Probing the Limits: Quality Issues Lead to Tragedy

July 1, 2004
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Horrible accident invokes quality soul-searching.

A recent accident killed three people and deeply saddened the residents of Denver. The horrible accident also has served as a poignant reminder about the importance of quality fundamentals and the potential consequences of not following those fundamentals.

The May 15 accident involved a young family that was killed when a 40-ton girder fell on their car from an overhead bridge that was under construction.

While the investigation is ongoing, the initial findings are chilling. Even though I'm not involved in bridge construction, the pressures and needs of multiple parties that led to the tragic chain of events are akin to the quality issues that quality people deal with every day.

Investigators are looking into why a girder fell at the site of a new bridge that is being built at an interchange of two major highways in Denver. To minimize disruption to traffic, the construction was done at night and the highway was required to be re-open by 5 a.m. each morning. The bridge girder fell on the car during the day when the construction crew was gone.

The night that the girder was to be placed on the bridge, several unexpected events caused delays in its installation. First, the girder was allegedly marked incorrectly as to how it should be placed. This caused delays in getting the 80,000-pound girder properly oriented. Further delays were attributed to having to make a special trip to replace some incorrect bolts.

After these significant delays, the first beam was lifted onto its supports. As the 5 a.m. re-opening deadline approached, the construction crew and the on-site state transportation representative realized that they would have to abandon the original specified plan to install a second beam and tie the two newly-installed beams together for added stability. The work crew and state officials at the site came up with a quick-fix solution to install temporary bracing to hold the single beam in place until the second beam could be installed at a later date. Evidently, the temporary bracing was not adequate and after a few days passed because of weather delays, the girder fell on the family car that was traveling beneath it.

To make the situation worse, a few hours before the beam fell, the unsafe condition was reported to the highway patrol by a passerby with bridge-

construction experience. The dispatcher taking the call misunderstood and thought that there was a problem with a road sign.

These domino-like events can be summarized from a quality perspective: The beam markings were out of specification and probably improperly inspected, causing the project to run late. A part shortage caused further delays that increased the need to circumvent specified procedures. Next, an unauthorized engineering change was made without any structural analysis and approved by a state inspector "on the fly." Rather than starting over and doing it correctly at a later date or working past the deadline to properly finish the job that morning, the pressures to finish on-time caused multiple "off-spec deviations" that led to disaster. Finally, when a passerby reported the problem, the information was misunderstood and the wrong preventive action was taken.

What scares me the most about this accident is when I question myself as to how I would have behaved on this job site. As a quality manager, on many occasions I have stood my ground and not let a questionable product ship. I'm proud of that. However, at other times, with the best of intentions, I have knowingly let people rush through a job or have approved procedure variances so that we could meet a ship date. I've approved cosmetic product marking deviations and quick fixes that appeared to be "safe" deviations. I've not always taken immediate action on potential problems that were reported to me.

How am I different than the crew involved in this accident? I hope that I would have seen the warning signs and had the backbone to take the beam down or take the time to install the second beam, but it's not as easy as it sounds. The pressures to complete a project on time can be tremendous. It's natural to look for justification to cut corners.

Every quality manager deals with these issues and has acted the same way. Even in the best quality systems, quality managers are asked to sign "off-spec deviations." At the same time, this accident has deeply saddened me. I hope it has permanently affected me and acted as a wake-up call to the incredibly important job that quality professionals fill.

Going forward, when quality issues arise, I hope that the comforting knowledge that we did a quality job will motivate me to fight for delaying a questionable shipment-even if it means shipping late and having to withstand the ire of an angry boss.

Send me an e-mail. I'm interested in hearing your thoughts on this difficult real-life quality management issue.

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