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Quality Manual for The Titan Submersible: ISO9001 Example

Posted on Jul 11, 2023, Modified : Jul 4, 2023 jshell55

We’re going to tackle the Titan Submersible Disaster. As we always do, we’re going to try to figure out if this tragic event was preventable. Lessons in human failure are everywhere, as we have recently found out. Just for illustrative purposes, let’s first tackle the job of creating an ISO9001 Quality Manual for this service.

ISO9001 Deployment is, of course, a method of third party validation. This method was developed in the 19th century, ironically, as a way for an interested potential customer to know whether an ocean going vessel was “seaworthy.”

This is the sort of thing we do occasionally.

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Back Story: Quality Manual for The Titan Submersible

The Ocean Gate Expeditions company has been trying to offer deep sea submersible missions to visit the wreckage site of the Titanic.

We’re supposing that everyone knows what the Titanic is. They named their little prototype vehicle “Titan” and have touted some unique design features to make this possible.

I have a link down below for the company website. They’ve deactivated some of the pages.

On June 18, 2023, this vehicle was reported “lost,” with five people on board. The Coast Guard reported a debris field, and recovery efforts are still underway.

The ISO9001 Quality Manual for the Titan Submersible

Here it is: We’re going to go through the clauses, and develop an ISO9001 conformant quality manual for this organization.

We’ll get into the nuances of this as we go. Needless to say, we think, all of this is based on media information and may be inaccurate. Also, needless to say, there is no indication of certification of this company, because evidently they weren’t certified for anything.

Internal and External Issues

The organization shall determine internal and external issues that are relevant to the quality system.

Here are some tables:

Internal Issues

Issue	Potential Consequence
Difficulty in Testing (hard to simulate 4000m depth)	Potential Design Questions
Cost is a factor	Temptation to cut corners
Development Partners are hesitant	Companies with better expertise may not wish to get involved
Support facilities are questionable	Hard to launch and retrieve vehicle due to having to lease a ship.

External Issues

Issue	Potential Consequence
Terrible weather	increases mission danger significantly
Regulatory Environment questionable	International waters equals minimal oversight
Customer Base is growing	Increased number of billionaires that want to take exotic trips
Costs are increasing	Support costs such as fuel and crew
Customer Base is suspicious of new technology	Untested technology has caused some customers to back out.

Interested Parties

Okay then, the organization is required to determine the needs and expectations of interested parties. Here’s another table.

Interested Party	Needs and Expectations
Customers	Contract and other communication to attract new billionaires to the project
Employees	Safe operating conditions, and employment while working on something interesting
Regulatory Officials	Even though the operation is in international waters, the launch ship is subject to regulations
Media	Need ongoing media engagement to promote the project
Financiers	Deep pocket investors and/or banks need some success stories
Coast Guard	Potential costs in rescue services

The Scope Statement

The ISO standard requires the scope statement to describe the boundaries of the QMS and in essence say what is being certified.

We can probably lift it from the website:

Our mission is to help expand understanding of the ocean by providing opportunities for citizen explorers and scientists to explore its depths with their own eyes.
Ocean Gate Website

We know that they’re engaged in some design work and also, we know that they have some measuring devices, so 8.3 and 7.1.5.2 are probably both applicable.

Once the service is delivered, namely providing the service of ferrying people down to the Titanic, there is probably some follow up activity, so 8.5.5 “post-delivery” is probably applicable.

The Processes

Well I think we can narrow this down to four or five processes in all of this. Here’s a first attempt. The requirement is to determine the process inputs, outputs, sequence and interactions, and measurements of effectiveness.

Process	Inputs	Outputs	Measurements
Management	Information from customers and previous tests	Decisions and other actions	Ongoing business viability and successful missions
Design	Design Requirements	Completed prototype vehicles	Data and other measurements to confirm that design requirements are met. Anticipation of potential long term issues
Contract Review (Sales)	Interested customers, Sales Funnel	Signed eco-tourist agreements	Sales meeting budget, conversion ratio (Market Communications)
Purchasing	Purchasing Requirements for vehicle construction and operation	Purchased Products	Products arrive on time and within budget
Service Delivery	Route Schedule and Safety Precautions	Trips completed	Trips completed on schedule, without performance issues, and within budget

Since the organization here is not in the business of selling vehicles to the public, the production of this little vehicle can be the output of the design process, which could be called “design and fabrication.”

The “Sales Funnel” of this business is the fraction of the internet and social media traffic that is eventually converted into the handful of trip sales.

Top Management Commitment

We can probably get this off the website as well:

According to Rush, the goal of the company was to use commercial tourism to support the development of new deep-diving submersibles that would enable further commercial ventures including resource mining and disaster mitigation.^[13]
Stockton Rush per Wikipedia

Ah, here we have a statement from the boss, Stockton Rush, who was a former McDonnell Test Pilot. This statement is not conforming to the ISO standard, since it does not commit to following requirements, and does not commit to continual improvement.

In fact, according to the Wikipedia article, Rush was complaining about the “Passenger Vessel Safety Act of 1993” which limits undersea expeditions to 150 feet, which is about 3975 meters short of the depth of the Titanic.

Test pilots are a certain kind of person. as we have already noted:

Responsibility and Authority

5.3 of the ISO standard specifies five different activities, and requires “the organization” to communicate this throughout the organization.

It looks like there is a boss, a public contact person, the R and D manager, a few others. There is probably a “deep pocket investor” in the background somewhere. The boss, by the way, was also the pilot who tragically died in the accident.

They’ve deleted their “About Our Team” page, which is probably just as well. No one likes peoples’ names being dragged through the mud at the bottom of the ocean floor.

Risk and Opportunity

This one is sort of interesting. A venture like this is big on opportunity, but at the same time, understanding and mitigating risks. There is a NASA analog in this as well.

As experienced Aerospace people, they are probably well aware of the methodology of prioritizing risk. The normal method is to apply values to the probability, consquence and detectability of a defect, so as to prioritize what projects to work on.

Here’s another table:

Risk	Probability	Consequence	Detectability
Loss of Steering	H	H	L
Hull Integrity	H	H	L
GPS	H	H	H
Life Support	H	H	L
Loss of Business	H	H	H

I know this is a bit snarky, but frankly, this is a much more dangerous environment than space.

The standard also requires the organization to update Risks and Opportunities periodically after it gains experience in the field, and not ignore warning signs.

There’s a video linked below that talks all about the warning signs that were ignored.

Opportunity

Ah, yes. The Opportunity. Well, it is all well and good to say that your company is going to provide adventure to billionaires. What’s really at stake is the chance to spin off technology.

One reliable output of the R and D process is the number of US Patents that are issued, that can later be licensed and sold.

It looks as though our CEO’s patent count is up to 5 or 6. If you wish to follow the link below, you will see an example.

Quality Objectives: Quality Manual for The Titan Submersible

This one should be straightforward. We talked before about the processes. In this case, this may have been enough of a professionally run organization to know that the four basic processes we identified have significantly different skillsets involved.

That being the case, each of these processes has different process owners, and it should be up to them to establish measurements as to whether they are doing their jobs.

We don’t have any specific inside information, of course, so all of this is hypothetical. Based on that, here are some potential process measurements, and their current status, to the extent we are able to deduce it:

Process	Process Measurement	Goal	Current Status
Management	Customer Satisfaction	100%	Fail
Sales/Contracts	Generation of sales leads (Sales Funnel)Seats Sold	100,000 views per month 12 seats per quarter	Probably successful Fail
Design	Patent ApplicationsLaunch delays due to design issues	4 per year1 per year	PassFail
Operations	Improved dive cycleDive success Rate	4 Dives Per Year100%	FailFail

Alignment of the Objectives

The objectives have to be in line with the quality policy, and we saw above that there was lack of clarity as to the combined goals of customer satisfaction and meeting requirements. Simultaneously, the quality policy has to suit the needs of the organization.

The company goals are not particularly well spelled out on the website. There is an ongoing requirement to communicate this to the employees.

Presumably they want to increase the number of safe trips to the bottom of the ocean, so as to get revenue. So, their design and operations departments should focus on their technology, solve performance issues, and have a fast turn-around on voyages.

So, setting up the company objectives to focus on operating viability is abundantly sensible.

The sales function needs to be able to accommodate the needs of the business for revenue. I picked the number “4” out of thin air. This represents 4 trips per year to see the Titanic, so with a crew of one and three passengers, that’s 12 paid trips per year.

So the sales department has to generate enough web traffic and/or leads to attract enough billionaires to sign up for the adventure.

Implementing Improvement

We now know, of course, that the organization, in their efforts to have a few successes under their belts, compromised on safety.

In a normal project, they would have focused on minimal operating standards, done 8 dives per day to 150 feet under Charleston Harbor, where the weather conditions are nice, and used their learning to eventually develop a vehicle that is more capable of survival 4000 meters below the surface.

They’d also have gotten experience in what the Carbon Fiber people call “usage cycle” which is that as you flex this stuff a number of times, it starts to break down.

So why did this not happen? That is where the startup mentality comes in.

Starting Up is Hard to Do

Here’s your real problem. Startup scenario on new technology.

I should be authoritative on this because I have been involved in two of these, and they had some commonalities. Here is how it works.

There are visionaries. In the words of Yoda, “always two there are.” There is usually a hard headed technical person, and there is a sales person and/or promotor. In a perfect world there is also a third person, a billionaire with patience. But, the world is not always perfect.

The startup people hatch the idea, and develop a basic business plan, and then try to attract investors. These investors are deep pocket people who can afford to lose everything they invest 9 times out of 10. But, the 10th is so successful that it pays for the failures.

So, in this project, there’s your “top gun pilot” and a second partner, who has his own website, as we noted below. I will leave it up to the reader to do further research on this character but the you tube channel he runs has 1290 subscribers, so he’s not that much more successful than I am.

He may have made his money 15 years ago working on speech recognition.

He’s mainly interested in “space entrepreneurship.” He’s something called an “independent director.” He does a lot of promotional work for startups, and his childhood hero was Captain Kirk.

Is he the deep pocket investor? Unlikely. Part of the project of the startup is to find one.

The Business Plan

Do you know how this works? They develop something that approaches a business plan. They lay out what their business objective is, how long it will take, and the resources needed. They then beat the bushes to find deep pocket investors.

The investors then agree to finance some or all of the plan. There may be more than one investor. But, entrepreneurs are born optimists. They always greatly under estimate the cost and time, and inevitably run out of money. Stuff happens, particularly when you’re fighting the laws of physics.

That sets up a creative tension with the two entrepreneurs, where there are threats to pull the plug, and not throw good money after bad. So there is an enormous temptation to cut corners somewhere.

In my opinion, the “somewhere” in this case is time. When we get down to the “design process” down below, we’re going to see that. They accepted risk, in terms of developing some of the technology and testing, and we all know what happened.

Anyway, this has a lot of the characteristics of a startup. There must also be one or more “experts” in the field of deep sea engineering on the team, but since their “about our team” page has been disconnected we can’t really tell who they are. There may be a few of these people on the street somewhere.

What is missing?

There is a missing piece to this. Someone who will say “no.”

These are people with enough experience, expertise, and fortitude to say “no, this thing is not safe.” The organizational culture of a startup needs to be such that there are not too many of these people, but “enough.” They’re the ones who insist on standard operating procedures, agreed-to design parameters and everything else.

If you have too many, nothing gets done. There are always objections.

One of the benefits of the ISO standard, and third party validation, is that it gives structure to this discussion. When we get to the design process, the first thing that is agreed on by all parties is the design parameters and measurements. The organization as a whole, and the bosses in particular, agree on all of this up front, and there is no equivocation. The investors may also weigh in on this.

In the video we had earlier, there was something called the “NASA Culture” which was, ignore the critics. Full speed ahead. Forget the SOP. The NASA program was 98% successful but a lot of people tragically died in the two failures for exactly this reason.

Change Control

Anyhow, there is one more thing that we’re going to tackle at the moment which is change control.

Here is what happens, particularly in design.

There is a design plan. The engineers decide at one point, due to circumstances beyond their control, that one of the requirements can’t be met.

The two options are to spend more money to solve the problem or change the design requirements.

So the standard wants you to have a process by which changes, not just with design but with anything else, require a review and approval.

The rules for this approval can be different depending on what that is. In automotive, a change in processing, design, materials or anything else requires pre-approval, which is called a PPAP.

This is to prevent changes from being made in the system without knowing what the effects are. This is extremely important in Automotive, where change control is considered essential for just this reason.

Here is yet another video.

In medical, there is something called a “device history record.” this records all of the process conditions, materials, personnel, operating procedures and everything that went into producing whatever the medical device was.

If anything changes, there’s a record of who approved the change.

Hopefully there is an authority figure somewhere in the company who doesn’t want to be Captain Kirk that will say “no”.

There is so much more to say

We’re going to have to split this into two parts. Stay tuned for Part 2. We will further explore this issue and come to some interesting conclusions about why this happened.

Also, not to put to fine a point on it, if any of this had been third party validated, some lives might have been saved.

Here is my link to Udemy course, “How Not to Fail at ISO9001”

https://www.udemy.com/course/how-not-to-fail-at-iso9001/learn/lecture/34733460#content

Here’s the link to my Quality Systems Training. You can hire me to give this training in person, complete with questions and answers, and along with a few decades worth of horror stories about product quality, dangerous products, and why people don’t do their jobs.

And, here’s the link to my book “How Not to Fail at ISO9001” available at Amazon.

The Spanish version is also available.