Hidden in Plain Sight

the Challenge of eliminating Product Hazards

Every year, millions of consumer products are recalled in the U.S. because of safety related defects that expose consumers to unreasonable risks – burns, choking, fire, lacerations, falls, explosion, asphyxiation, and other dangerous hazards.  These defects occur in products of all price ranges and from companies of all sizes.  No product, brand or company is immune.  But it would not be accurate to conclude that because safety defects occur in all types of products and from all types of companies that they are unavoidable.   Investigations following product safety incidents inevitably reveal a moment when something that could have been done to avoid the incident was not done, where a wrong decision was taken, a cost was cut, a step eliminated, or when someone in a position to do something, say something or see something, did not, and that made all the difference.   With many recalled products, the potential for the problem seems obvious in retrospect, as if it was hidden in plain sight, if only someone had raised a red flag, asked more questions or insisted on more testing.  For all of these challenges, the most effective approach is for senior management to redouble their efforts to instill a companywide product safety culture, where the safety implications of every product decision are continuously examined, evaluated and even reevaluated, in a collaborative, pressure-free environment that rewards double checks and caution. 

Product safety would be easier if it was something one could specify, as in selecting fabric of a certain denier and tensile strength or requiring compliance with a particular voluntary standard.  These decisions are obviously important, but they are only elements of creating a safe product – not the whole task.  Product safety would also be easier if it could be one department’s responsibility, like compliance or legal, where a small group of individuals would ensure that all of a company’s products were safe.  Such a department could certainly be helpful – for oversight, for education, and for evangelizing a product safety culture – but still just part of the overall task.  More than just good design and manufacturing to spec, product safety is the result of a broad range of systematic and disciplined processes in each of these areas, vigilance by all employees involved and a comprehensive program of performance testing, compliance testing and quality management.  It is the quintessential example of an objective that requires a unified team effort.  

Without a doubt, planning for safety has to begin at the product concept stage, even before a preliminary design is drafted.  How will the product work?  How is a consumer likely to use it?   What kinds of safety hazards can arise with this type of product?   Will the environment or locale where the product is used contribute to potential hazards?  Lithium ion powered products present hazards in all environments.  Electric products present special hazards in wet areas like locker rooms, bathrooms and kitchens.  Outdoor products can become hazardous over time as materials are exposed to the elements and degrade.  No relevant detail is unimportant when a product is designed.  

A critical starting point for product developers and manufacturers is to determine if they have the required technical expertise to design and develop whatever product they’re considering.  As companies seek to accelerate their growth, it is common that many will consider products with technologies or features that are beyond the expertise of their internal staff.  Experts should be consulted for product design, applicable standards and design expertise for every technology involved.  From construction specifications for each component to a detailed bill of materials and performance specifications, each decision has potential implications for product safety.  If the culture rewards everyone involved for considering the safety implications of every design decision they make, then no one will have to be reminded to consider safety.  It will be automatic.  

A valuable methodology most quality oriented companies use to detect and eliminate potential safety issues early in the product design phase is called Failure Modes and Effects Analysis (design FMEA).  In an FMEA exercise, a multi-disciplinary team of individuals with diverse expertise brainstorms on all the ways that a product can fail (failure mode) and the potential effects of each failure mode.  By estimating the severity of each failure mode, the frequency with which each failure is likely to occur and the systems currently in place to prevent each one, the team can calculate a risk priority number (RPN) for each failure mode and suggest design modifications.  In product design, FMEA is a particularly valuable exercise because the more time and effort anticipating what could go wrong, the greater chance that the final product will operate safely and effectively throughout its life cycle.  

One additional cautionary note during the design stage concerns prototypes.  It is likely that prototypes will be fabricated, constructed or assembled, typically by hand, one-by-one, with greater care and attention than may be possible during mass production.   While prototypes are valuable for market testing, performance testing, and compliance testing, product engineers should be wary of how a hand-made, “mothered” prototype might perform differently than a mass-produced piece.  At a minimum, actual production pieces should be subjected to the same testing protocol as the prototypes.  

Once the design of a product is frozen and a product proceeds to manufacturing, a host of new threats to product safety arise in the factory.   To identify what could go wrong, manufacturers and product developers would benefit greatly from a process FMEA – the identical kind of brainstorming done to identify failure modes in product design can reveal process failure modes during manufacturing.  What if the raw material supplier delivers a different quality of material than specified?  Are there systems in the receiving department to log and test the incoming material and catch this mistake?  Were the circuit boards from a subcontractor built to specifications?  Have they been certified by an independent lab? From training to tooling to assembly to finishing and packing, there are many questions to be answered to ensure that the final product will be produced exactly as it was designed.  These questions are even more challenging if manufacturing is outsourced to a non-owned facility where there may be less direct oversight, cultural differences and a language barrier.  Like so many processes that contribute to product safety, these are obvious and basic, but like hazards hidden in plain sight, they’re easy to overlook when faced with a busy workload and other distractions.  This is why evangelizing a product safety culture is so critical – so everyone involved in the design and manufacture of products thinks about these issues, automatically, every time.

How serious is the problem?  How often do seemingly obvious oversights mushroom into major product safety defects?   Recent CPSC recalls show example after example.   1.1 million pocketknives were recalled because a safety failed to engage when the blade was extended.  660,000 lighter torches were recalled because the flame didn’t extinguish when the switch was turned off.  One million 4-drawer dressers were recalled because of tip-over and entrapment hazards.   5.7 million kid’s water bottles were recalled because the spouts were detaching and becoming a dangerous choke hazard.  18,800 folding patio chairs were recalled because the metal legs collapsed when someone sat on one.  

Some of these recalls may have been caused by a design defect and some by a manufacturing defect.  But all of them were foreseeable, obvious and easy to avoid.  They were all hidden in plain sight, if only someone was looking.

Product safety is a team endeavor and the product of well-conceived processes in every department involved in product development and manufacturing.  It can only occur when design, testing and manufacturing intersect in a unified, coordinated effort.  This environment works best in companies who foster a product safety culture that rewards activities that promote product safety.  The true reward for companies who create this culture and implement these processes will be the knowledge that its products are safe.  If executed well, no customer will ever suspect all the hard work it took to deliver them a safe product.  In product safety, a job well done means that your customers never know you did it.  

 10 Steps to Product Safety
1Identify and communicate to all managers and employees their role in product safety.
2Develop redundant oversight processes to identify flaws in design and manufacturing.
3Encourage and reward employees who speak up and raise safety issues.
4Avoid rushing products to market with expedited crash plan development schedules.
5Assess your capabilities – engage experts for gaps in your internal expertise.
6Treat all industry consensus standards as minimum acceptable specifications.
7Establish performance and durability standards for your products and continuously inspect and test.
8Use FMEA to identify ways your products and processes can fail.
9Evangelize a product safety culture at all levels of employee and management.
10Be on guard for safety hazards in your products that are hidden in plain sight.  

Leave a Reply