Iwould never want to believe that a busi- ness, operated by intelligent and moral people, could sacrifice quality, and even
ethics, to produce a product and complete
a sale. Yet recently, I witnessed a business
that was so desperate to make a few deadlines, it bypassed due diligence to get a
I can’t discuss the specific challenges
or events I witnessed, but there are some
basic behaviors that turn good and reasonable intentions into news-making, busi-ness-damaging disasters.
Imagine a project engineer submits an
order for a complete product assembly,
even though it’s not complete or what the
engineering order (EO) process directs.
A manager explains that there is no
intent to build the product from this EO,
and that they only want to issue the EO
to get the bill of materials into the system.
Unfortunately, once the EO is issued, the
process takes over, and there is nothing to
prevent the manufacturing and assembly of
the project as parts start to arrive.
The production floor, upon looking for
drawings and documentation to begin the
assembly process, can’t find instructions in
the system because they are not completed
and nothing prevented them from starting
When the production team enters the discussion, they are handed redline drawings
and told to use them. This isn’t allowed,
according to the process, but the team is
assured that the redlines will be approved
drawings by the time the first product run is
Then more trouble emerges. Not every-
thing necessary to produce the product is
complete. Likewise, not every redline works
with every other redline, and some compo-
nents must be modified in order to assem-
ble. The drawings that are already behind
the production process must be reworked
to match what is built, and part orders with
suppliers must be amended. However, there
aren’t any official drawings to correct, so
there isn’t any trail to assure that the chang-
es are properly made.
Take this scenario to completion, and we
see how an innocent decision can become
a business-threatening mistake. The initial
run of the product makes it to the shipping
dock. The customer is already threatening
to cancel future business if another shipment is late, and the shipment must go.
Unfortunately, because the engineering and
other personnel are already overwhelmed
with emergencies, and since things progressed without first requiring the correct
documentation, the documentation package
was never completed.
The testing to prove product performance
was conducted without actually conforming
the product to the non-existent drawings
and, therefore, cannot truly represent proof
of performance according to expectations.
How can the quality team assign the seal of
approval to a product for which the documentation package and traceability of conformance cannot be compared?
The quality team must either be convinced to allow the product to ship based
on redlines and verbal assurances, or it
must hold the shipment until the documentation is complete.
If that product is a retail item and ships
and one of those undocumented production
modifications causes a safety issue, the
consequences could be serious and even
Another example of committing a crime
without meaning to starts when a custom ordered, aftermarket product is late.
The supply chain professional is deemed
responsible and is told to get that product
to the customer, “whatever it takes.”
So the agent and the project manager
get on a plane and fly to the manufactur-
er of the last component, personally take
receipt of the component, and carry it on
another international flight to the cus-
tomer. In the mean time, the rest of the
product is expedited to the customer.
The project manager, supply chain
agent, the missing component, and the
incomplete product then converge at the
customer’s facility. The project manager
installs the component and they turn over
No, a big
it could not possibly have been approved
for quality conformance. In some environments, that might not be a big issue, but in
regulated environments, it is a violation and
Additionally, they have violated customs
and trade law. If that component included
controlled substances or materials, or if it
included sensitive or controlled electronics,
the violation of customs law could be severe.
If someone back at the office decides to
cancel an engineering order that cannot be
completed and signed off because the last
component did not arrive for final assembly
and now it never will, it could be perceived
by a future investigation or audit as an
attempt to cover up the violation of customs
and trade law. After all, if that order doesn’t
exist on record, then there’s no traceability
for the component or perhaps the whole
These things can happen without intent.
After all, the entire process of building a
product involves a great many people in
numerous functions. When everyone follows
a well-established process, everyone knows
pretty well what the plan is.
However, when the process is bypassed
and the plan is verbally communicated from
one person to a few others, and that plan
changes, it’s easy for one or more people
to do what they believe is right, only to
inadvertently create a problem they don’t
When we choose to forget that our processes and procedures and policies are in
place to protect us from disaster, then we
invite disaster by ignoring them.
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By Alan Nicol