Copyright by Doug Hutchison, 1996. No unauthorized reproduction. In it, I put forth the argument that traditional TQM process management techniques were inadequate to remediate very low frequency error, and that this idea had a mathematical basis in chaos theory. In my most recent book on safety systems published by Lanchester Press, I use traditional TQM techniques, in particular those of Deming and Juran, to show how safety systems can be designed, deployed, assessed, and improved using the management structures proposed by these masters. In this book, I revisit the topic of very critical safety systems in which no error can be tolerated, and again reach the conclusion that traditional TQM techniques are wanting in providing the safety systems manager the insight needed to deploy zero error systems.
Traditional remediation is based on cause and effect.
Find the mistake in the system design and make it go away. To show how this is wanting in zero error safety systems, I briefly digress on causality. The following is freely adapted from the book, and the accompanying figure helps clarify the analysis. The topic is general enough that even those expert in areas other than safety may find it interesting. Cause and Effect - Relevance to Safety Systems Cultural anthropologists tell us that society 30,000 years ago was organized much differently than it is now.