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--- articles:crosbys_church_of_zero_defects [2022/08/16 08:49] – ["How "Zero Defects" followers view "risk"] rrandall
+++ articles:crosbys_church_of_zero_defects [2024/02/05 21:05] (current) – [Why "Zero Defects" is a flawed concept] rrandall
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 ===== Crosby's Church of "Zero Defects" =====
 ~~NOTOC~~
-It is surprising that a common topic of debate among quality professionals today is whether the "Zero Defects" concept is valid.
+It is shocking that a common topic of debate among quality professionals today is whether the "Zero Defects" concept is valid.
 ==== What is "Zero Defects" ====
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 This was most popularly demonstrated through Deming’s “[[https://www.youtube.com/watch?v=ckBfbvOXDvU|Red Bead Experiment]]”. In fact, point 10 of [[https://deming.org/explore/fourteen-points/|Deming's 14 points]] specifically rejects the “Zero Defects” concept, stating: <blockquote>//Eliminate slogans, exhortations, and targets for the work force asking for __zero defects__ and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the workforce//.
 </blockquote>
-When performing causal analysis, we must be able to identify and link an “assignable cause” to a problem in order to have a “root cause”. “Assignable Causes” can often be eliminated (e.g., through corrective action). However, when unable to identify and clearly link an “assignable cause” to a problem, we must recognize and acknowledge that those variations are most likely inherent to the process and cannot be eliminated; without completely re-engineering that process. And re-engineering a process may be cost-prohibitive… or impossible (e.g., due to technological constraints/limitations). However, there are usually risk controls we can institute to mitigate the likelihood/probability and/or consequences/impacts of these problems to an acceptable risk tolerance level.
+{{ :articles:tree_branches_and_roots_01.svg.med.png?direct&260|Source: http://www.clker.com/clipart-2525.html}}
+When performing "Cause & Effect" analysis, we must be able to identify and link an “assignable cause” to the event (nonconformity). “Assignable Causes” can potentially be eliminated (e.g., through corrective action). However, when unable to identify and clearly link an “assignable cause” to a problem, we must recognize and acknowledge that those variations are most likely inherent to the process and cannot be eliminated; without completely re-engineering that process. And re-engineering a process may be cost-prohibitive… or impossible (e.g., due to technological constraints/limitations or even "technical contradictions"). However, there are usually risk controls we can institute to mitigate the likelihood/probability and/or consequences/impacts of these problems to an acceptable risk tolerance level.
-Ultimately, the "Zero Defects" management approach should have been abandoned long ago. Unfortunately, this delusional concept has persisted well into the 21<sup>st</sup> century!
+Ultimately, no amount of "cheerleading" or impassioned motivational speeches will ever eliminate human error. Human error is and always has been "//a normal byproduct of personal effort//". However, there are steps that companies __can__ take, such as "error-proofing" (Poka Yoke) or removing the human component from a process through a redesign (aka ReEngineering) of the Process OR taking steps to "//mitigate//" the potential for human errors (e.g., rotating personnel to avoid fatigue).
+Delusional attempts to "eliminate" human error through motivational efforts only serve to exacerbate the problem. It is a truly poor reflection on the Quality Profession that such an obviously flawed concept has persisted well into the 21<sup>st</sup> century!
+Only through accepting that human error is a "//common cause//" variation can we address the problem for what it truly is. Whenever there is a  "common cause" variation in a process, we have two options. We can either change the process OR we can implement risk controls (e.g., to mitigate the risk). For example, changing the process to include "error-proofing" (poke yoke) can eliminate human error by eliminating the possibility of an error being introduced. Alternatively, we can greatly reduce the risk of human error being introduced through:
+  * Developing better-understood, comprehensive work instructions/procedures
+  * Developing more effective training of personnel
+  * Ensuring that personnel have the resources needed to perform the work
+  * Reducing the number of times that people "touch" or move a product (as every instance that a product is touched or moved increases the risk of a defect error being introduced).
+The above list is not intended to be all-inclusive.
 ==== "How "Zero Defects" followers view "risk" ====
 Upon being asked about how "risks" relate to "Zero Defects", a follower of Philip Cosby stated that there are two types of risks. There are "expected risks" (that have not occurred) and "realized risks" (which have occurred). Going to great lengths to avoid recognizing "common cause" variation, this individual explained that "risk mitigation" actions are taken to prevent a risk from occurring. but once a risk has been realized, then corrective action must be taken. This individual completely ignored the lesson from Deming's “[[https://www.youtube.com/watch?v=ckBfbvOXDvU|Red Bead Experiment]]”.
+==== "How "Zero Defects" followers view "human factors" ====
+One of the first "Zero Defects" followers I met explained that he had worked at a company that had subscribed to Deming's philosophies... and had focused 100% of their attention on their processes. His complaint was that this company refused to hold people accountable for their actions.
+Deming NEVER stated or suggested that companies not hold personnel accountable for their actions. What he emphasized was to not punish workers for process-related nonconformities that are out of the worker's control (i.e., process-related common cause variations). Workers should only be held accountable for actions that are within their personal control (e.g., not following a procedure, failure to monitor and take action when a trend is identified and confirmed).
 ==== ISO 9001 & AS 9100... still stuck in the '60s & '70s ====