safety – The OM Blog by Heizer, Render, & Munson

Guest Post: Martin Guitars and Operations

Prof. Howard Weiss, retired from Temple U., illustrates his wide range of interests.

Martin is a guitar manufacturer that began operations in 1833. Martin specializes in acoustic guitars which account for about half as many guitars as electric guitars in the global guitar market. It is one of the most popular brands along with Fender, Gibson, Yamaha, Ibanez and Taylor.

Location: Martin began its operation in Manhattan. In 1839 Martin opened a plant in Nazareth PA, 90 miles due west of its NYC plant. In 1989 Martin opened a plant in Sonora, Mexico in order to make guitars that were more affordable. It is worth noting that two of Martin’s competitors, Fender and Taylor guitars also have plants in Mexico. These guitars are commonly referred to as MIM (Made in Mexico). See Ch.8.

Capacity: Martin has made over 3 million guitars since its inception, including one million since 2016. It currently produces a total of 500 guitars per day, 6 days per week, at the two plants. (See Supp. 7)

Forecasting: Clearly demand has been increasing. Martin’s forecasting needs to consider historical and causal analysis (see Ch. 4) since certain events can spike or drop the sales. For example, sales increased more than usual during the folk music craze and also when MTV was running its Unplugged series (featuring acoustic guitars). At first, COVID caused a decline in sales due to cancelled concerts and closed stores. But then there was an increase in demand, especially for beginner guitars since people were looking for activities while at home and could order guitars online.

Supply Chain: The supply chain (Ch. 11) begins in the forest and at the lumber facilities both in the U.S. and India.

Layout: Martin uses process layout–see Ch.7. Most of the work is done by hand but there are robots in the factory.

Safety: With all of the woodwork that is being performed the major safety concern is that of sawdust.

Quality Control: The incoming wood is inspected by humans because machines cannot pick up defects in the wood. Each guitar is checked for tone. The guitar gets put in a case, but then sits for 4 days and then undergoes rigorous testing to make certain the guitar parts, e.g. neck, bridge, tuning pegs, still work. (See Ch. 6).

Classroom Discussion Questions

How could Martin use the Quality Control techniques discussed in Ch. 6 of your text book?
What are some possible reasons Martin relocated from Manhattan to Nazareth, PA?

OM in the News: Behind Boeing’s Alaska Blowout

Just last week, we posted the story of Boeing’s intended takeover of its troubled fuselage provider, Spirit AeroSystems. Today’s post is a story of quality control at Boeing. You will recall that a door blew off an Alaska Airlines flight in January because a few bolts were not properly installed. Months before the 737 piece blew out midflight, the plane spent nearly three weeks shuffling down an assembly line with faulty rivets.

*Traveled work*—when work is completed out of the production line’s ordinary sequence—is a problem of Boeing’s safety culture.

In turns out that workers had spotted the bad parts almost immediately after the plane’s fuselage arrived at the factory from Spirit, reports The Wall Street Journal (March 12, 2024) . But they didn’t make the fix right away and the 737 continued on to the next workstation. (See the Chapter 9 photo on page 383 illustrating the assembly line process). When crews completed the repair 19 days later, they failed to replace four critical bolts on a plug door they had opened to do the job, leading to the accident.

At Boeing, there is a term for situations when work is completed out of the production line’s ordinary sequence: traveled work. This practice of completing work out of sequence is a liability when it comes to airplane quality. “The folks on the line, they know what it is,” Boeing CEO said. “It creates opportunities for failure.” Yet, four years ago, Boeing laid out 5 values central to improving safety. Number 3 on the list: eliminate traveled work.

Doing work out of order complicates the intricate, taxing process of putting together an airplane. In the 737 factory, each plane moves its way through a series of stations, where crews are tasked with completing certain tasks. Those stations are equipped with tooling, platforms and crews trained to do the jobs designated for the site. Planes advance to the next station every 24 hours. Keeping production lines moving even when certain parts aren’t available for a given job helps avoid costly slowdowns.

When a missing part prevents workers from finishing, the plane still moves ahead and the part gets added or repair is completed somewhere down the line. Sometimes, the work isn’t done until the plane leaves the factory. But the proper tooling may not be on hand there, leaving workers moving back and forth to get the necessary equipment.

Classroom discussion questions:

As the new OM head of the 737 line, what is your recommendation?
Can an assembly line like this be stopped?

Guest Post: Process Design–Drug Dispensing Machines

Prof. Howard Weiss, developer of our POM and Excel OM software, provides his insights monthly.

Table 7.4 of your Heizer/Render/Munson textbook lists examples of the use of technology in health care and other service industries. One technology in health care that is often used in hospitals is the computerized medication cabinet also known as the automated dispensing cabinet. (See page 215 for an example). These drug cabinets offer a number of advantages over the former non-powered old-school medication carts, but can lead to serious problems when the wrong drug is selected. Unfortunately, hospitals are not required to report when wrong drugs are administered so we do not know the depth of the problem. (A nurse in Tennessee was recently prosecuted for wrongful death when she selected the wrong drug).

The current process requires the nurse to enter the first 3 letters of the drug that they want. Safety advocates want at least 5 letters to be entered to reduce or avoid confusion and the cabinet makers are currently in the process of making the change to require 5 letters. While a 5 letter requirement seems better than 3 letters from a safety standpoint, requiring more letters leads to problems other than safety. This will require that nurses can correctly spell names of difficult pharmaceuticals. Sometimes these drugs are needed in chaotic emergency situations and using 5 letters instead of 3, while intended to improve safety, will slow the process down. Of course, three letter names can cause spelling problems, for example, if the nurse is unsure whether the drug begins with “ph” or “f”.

The general goal when dealing with dispensing drugs is to have as many layers of safety as possible. This is sometimes called the Swiss cheese model. The holes in Swiss cheese do not generally align so having enough pieces of Swiss cheese will prevent a mistake from going through all of the holes. The 5 letter requirement is a better slice of cheese than the 3 letter requirement.

This Swiss cheese approach of adding layers for safety is similar to web sites requiring a code sent by text to be entered in addition to entering your name and password. The CDC has essentially been using a Swiss cheese model for COVID protection, as seen in the figure.

As a final note on reliability, many hospitals still maintain the old-school carts as a backup in case of a power failure.

Classroom discussion questions :

What industries, other than healthcare, use a Swiss cheese approach?
If requiring 5 letters is better than requiring 3 letters, wouldn’t requiring 6 letters be better than 5 letters?

OM in the News: Hospitals Learn About Safety From Airlines?

Major U.S. passenger airlines have forged a phenomenal safety record largely by relying on pilots, controllers and mechanics to voluntarily report incipient hazards. Analyzing such incident data and then disseminating lessons from it has meant more than a decade without a fatal crash.

Over the same period, the country’s healthcare system has tried to mimic some of these air-safety principles, but it has made scant progress in eliminating deadly treatment errors. Mistakes in hospitals are estimated to cause at least 250,000 unnecessary patient deaths annually in the U.S., reports The Wall Street Journal (Sept. 4-5, 2021).This makes it the fourth leading cause of medical fatalities after cancer, heart disease and Covid-19. Determined to do better, healthcare leaders are now doubling down on aviation’s lead.

The heart of the idea is prodding doctors and hospitals to share more digital data and wholeheartedly embrace self-reporting of their potentially deadly “near misses,” the way that pilots already do without fear of punishment. But as long as hospital equipment isn’t designed to guard against human slip-ups, as jetliner cockpits are, “it will be far too easy to crash the plane in healthcare,” says one hospital Chief Quality Officer.

One obstacle is that financial incentives for hospitals are still not aligned around quality and safety. Typical billing practices track the number and complexity of procedures instead of the outcomes. Information sharing in healthcare is pitiful compared to aviation. When medical errors are reported, it’s usually well after the fact, and information usually stays within the organization.

One element of air safety that has already made big inroads in medicine is reliance on checklists, in large part thanks to Dr. Atul Gawande’s 2009 bestselling book “The Checklist Manifesto.” which we previously noted in this blog.

Classroom discussion questions:

Compare this article to the OM in Action box called “A Hospital Benchmarks Against the Ferrari Racing Team” on page 223 of your Heizer/Render/Munson text.
Now discuss this article in light of the OM box called “Safe Patients, Safe Hospitals” on page 231.

Guest Post: Safety and Government Oversight

Prof. Howard Weiss presents his monthly Guest Post today. Howard recently retired from Temple U.

Recently, we have seen three articles about the lack of safety, in different industries – food processing, shipping, and manufacturing/product design.

Fooddive.com reported that line speeds at U.S. pork plants will be slowing down after a federal judge ruled the U.S. Department of Agriculture’s removal of processing speed limits did not adequately take worker safety into consideration. The USDA is rolling back the capacity to what it had formerly been – 1,106 hogs per hour. Your Heizer/Render/Munson Capacity Management chapter (Supplement 7) notes that organizations “have found that they can operate more efficiently when their resources are not stretched to the limit.” In this case, when the capacity was increased, additional workers were not hired and the existing workers had to work faster increasing the chance of injury or pain from repetitive motions.

An earlier blog this year identified Supply Chain Risks on the High Seas. Container ships are not the only means of transportation with risks. According to Vice.com, in 2019, railroads reported 341 derailments on main line track. Of those 341 derailments, 24 were freight trains carrying 159 cars of hazardous material. While cargo loss is a concern, in the case of trains, another frightening possibility is hazardous materials leaking. Similar to hog plants, “workers have to inspect many more rail cars in a fraction of the time” than previously. Rail regulation is set by the Federal Railroad Administration.

And then, The Wall Street Journal reported that “Peloton Interactive Inc. has agreed to recall its treadmills, and its chief executive apologized for the company’s initial refusal to comply with federal safety regulators who pushed for the action weeks ago.” The Consumer Products Safety Commission has to negotiate with companies in order to release warnings about potential hazards.

Classroom discussion questions:

How has COVID affected capacity at your university or school?
What is the major advantage of shipping by rail?

OM in the News: NASA’s “Failed Mission” Probabilities

NASA is working with Elon Musk’s SpaceX to redesign part of the fuel system for the company’s Falcon 9 rockets and then will demand at least 7 successful unmanned flights before allowing astronauts on board. With routine flights ferrying U.S. astronauts to the orbiting international space station slated to begin in fall of 2019, the agency has raised new questions about potential hazards and longstanding NASA safety standards, writes The Wall Street Journal (Jan.18, 2018). Ending current U.S. reliance on Russian capsules for crew transportation may “require decisions to accept a higher risk” on next-generation U.S. systems than anticipated, says NASA.

NASA’s statistical limit for a “failed mission” remains 1 in 55 launches, despite several years of intense development, NASA expenditures of about $5 billion and significant additional investment by the two companies bidding for contracts–Boeing and SpaceX. That limit applies to mission failures in which the vehicle doesn’t reach the space station but the crew uses emergency procedures to survive.

NASA’s statistical standard for crew fatalities is no greater than one in 270 flights, though neither Boeing nor SpaceX is on track to meet that precise mandatory benchmark. By contrast, the global airline industry has achieved fatal accident rates for jetliners of 1 crash for several million flights.

System reliability is an old, but crucial issue at NASA. During the long era of the Space Shuttle, which I was proud to be a part of, mission reliability was set at 98%. This meant a critical failure was anticipated every 50 flights. And indeed, the first Shuttle exploded on flight no. 25 (Challenger), and the 2nd loss on flight 113 (Columbia) . The Shuttle program ended with flight no. 135, as a 3rd crash was viewed as unsustainable.

Classroom discussion questions:

Is 1 in 55 (reliability = .982) acceptable? Why?
Why is NASA seeking this alternative to Russia’s Soyuz ferrying rockets?

OM in the News: The Toll of Cheap Clothing

Relatives hold photos of workers missing in the Rana Plaza collapse

In April 2013, when the Rana Plaza building in Bangladesh crumbled and killed more than a thousand garment workers, Western clothing executives were chastened. They were the ones, after all, who’d been pressuring Bangladesh’s apparel factories to cheaply reproduce runway trends for consumers in the U.S. and Europe who’d grown used to $10 dresses. Following the accident, H&M, Zara, Walmart, Gap, and other major brands announced they’d fund and oversee factory inspections in Bangladesh, demanding improvements from facilities that fell short and cutting off business with those that didn’t get better.

“Three years have passed, and an uncomfortable truth is emerging,” reports BusinessWeek (Oct. 31-Nov.6, 2016). Of some 1,600 factories, more than 80% are behind schedule on improvements. The government, too, has made limited progress: It’s shut down just 39 facilities that posed an “immediate” danger to workers. Meanwhile, investigators keep finding defects: faulty sprinklers, exit stairwells used for storage, missing fire doors.

Surprising? The craze for cheap, on-trend clothing that helped turn Bangladesh into the world’s second-biggest apparel exporter, after China, has actually intensified since the disaster. Low-priced brands keep undercutting one another, and that keeps squeezing the factories that produce their clothes. This is the backdrop against which factory owners are expected to make time-consuming, expensive improvements.

So far, the government has shut down only those factories that posed an imminent risk to employees. If it lets imperfect, if not immediately dangerous, factories continue to operate, that could endanger garment workers. At the same time, the garment industry is a major employer, credited with helping to cut the country’s poverty rate almost in half since the 1990s, to just over 31%. Also, Bangladesh’s garment industry is facing serious competition from other countries, and if it becomes costlier to source clothing from Bangladesh, Western brands could migrate to Cambodia, Vietnam, Burma, or Ethiopia.

Classroom discussion questions:

What is the ethical dilemma facing both U.S. brands and the Bangladesh government?
Why are the safety fixes not corrected more quickly?

OM in the News: How Much Should Employees Be Monitored?

Harvard Professor Ethan Bernstein asks the question: How well do workers perform when they are being monitored (Chicago Tribune -April 4, 2016). “Unrehearsed, experimental behaviors sometimes cease altogether,” says Bernstein. “Wide-open workspaces and copious real-time data on how individuals spend their time can leave employees feeling exposed and vulnerable.”

To conduct his research, Bernstein embedded 5 Chinese-born Harvard undergrads into the lines of the world’s second largest mobile phone factory, located in China. The 5 worked, ate, and lived alongside their coworkers, who were not privy to the experiment. Here’s what they observed: Even seemingly unremarkable behavior–such as wearing rubber gloves when assembling or handling components–changed immensely, because the employees knew they were being watched. Factory rules stated that line workers were supposed to wear gloves. But students noticed that when the workers were unobserved: “People either wear a glove on only one hand or they cut their gloves so their fingertips stick out, giving them a bare hand or bare fingertips so when they are doing little things it goes a lot faster.” On the macro level, this reveals employees obey glove procedures only when they’re watched. On another level, it suggests that the gloves are poorly designed; that employees will break rules (and endure safety risks) to meet productivity goals; and that management has possibly overstressed productivity at the expense of safety.

Bernstein also noticed that factory teams worked faster–that is, they were more productive–when they were unobserved. Bernstein set up curtains around 4 of the factory’s 32 lines, shielding the workers on those lines from observation. “Over the next 5 months, to my surprise, the lines with curtains were 10-15% more productive than the rest,” he says. By contrast, the employees on regularly observed lines routinely hid process improvements from managers. The reason? One worker said that it was “most efficient to hide it now and discuss it later. Everyone is happy: They see what they expect to see, and we meet our targets.”

Classroom discussion questions:

Describe the 4 measures for measuring work (see Chapter 10).
Do you think Bernstein’s conclusions relate to all fields?

OM in the News: Ethical Issues and Bengladesh’s Clothing Factories

Factory workers in Dhaka, bangladesh — Factory workers in Dhaka, Bangladesh

A group of 17 major North American retailers, including Wal-Mart, Gap, Target and Macy’s, just announced a plan to improve factory safety in Bangladesh, drawing immediate criticism from labor groups who complained that it was less stringent than an accord reached among European companies. The American plan, according to The New York Times (July 11, 2013), commits $42 million for worker safety, including inspections and an anonymous hot line for workers to report concerns about their factories, and more than $100 million in loans and other financing to help Bangladeshi factory owners correct safety problems. But unlike the accord joined mainly by European retailers, the plan lacks legally binding commitments to pay for those improvements.

Labor rights groups estimated that it would cost as much as $3 billion to bring Bangladesh’s garment factories up to an acceptable safety standard. “Wal-Mart, Gap and the corporations that have chosen to join them, are unwilling to commit to a program under which they actually have to keep the promises they make to workers and accept financial responsibility for ensuring that their factories are made safe,” stated five of the groups. They faulted the plan for being “company-developed and company-controlled,” adding that “under the Gap/Wal-Mart scheme, brands and retailers are not obligated to pay one cent toward the renovation and repair of their factories in Bangladesh.”

The problems in Bangladesh’s garment industry have not affected the retail industry’s demand for cheap goods made there. Exports in June rose 16.3% to $2.7 billion, based on strong clothing sales. Bangladesh has quickly grown into the world’s 2nd largest apparel maker after China. But in a race to keep up with demand, many older buildings that lacked structural support were converted into factories, and building codes were ignored.

Discussion questions:

1. What is the responsibility of US and other firms that contract to have their products made in Bangladesh.

2. Are the critical labor rights groups correct in that US firms need to make stronger commitments to revamping the infrastructure?