What is defect management
10/25/2019 - Defect management - definition and a few suggestions
Errors are an everyday occurrence in companies - do you need error management?Here you will find information and a definition of defect management.
Definition of errors and error management
Here is the definition:
- error*): An unintended, often not expected, undesirable result of a consciously or unconsciously implemented or omitted measure. error
- are rarely justified individually (forgetfulness, ignorance, intention)
- with larger consequences almost always have a systemic character
- Defect management: Systematically operated error prevention, error detection, error diagnosis and evaluation as well as the initiation and evaluation of countermeasures with the aim of minimizing the risk of serious consequences.
Error events from practice
- Chernobyl reactor accident
- Two planes crash over Lake Constance (Skyguide)
- Accident on the Transrapid test track
- Train accident on the Tokyo - Osaka route in 2005 (zero-error target on punctuality)
- People Airlines is taken over by Texas Air in 1986 after six months of massive losses after an initially extremely successful year. Due to its extreme growth, the company was weakening in the fields that originally represented its pull for customers.
- Very experienced pilots sit in the cockpits of the Boeings 747, which collided on Tenerife in March 1977 (583 dead); the pilot who makes the crucial mistake is an instructor, safety director and has a reputation for being a top pilot
- Experienced long-time machine operator dies on the night shift - as is so often the case, he had put a safety function out of operation.
- Switching to a different supplier means that products worth € 2 million have to be replaced - a slightly different color coding led to incorrect installation, and the advice from an employee was dismissed by a process engineer.
- In 2018 and 2019, two planes of the Boeing 737 Max, a bringer of hope, crash during scheduled operations. It turns out that the errors in the software already occurred during internal tests but were not communicated to the customers after delivery
Just ask yourself what the commonalities of all these incidents are ... (resolution at the bottom of the page).
Who has to deal with defect management?
The detection and reduction of errors play a role in every company. A large number of instruments are available for this, such as QM, CIP, complaint management, QFD and many more.
However, there are companies for which this is not enough, because the type and dimension of the risks are much higher than for others. These are nuclear power plants, correctional facilities, hospitals, chemical companies, aviation, etc. They strive for the state described by Weick / Sutcliffe as a High Reliability Organization or HRO.
These companies need a specific system of error management, which in its complexity cannot be implemented here. For all other companies, however, it is worthwhile to use these points when errors occur, especially the larger ones system-oriented perspective of error management to be observed:
- Different people make the same mistakes in the same situation!
- Error-prone situations and bad organizational design cause errors.
- The focus is on all causative factors not just on the actions of individuals. Processes and attitudes (the whole system) must therefore be changed to improve security.
(according to Fletcher, NPSA 11/2003 and Reason 1994)
Advantages of systematic error management
Anyone who, in view of the increasing complexity and risks of their own business, is now also thinking about their own - perhaps slimmed-down - error management, here are a few advantages of each error management system as encouragement:
- Competence advantages in competition are systematically built up
- Cost reduction and increased profitability
- Improved responsiveness and forward thinking
- Increased awareness of everyone and respect for the pitfalls of business
- Knowledge of the sensitive and success-relevant factors
- Reduction of damaging events and accidents
- Reduction of claims for damages
*)according to Rall M, Manser T, Guggenberger H, Gaba DM, Unertl K. Patient safety and errors in medicine. Creation, prevention and analysis of incidents. Anesthesiology Intensivmed Emergency Med Schmerzther 2001; 36: 321-330
Resolution to the above question:
All the error events described had in common:
- excellently qualified staff was involved
- the technology used was of the highest standard
- Safety devices were in place and working
- the real cause was much earlier than the damaging event
- an abundance of individually harmless and often well-known individual factors acted together
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