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The ISO9001 Quality Manual for the Titan Submersible (Part 2)
We’re on to the second part of our effort to develop a hypothetical ISO9001 quality manual for the Titan Submersible. For those unaware, this vehicle tragically imploded, costing the lives of the people on board at the time. The company Ocean Gate was trying to charge billionaires to voyage to the Titanic. This was so as to finance their research, the result of which would have been an inexpensive, practical way to explore the ocean floor.
In Part 1 of this we made it partway through. That part covered the organizational context, top management, and measurement sections of the ISO standard. We’re about to tackle the issues of resource allocation.
News Update
In the past few days, recordings and transcripts have surfaced. These are to the effect that the passengers and crew of this vessel knew they were doomed. There is a link below. I, frankly didn’t have the stomach to listen to it. If it’s on TikTok it might be fake anyway.
Summary of Part 1
Well, here is what we found out. Based on the website information, we figure that the founders of the company were not especially customer focused. They were heavily mission focused, and had an underlying want to be somewhere between Jacques Cousteau and Captain Kirk.
Furthermore, we’re seeing a fairly obvious issue with checks and balances. The boss, is the main fund raiser, plus wants to be the pilot. The number two person involved with the project also wants to be Captain Kirk.
What is missing is a process by which someone can say “no.” Example: There is agreement that the project meet some engineering threshold before human life is endangered. They run a lot of tests, and there is a lot of question. They run full scale missions many of which have known problems.
Rather than address the deficiencies, the decision is made somehow to forge ahead despite the danger.
Disclaimer: It is possible that we are wrong on this, and if so, the company should have plenty of test documentation. They need this because they need to prove that they did their job right. We’re speculating at the moment that the remaining officials in “the organization” will be hard pressed to do this. They need to prove their processes are strong when the issue comes to trial, which it will.
We will see what happens.
Resources (ISO Clause 7.1)
We’re going to look at resources now. The ISO standard says that The organization shall determine and provide the resources needed for the establishment, implementation, maintenance and continual improvement of the quality management system.
A professionally run organization would have addressed this by process, because that is a critical element. We identified the processes back in Part 1.
The resources are classified as follows: People, Infrastructure, .Environment, monitoring and measuring, and something called “organizational knowledge.”
So let’s take these one at a time:
People (Clause 7.1.2)
| Process | Resources Needed | Comments |
| Management | Leadership experts, attorneys, management team, and solid processes | Present in a professionally run organization |
| Sales/Contract Review | Promotional activities, including social media, also contract specialists and “conversion specialists” who can sell the adventure | PR and other publicity efforts |
| Design and Fabrication | Experienced scientists and engineers with deep sea exploration experience | These people are rare enough but may be available from the N |
| Operations | Experienced launch and service crew, including salvage experts | These may be available from the oil field service companies. |
Infrastructure (Clause 7.1.3)
| Process | Resources Needed | Comments |
| Management | Office facilities close to customers and/or launch facility | Possible travel resources needed as well |
| Sales/Contract Review | Internet facilities, websites, | Need for market communication |
| Design and Fabrication | Extensive laboratory and fabrication facilities to build the vehicle | Ideally close to salt water |
| Operations | Extensive vehicle service equipment, including prep equipment, boats, cranes etc. | Possibility to lease this |
Environment (Clause 7.1.4)
| Process | Resources Needed | Comments |
| Management | Management of offices, facilities, offsite workers. Workplace policies such as anti-discrimination, anti-slave labor, etc. | Difficult pre-Covid, practically impossible post-covid |
| Sales/Contract Review | Sales offices and communications | Can/Should this be done offsite or by outsourced people? Do you need to have a physical office? |
| Design and Fabrication | Safe operating facilities for design and fabrication | Can, or should, these be done “remotely”. What is the ownership of some home office person? |
| Operations | Safe operating facilities for operational personnel | Could be leased facilities or other |
Measurement (Clause 7.1.5)
| Process | Resources Needed | Comments |
| Management | Determine and calculate project effectiveness | Can be derived manually |
| Sales/Contract Review | Internet analytics, conversion rate calculations | Exist in Google Analytics |
| Design and Fabrication | Gadgets that measure material strength, behavior under pressure | These may have to be invented and validated |
| Operations | Measuring devices for misc. pressures, temperatures, other operating conditions | These exist in other areas of undersea work |
Organizational Knowledge (Clause 7.1.6)
| Process | Resources Needed | Comments |
| Management | Experts in undersea exploration, finance, angel investors | Ongoing efforts to promote and position the business |
| Sales/Contract Review | Marketing specialists, contract specialists, experts in reaching high-end customers, media consultants | Marketing people familiar with billionaires and ongoing business promotion |
| Design and Fabrication | Materials scientists, fabrication specialists, undersea vehicle experts | Do not ignore warning signals |
| Operations | Oilfield experts, undersea robotics experts, control systems experts, remote operating experts (Bob Ballard, James Cameron) | Do not ignore warning signals |
Resources (General)
The above tables sort of represent a best guess of the resources required for this project.
If this were a professionally run startup, you would see a dollar sign attached to each one of these resource needs, that would be compatible with the sales forecast. That could in turn be used to go to the angel investor and ask for money.
What you would also see is that if a resource is needed that is required for providing the service within the scope, namely taking sightseeing tours to the Titanic, they would be provided.
If this was a Junior Achievement project, or a vanity project, I, your third party auditor, would not see these things. That would be a red flag to the effect that there were obvious needs, and they were not being met.
Presumably the process owners would be actively involved in this process as well.
What I see all the time is a “review” of these resources, either in some kind of review meeting or a management review scenario. This “review” basically says “yeah, yeah, we have everything we need” and this may not actually be the case.
Organizational Knowledge
I have to say something about this. The organization did see fit to bring in some design consultants and other outsiders. This is a requirement of the standard and is advisable where you are doing innovative research.
What has happened since the “disaster” is that these people have started coming out of the woodwork and pointing out the warnings they gave to the effect that the submersible was unsafe.
Here are a few video clips:
Get the picture? Despite warnings, the organization went ahead with the design and we now know what happened.
Competence (Clause 7.2)
Well, the ISO standard says something to the effect that the organization needs to determine the necessary qualifications for people doing work.
Since we’ve already determined in the processes above what sort of people we need to have around, this is a fairly simple project. Each of the process owners determines the qualification level for the staff.
This is one of those places where this is highly variable. There may be high-end underwater engineers and very experienced scientists. There may also be “grunts” that do carbon fiber construction for a living and get their hands dirty. There may be third-party requirements, such as for welders and other technical specialists.
People work for a place like this because they are interested in the mission.
Documented Information on Employee Qualifications
The standard also requires the organization to keep “information”, that is “records” of peoples’ job qualifications. So if there are people making engineering decisions that might affect safety, we’d expect to see records of all of that.
When the investigation happens, which it will, some annoying third party investigative lawyer will go through these and find out how good of a job the organization did in this. It will ultimately be up to the organization to prove that anybody who worked on this submersible or in “mission control” was “qualified” to do so, as determined somehow.
A crafty lawyer might be able to convince a jury that the employees were insufficiently screened and not knowledgeable. The underlying business reason for retaining this “information” is so that the organization can prove it was responsible in staffing the crew.
In an organization like this, run by a “top gun pilot” HR records are sometimes an afterthought. . So, if you were setting this up from scratch, you might make sure a sufficiently good job is done of this, for just this sort of moment.
Awareness and Communication (Clauses 7.3 and 7.4)
The first part of this is Awareness.
The ISO standard says you have to make employees aware of the quality policy, the quality objectives, and in a general way, how things are going.
Now that the disaster has happened, the need for this may have diminished. In a normal quality manual this requirement is normally satisfied by a sign-off when someone new is hired, and possibly some sort of annual refresher, which can be documented.
Communication is a little more tricky. The ISO standard requires you to determine what communication needs you have, and then make arrangements to fulfill them. For example, if there is an annual communication with the EPA or the local fire department, it can be scheduled somehow in your system so that the responsible people can do the communicating.
In this case, if there is a notification of the coast guard, or any similar communication requirements, it can be captured as well.
For that matter, it also allows the company to plan in advance who that person or people may be. This can be the same or over-and-above the social media/market communications that we’ll talk about later. That’s to prevent the guy that is running the forklift from making a lot of public statements.
Documented Information (Clause 7.5)
The standard also requires “the organization” to come up with a plan to retain and preserve something called “documented information. What are we talking about? Let’s go through our processes and give some examples.
| Process | Type of Documents | Comments |
| Management | Management review records, records about the objectives, HR records, internal audit and corrective action records | Proves that you are meeting the requirements to measure, review and improve your processes |
| Sales/Contract Review | Product information, catalogs, website information, brochures, and other means of market communication. Signed contracts. | Provides documentation of how you represented your “product” to the marketplace. Also documents who within the company approved the market communication, and also documents the sales order and/or sales contracts |
| Design and Fabrication | Design plan, Design records, material test validation, prototype test records, records of design requirements, records of design validation and verification, test method documents, measuring device documentation, fabrication records | Design requirements are compared to design reality, to confirm that there were no compromises with the original design plan. |
| Operations | “Operational Plan” and subsequent operational records. Standard operating procedures. Pre-mission inspection documents, corrections and corrective actions, design change controls that were enacted. Customer satisfaction data. What happens if there is a non-conformity? Purchasing records, including raw material certificates of conformity. | Proves that the company did its job properly with properly selected and received materials. |
We will have more to say about some of these later.
The requirements of the standard are fairly clear on this. The organization has to have a way of capturing the 38 types of records that are required by the standard. It also has to have a way to determine what other documents are needed to run the process properly.
The standard requires “the organization” to determine a standardized format, determine how to modify them in a controlled way, and defines how long to keep the records. That’s so an employee, or an investigator, knows what is a “real requirement” at a given time.
It isn’t considered good practice to have an instruction manual with a lot of sticky notes in it, and a lot of crossouts and marks in the margin. Same goes for a fabrication plan.
The medical device people have something called a “device history record” in which for each lot or batch of material, all of the required information is documented. That’s so in case there has to be a recall, or investigation, you can go back in time and see, in an unaltered way, what the entire life of the project was at the time it was produced.
In this case, the lawyers will want to know all of that, and one of the potential failure modes on this is that the local organization didn’t have a good system of process record keeping.
The Bottom Line So Far
There is a lot in this already, and we’re not even to operations.
Here is the story. The whole purpose of this system of ISO certification is for just this situation. It’s a way to have a system that can be used to prove you did your job correctly.
It’s validated by an independent third party, so that a prospective customer can have an educated set of eyes estimate the risks of doing business with the company.
As we will see later, this goes double for market communications. If “the organization” makes a lot of claims about its service capability, there’s someone who can call it out.
The resources, including documents, are around to make sure that the company is capable of carrying out its job, and can improve the process if it needs to.
Whether or not it “will” improve the process is a slightly different issue that we’ll get into later.
Links and References
Titan Disaster Recordings and Transcripts
https://www.newsweek.com/titan-submersible-implosion-screams-tiktok-1811033
Prior submersible failures
https://www.insider.com/titan-sub-reached-titanic-depth-dive-stockton-rush-2023-7
“Sully” operations manual
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.
