entirely different matter than we were discussing with
Gumdrop's post. Maybe poor choice of question lead to ambiguity. I still
believe that it is people that are complacent. If a system leads to more
complacency, the root cause is still complacency, misunderstanding and
misinterpretation. No one can say that the ISO or any other system is
flawless, without fault or perfect. It isn't true. The audit process which
verifies a system is active and in place does not guarantee that it is going
to produce high quality product or a safe and incident free work place.
"John Duffus" <john....@sympatico.ca> wrote in message
news:L2s3a.35052$Ww1.9...@news20.bellglobal.com...
jones
think it will make some incidents. BUT, some bad ISO9000 certificate will
mislead the clients thinking. I am a QMS auditor locate in China. Many
companies show me some ISO9000 certificates, but I found that the systems
haven't been set up yet.
So if somebody show you a QMS certificate to let you know their good quality
or good management, DON'T TRUST IT!
ISO9000 is a good management standard. But it doesn't mean that all the
systems behind the certificates are good too.
"GumDrop" <Wh...@dumpmail.com> 写入消息新闻
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