The March 2012 issue of Consumer Reports Magazine contains a very revealing article entitled: “Appliance fires: Is your home safe?” The editors dedicated nearly seven pages to this extremely important topic and I applaud them for showcasing these hazards to the American consumer.

Some of the statistics that CR cites include: In 2006-2008 major appliance failures caused more than 150,000 fires resulting in 3,670 injuries and 150 deaths. More than 15 million appliances have been recalled in the last 5 years.

Most of the products liability cases I work as an expert witness in quality assurance involve defective electrical devices. Many involve loss of life from a fire or electrocution. I have chronicled many of these cases in my new book, Foreseeable Risk.

While CR infers that product design is the proximate cause of these failures is related to the design of the product, my experience is that there are most often compound causes for product failures. The potential for failure starts with marginal design that is exacerbated by manufacturing processes that are sub-optimized, quality and safety standards that are too lax and lack of accountability both by manufacturing personnel and by the entire management chain. When a poorly constructed product is placed in the hands of a consumer who may or may not use it exactly as the instruction book prescribes, the latent defects are virtually certain to manifest themselves in some unplanned an unfortunate manner.

As a result of the reality of compound causes, there are two sentences that appear in nearly every one of my expert reports. “Disastrous outcomes are most often the result of individuals operating a marginal product inappropriately” and “This disaster was completely foreseeable and avoidable.” It is my fervent hope that business leaders will learn from the CR article, absorb the profound meaning of these two sentences and begin analyzing the products they produce and/or import for foreseeable risk.

Add to the inferior product mix the new business model that covertly abdicates accountability for product safety by box stores and retail chains. In order to meet price points, offshore manufacturers and importers are tacitly encouraged to cut costs without regard to product reliability or safety. The reality is that there is usually an intermediary between the actual manufacturer and the retailer that has built into his costs the routine expense of large warranty replacement parts and lawsuits.  The manufacturer seldom suffers any penalties from a product failure and the retailer typically has someone else to blame.

The consuming public also needs to be aware that required safety testing from companies like Underwriter’s Labs (UL) and The Canadian Standards Association (CSA) are routinely being circumvented and corrupted by unscrupulous business people. These same actors have caused the Consumer Product Safety Committee to become the tollgate for dangerous products, instead of a watchdog agency. It is impossible to catch all potential hazardous products when there is little incentive to manufacture safe and reliable ones.

Until we, as a consuming nation, become acutely aware of the dangers of the products currently in each of our homes and demand that workmanship be restored to consumer products, the statistics for foreseeable risk, such as appliance safety, will only become more egregious, more lives will be lost and more businesses will be encouraged to abdicate their accountability to their customers.

There is an ancient parable that says: Give a man a fish and he will have a meal. Teach a man to fish and he will feed himself. Unfortunately, the common sense of this lesson has been discarded in favor of providing not only the fish, but adding the subsidized housing in which to consume the fish.

We do not learn from history but choose to repeat it.  During the Great Depression there were hundreds of thousands of jobless people in the US. FDR developed agencies such as the WPA, PWA, CCC, TVA and other agencies that not only put many of these people to work, but they were “building” sustainable projects such as the National Park System. The jobs gave them dignity. They learned hard work and teamwork. They learned empowerment. FDR visited them regularly and ate lunch with them. Upon leaving these jobs, the workers had skills that they could translate into honorable professions back in their home towns.

There are many stories of former CCC workers rising to prominence in construction and forestry. They then took their grandkids to their former work site and showed them the bridge they built or the nature trail they cleared. Building on the fisherman parable, they not only learned to fish, they became excellent fishermen. Now, we are slashing the budgets to the national parks to give entitlements to those who do not work. We do not learn from history but choose to repeat it. 

In the second half of the 20 th Century, NASA was created to explore space and consequently renewed the national pride created by WWII through the space race. I grew up on the mean streets of Brooklyn. My father sold pots and pans, door-to-door, to make a living for us. He taught us that we could be better than he by working hard and aspiring to be excellent at what we did. As a teenager, I heard JFK’s challenge to send men to the moon and return them home safely. I left home on my 19 th birthday and spent 14 years at NASA’s Mission Control Center in Houston where I became one of the first Quality Control Engineers. I have gone on to reach some degree of preeminence in my field and have written ten books on organizational excellence.

My success story pales in comparison to the massive contribution that NASA has made to the world we live in. Nearly every device in our homes, cars, planes and trains contains electronics that spun off from the space program. When I show my grandkids what we created from Project Apollo, they pick up their Wee controllers and revert back into the fantasy of computerized combat. Today, we are going to end the exploration of space to give entitlements to those who do not work. We do not learn from history but choose to repeat it.  

From the crater left by the current economic implosion, businesses are scrambling for ideas to enable their recovery. They are searching for a magic cure to a problem that was solved eons ago by teaching people to fish. If we need a new call to arms, it must be that empowerment equals personal accountability. That is: Teach a person to fish. Create the environment where fishing is a noble profession. The human spirit will then precipitate competition among fishermen until the best will rise to the top and the rest will emulate them and strive to become the best. I learned this lesson from the Brooklyn Dodgers, not from parable. The next great depression is only moments away. Why must we have a great depression or world war to re-learn the lessons of the fishermen? Perhaps because there is no incentive to fish? We do not learn from history but choose to repeat it.

Tort Reform. The very term makes no sense: TORT noun. A wrongful act that results in injury to another's person, property, reputation, or the like. How can we reform a wrongful act?

The most learned leaders of our time debate tort reform as if there were a simple solution for reducing the number of lawsuits that result in staggering compensatory and punitive damage settlements. The reality is that tort litigation is filling a market need precipitated by the decay of our societal and business ethics.

My work as an expert witness has yielded volumes of conclusive data that the abdication of personal and corporate accountability is the predominant reason that the court dockets are full of consumers suing manufacturers, distributors, importers and purveyors of services. The only true tort reform is removing the conditions that precipitate defective products and organizational negligence.

The deciding factor in nearly every products liability case I have testified in over the last decade has been irrefutable evidence we have uncovered that the provider of the product did or did not an exercise an appropriate standard of care for the safety of the product in normal use. Our case studies have shown clearly that many organizations entropy over time, consciously or unconsciously allowing the quality of their products decay to the point where catastrophic failure is nearly inevitable. Only a very few enterprises have created a culture where defective products simply never reach a customer.

The question I asked at the onset is “How can we reform a wrongful act?” The answer is to prevent the wrongful act from ever happening. The business processes and personal accountability models exist. Implementing them is as daunting as avoiding the circumstances that expose us to the common cold.

Tort reform is applying the “Do No Harm” imperative that is embraced by the medical profession as an absolute for every business and every person in every business, including the healthcare profession. Those who created the do no harm model and the Hippocratic Oath have more than its share of entropic decay, which is the root of the cause of negligence suits. We can’t reform malpractice litigation. We can only reform malpractice.

It Was Rocket Science – Part III

It’s a Process

Now that we’ve discussed the importance of a vision and mission and addressed the human component in our organizational success journey, it is time to discuss the work to be done. Regardless of your business or industry, every work activity, every day, is a process. That is, it has a beginning an end and is measurable.

In auto manufacturing installing headlights is a process. The components of the process are the headlight assemblies, the partially built vehicle, tools and procedures. The assembler is trained in the procedures, begins the installation, finishes the installation and then determines that is was done correctly. The number installed each day free of defects divided by the total number installed becomes the measure of success. This sounds parochial but all product failures are the result of a process out of control. I challenge you to cite a product or service disaster that was not the result of process failure!

On the Apollo 13 Command and Service Module, process failure led to the disastrous explosion during their lunar mission. The fuel cell that exploded had a frayed wire inside that was not detected in the manufacturing, inspection and test processes. There were procedures. The assemblers and testers were well trained. All inspections were performed, but it was a process anomaly led to that frayed wire inside the fuel cell. By continually evaluating each process for effectiveness, these errors are avoidable.

Armed with a more exact understanding of the definition of a process, it is then accurate to state that your business is nothing more than a series of interrelated and interdependent processes. In the Apollo 13 incident, the technician who installed the defective fuel cell failed to notice that it had a history of failures and repairs and it was not within parameters for use on a manned vehicle. No, this is not human failure. The process measures were obviously not appropriate for the application.

If a business is a series of interrelated and interdependent processes, then, in my experience, all failures and defects are then a serendipitous convergence of processes that are out of control. In the case of Apollo 13, if ether process discussed above had been effective, the failure would not have happened. That is why no single process can be dismissed as less important than another in a manufacturing or service business.

Bottom line is that even installing headlights requires critical thinking about processes and their effectiveness. What are the consequences if just one set of headlights malfunctions in the dark of night on an unlighted road? Assessments of effectiveness must include brainstorming every foreseeable risk if the process is not done correctly.

 While litigators can benefit from understanding process control by narrowing the failures in a case to their specific and interrelated activities, business executives who embrace process theory can continually evaluate and improve each process leading to lower liability and greater customer satisfaction.

It WAS Rocket Science – Part II

The People

In the first installment, I introduced the conundrum that most of the technological advances of the last half century are the direct result of the science spun off from NASA and the space program, but little is known about the model of leadership that successfully got us to the moon and back. That model began with a shared vision. This edition will discuss the people who executed the vision.

As most businesses move from start-up to initial success, the seminal operational processes typically evolve pragmatically and by tribal knowledge. That is, a small group of people work through issues and select seemingly viable approaches for achieving key milestones. That same group works through the steps of problem solving until an acceptable outcome is realized for each stage of development.

 In the evolution of these businesses, there is seldom an attempt to analyze, define and codify the leadership model and the interpersonal skills that made the early entrepreneurship successful. It is mistakenly assumed that the success models of Dell, Apple and Microsoft were somehow inspirationally communicated to the future members of the company through product or service success and charismatic leadership.

Most of those who were on the Project Apollo team had attributes that went beyond their technical skills and team spirit. They exhibited a fundamental character trait that was essential to work in an environment where failure is not an option. The leadership model created by pioneers like Chief Flight Controller Gene Kranz, were the product of a shared vision carried out in an environment that fostered individual and group success and measured performance with the same precision as operational parameters.

When I left NASA, I asked the manager who selected me to be one of the first quality control engineers why he picked me above other more credentialed applicants. He said that the most compelling reason was that I left home for Houston on my 19^th birthday, worked my way through college and relentlessly applied for electronics technician work at NASA until Philco finally hired me. He said that anyone with that tenacity and dedication was the right candidate and that I could be taught any needed technical skills.

Today, when I assess an organization either as a business process improvement consultant or as an expert witness, the people unconsciously reveal a picture of the duty of care, standard of care and acceptance of accountability that will become the foundation for business optimization or for litigation strategy. Who the leaders are and how they present their organization will cast a foundation that will hold them harmless or convict them of gross negligence.

Those who demonstrate a shared vision, commitment to excellence and a genuine dedication to the success of their people and customers are also likely to avoid the conditions that lead to products liability. Those who manipulate, pragmatically cut corners, and encourage tribal knowledge are those destined to meet the process server.

Assessing the leadership style and effectiveness of defendant organizations does not require a body language expert to interview the senior staff. Their actions are documented in quality manuals, policy manuals, training records, inspection records, warranty information, customer satisfaction data or the lack of one or more of these evidence trails.

By assessing the process data and comparing it to what is said and implied in depositions and testimony of the leadership, compelling evidence can be presented that, what an organization says it does and what actually happens ran the gamut from industry excellence to abdication of duty to intentional fraud.