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Haery Sihombing @ IP

QUALITY PARADIGM:
Values, Goals, Controls, Information, and Consciousness
We all have needs, requirements, wants, expectations and desires. Needs are essential for life, to maintain certain standards or essential for products and services to fulfill the purpose for which they have been acquired. Requirements are what we request of others and may encompass our needs but often we don't fully realize what we need until after we have made our request. For example, now that we own a mobile phone we later discover we need hands free operation while driving and didn't think to ask at the time of purchase. Hence our requirements at the moment of sale may or may not express all our needs. Our requirements may include wants - what we would like to have but its not practical. For example, we want a cheap computer but we need a top of the range model for what we need it for. Expectations are implied needs or requirements. They have not been requested because we take them for granted - we regard them to be understood within our particular society as the accepted norm. They may be things to which we are accustomed based on fashion, style, trends or previous experience. Hence one expects sales staff to be polite and courteous, electronic products to be safe and reliable, food to be fresh and uncontaminated, tap water to be potable, policemen to be honest and people or organizations to do what they promise to do. In particular we expect goods and services to comply with the relevant laws of the country of sale and expect the supplier to know which laws apply. Desires are our innermost feelings about ourselves and our surroundings, what we would like most. Everyone nowadays is laying claim to quality. At Ford, quality is job one. GM is putting quality on the road. Chrysler makes the best built American car, and Lee Iacocca can't figure out why two cars come off the same American assembly line, and people prefer the one with the foreign label. Quality has given vanquished economies mighty post war powers. The American posture is uneasy, looking back on neighboring progress for a fix on quality. In Japan, Japanese Quality Control is a thought revolution in management. It represents a new way of thinking about management. Dr. Kaoru Ishikawa, Japan’s foremost authority in this field defines quality control as, “To practice quality control is to develop, design, produce, and service a quality product which is most economical, most useful, and always satisfactory to the customer”. Quality Control is an integral, yet often underrated concept key to successful day-to-day operation of any large or small manufacturing or factory-based company. The narrow interpretation of quality control is producing a quality product. The Japanese expand this definition in a broader sense to include: quality of work, quality of service, quality of information, quality of process, quality of division, quality of people, including workers, engineers, managers, and executives, quality of system, quality of company, and quality of objectives.

1. THE QUALITY REVOLUTION The idea of quality control began in the United States in the Post World War II era with the innovations of engineers such as Dr. W. E. Deming, Dr. J. M. Juran, and Dr. W. E. Shewhart. They developed the basic ideas of quality control and developed statistical methods for evaluating quality. Many of the quality control principles taught in American institutions of
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higher learning today revolve around the basic principles developed by these individuals. These predecessors based their ideas mainly around improving the production processes in firms and did not expand these ideas to other functional departments in companies. The Japanese, specifically, Dr. Ishikawa, decided to expand on the American ideas and relate them to the operation of every department. He expanded on these ideas with the same goal as his American colleagues, to provide a quality product to maintain a high service level and good working relationship with customers. Dr. Ishikawa expanded the idea to develop new principles for quality control: always use quality control as the basis for decisions, integrate the control of cost, price, and profit, and control quantity of stock, production, and sales, and date of delivery.

2. QUALITY PERSPECTIVES In supplying products or services there are three fundamental parameters which determine their saleability or usability. They are price, quality and delivery. Customers require products and services of a given quality to be delivered by or be available by a given time and to be of a price which reflects value for money. These are the requirements of customers. An organization will survive only if it creates and retains satisfied customers and this will only be achieved if it offers for sale products or services which respond to customer needs, expectations, requirements and desires. Whilst price is a function of cost, profit margin and market forces and delivery is a function of the organization’s efficiency and effectiveness, quality is determined by the extent to which a product or service successfully meets the expectations, needs and requirements of the user during usage (not just at the point of sale). 2.1 Quality Goals To control, assure and improve quality you need to focus on certain goals. Let's call them the quality goals. There follows some key actions form which specific goals may be derived: Establish your customer needs and expectations - not doing this will certainly lead to unsatisfied customers. Design products and services with features that reflect customer needs and expectations Build products and services so as to faithfully reproduce the design which meets the customer's needs and expectations Verify before delivery that your products and services possess the features required to meet the customer's needs and expectations Prevent supplying products and services that possess features that dissatisfy customers. Discover and eliminate undesirable features in products and services even if they possess the requisite features Find less expensive solutions to customer needs because products and services which satisfy these needs may be too expensive. Make your operations more efficient and effective so as to reduce costs because products and services that satisfy customer needs may cost more to produce than the customer is prepared to pay. Discover what will delight your customer and provide it. (Regardless of satisfying customer needs your competitor may have provided products with features that give greater satisfaction!) Establish and maintain a management system that enables you to achieve these goals reliably, repeatedly and economically.

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ISO 9001 addresses quality goals through the use of the term ‘quality objectives’ but goes no further. The purpose of a quality system is to enable you to achieve, sustain and improve quality economically. It is unlikely that you will be able to produce and sustain the required quality unless you organize yourselves to do so. Quality does not happen by chance - it has to be managed. No human endeavour has ever been successful without having been planned, organized and controlled in some way. The quality system is a tool and like any tool can be a valuable asset. (or be abused, neglected, misused!) Depending on your strategy quality systems enable you to achieve all the quality goals. Quality systems have a similar purpose to the financial control systems, information technology systems, inventory control systems, personnel management systems. They organize resources so as to achieve certain objectives by laying down rules and an infrastructure which, if followed and maintained, will yield the desired results. Whether it is the management of costs, inventory, personnel or quality, systems are needed to focus the thought and effort of people towards prescribed objectives. Quality systems focus on the quality of what the organization produces, the factors which will cause the organization to achieve its goals, the factors which might prevent it satisfying customers and the factors which might prevent it from being productive, innovative and profitable. Quality systems should therefore cause conforming product and prevent nonconforming product. Quality systems can address one of the quality goals or all of them, they can be as small or as large as you want them to be. They can be project specific, or they can be limited to quality control that is, maintaining standards rather than improving them. They can include Quality Improvement Programmes (QIPs) or encompass what is called Total Quality Management (TQM). This book, however, only addresses one type of quality system - that which is intended to meet ISO 9000 which currently focuses on the quality of the outgoing product alone 2.2 Achieving Quality There are two schools of thought on quality management. One views quality management as the management of success and the other the elimination of failure. They are both valid. Each approaches the subject from a different angle. In an ideal world if we could design products, services and processes that could not fail we would have achieved the ultimate goal. Failure means not only that products, services and processes would fail to fulfill their function but that their function was not what our customers desired. A gold plated mousetrap that does not fail is not a success if no one needs a gold plated mousetrap! We have only to look at the introductory clauses of ISO 9001 to find that the aim of the requirements is to achieve customer satisfaction by prevention of nonconformities. Hence quality management is a means for planning, organizing and controlling the prevention of failure. All the tools and techniques that are used in quality management serve to improve our ability to succeed in our pursuit of excellence. Quality does not appear by chance or if it does it may not be repeated. One has to design quality into the products and services. It has often been said that one cannot inspect quality into a product. A product remains the same after inspection as it did before so no amount of inspection will change the quality of the product. However, what inspection does is measure quality in a way that allows us to make decisions on whether to release a piece of work. Work that passes inspection should be quality work but inspection unfortunately is not 100% reliable. Most inspection relies on the human judgment of the inspector and human judgment

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can be affected by many factors some of which are outside our control such as the private life, health or mood of the inspector. We may fail to predict the effect that our decisions have on others. Sometimes we go to great lengths in preparing organization changes and find to our surprise that we neglected something or underestimated the effect of something. So we need other means than inspection to deliver quality products. It is costly anyway to rely only on inspection to detect failures - we have to adopt practices that enable us to prevent failures from occurring. This is what quality management is all about. Quality management is both a technical subject and a behavioral subject. It is not a bureaucratic administrative technique. The rise in popularity of ISO 9000 has created some unhelpful messages such as the 'document what you do' strategy. There has also been a perception in the service industries that ISO 9000 quality systems only deal with the procedural aspects of a service and not the professional aspects. For instance in a medical practice, the ISO 9000 quality system is often used only for processing patients and not for the medical treatment. In legal practices, the quality system again has been focused only on the administrative aspects and not the legal issues. The argument for this is that there are professional bodies that deal with the professional side of the business. In other words the quality system addresses the non-technical issues and the profession the technical issues. This is not quality management. The quality of the service depends upon both the technical and non-technical aspects of the service. Patients who are given the wrong advice would remain dissatisfied even if his/her papers were in order or even if he/she were given courteous attention and informed of the decision promptly. To achieve quality one has to consider both the product and the service. A faulty product delivered on time within budget and with a smile remains a faulty product. Another often forgotten aspect of quality management is the behavior of people in an organization. Such behavior is formed by the core values to which that organization subscribes. The absence of core values that form a positive behavior, may not have an immediate effect because individuals will operate according to their own personal values. When these conflict with the organization's values, an individual could resent being forced to comply and may eventually adopt the values of the majority or leave to find a more suitable company to work for. The management of quality involves many aspects of an organization. In essence quality management is concerned with the failure potential of processes, products and services as stated previously. Organizations comprise many functions and all must be essential for the organization to function efficiently and effectively. It follows therefore that if any function fails to perform, there will be a corresponding detrimental effect on the organization. Whether this failure has any effect on the products and services offered for sale depends on the time taken for the effect to be damaging. Some failures have an immediate effect where they contribute directly to the supply of products and services. Others have a long term effect where their contribution is indirect such as the behavioral aspects. People work best when management shows it cares about them. Neglect the people and you eventually impact product quality. A failure in a support function, such as office cleaning, may not affect anything initially, but if the office remains unclean for a prolonged period it will begin to have an effect on productivity. If a Total Quality Management philosophy is to be adopted, every function in the organization regardless of the magnitude of its effect on processes, products and services is brought into the system. ISO 9000 only addresses those functions that contribute directly to

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the sale of products and services to customers. The difference is that ISO 9000 and other standards used in a regulatory manner are not concerned with an organization's efficiency or effectiveness in delivering profit. However, they are concerned indirectly with nurturing the values that determine the behavior of the people who make decisions that affect product or service quality. 2.3 Quality Management One of the most important issues that businesses have focused on in the last 20-30 years has been quality. As markets have become much more competitive - quality has become widely regarded as a key ingredient for success in business. In this revision note, we introduce what is meant by quality by focusing on the key terms you will come up against. What is quality? You will comes across several terms that all seem to relate to the concept of quality. It can be quite confusing working out what the difference is between them. We've defined the key terms that you need to know below: Term Description
Quality is first and foremost about meeting the needs and expectations of customers. It is important to understand that quality is about more than a product simply "working properly".

Quality

Think about your needs and expectations as a customer when you buy a product or service. These may include performance, appearance, availability, delivery, reliability, maintainability, cost effectiveness and price. Think of quality as representing all the features of a product or service that affect its ability to meet customer needs. If the product or service meets all those needs - then it passes the quality test. If it doesn't, then it is sub-standard. Producing products of the required quality does not happen by accident. There has to be a production process which is properly managed. Ensuring satisfactory quality is a vital part of the production process.

Quality Management

Quality management is concerned with controlling activities with the aim of ensuring that products and services are fit for their purpose and meet the specifications. There are two main parts to quality management (1) Quality assurance (2) Quality control Quality assurance is about how a business can design the way a product of service is produced or delivered to minimize the chances that output will be sub-standard. The focus of quality assurance is, therefore on the product design/development stage.

Quality Assurance

Why focus on these stages? The idea is that - if the processes and procedures used to produce a product or service are tightly controlled - then quality will be "built-in". This will make the production process much more reliable, so there will be less need to inspect production output (quality control). Quality assurance involves developing close relationships with customers and suppliers. A business will want to make sure that the suppliers to its production process understand exactly what is required - and deliver! Quality control is the traditional way of managing quality. A further revision note (see the list on the right) deals with this in more detail.

Quality Control

Quality control is concerned with checking and reviewing work that has been done. For example, this would include lots of inspection, testing and sampling. Quality control is mainly about "detecting" defective output - rather than preventing it. Quality control can also be a very expensive process. Hence, in recent years, businesses have focused on quality management and quality assurance.

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Total Quality Management

Total quality management (usually shortened to "TQM") is a modern form of quality management. In essence, it is about a kind of business philosophy which emphasizes the need for all parts of a business to continuously look for ways to improve quality. We cover this important concept in further revision notes.

2.4 Quality Control Quality control is the more traditional way that businesses have used to manage quality. Quality control is concerned with checking and reviewing work that has been done. But is this the best way for a business to manage quality? Under traditional quality control, inspection of products and services (checking to make sure that what's being produced is meeting the required standard) takes place during and at the end of the operations process. There are three main points during the production process when inspection is performed:
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When raw materials are received prior to entering production Whilst products are going through the production process When products are finished - inspection or testing takes place before products are dispatched to customers

The problem with this sort of inspection is that it doesn't work very well! There are several problems with inspection under traditional quality control:
1 The inspection process does not add any "value". If there were any guarantees that no defective output would be produced, then there would be no need for an inspection process in the first place! Inspection is costly, in terms of both tangible and intangible costs. For example, materials, labor, time, employee morale, customer goodwill, lost sales It is sometimes done too late in the production process. This often results in defective or nonacceptable goods actually being received by the customer It is usually done by the wrong people - e.g. by a separate "quality control inspection team" rather than by the workers themselves Inspection is often not compatible with more modern production techniques (e.g. "Just in Time Manufacturing") which do not allow time for much (if any) inspection. Working capital is tied up in stocks which cannot be sold There is often disagreement as to what constitutes a "quality product". For example, to meet quotas, inspectors may approve goods that don't meet 100% conformance, giving the message to workers that it doesn't matter if their work is a bit sloppy. Or one quality control inspector may follow different procedures from another, or use different measurements.

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As a result of the above problems, many businesses have focused their efforts on improving quality by implementing quality management techniques - which emphasize the role of quality assurance. As Deming (a "quality guru") wrote: "Inspection with the aim of finding the bad ones and throwing them out is too late, ineffective, costly. Quality comes not from inspection but from improvement of the process." The ISO definition states that quality control is the operational techniques and activities that are used to fulfill requirements for quality. This definition could imply that any activity whether serving the improvement, control, management or assurance of quality could be a quality control activity. What the definition fails to tell us is that controls regulate

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performance. They prevent change and when applied to quality regulate quality performance and prevent undesirable changes in the quality standards. Quality control is a process for maintaining standards and not for creating them. Standards are maintained through a process of selection, measurement and correction of work, so that only those products or services which emerge from the process meet the standards. In simple terms quality control prevents undesirable changes being present in the quality of the product or service being supplied. The simplest form of quality control is illustrated in the Figure below. Quality control can be applied to particular products, to processes which produce the products or to the output of the whole organization by measuring the overall quality performance of the organization.

Quality control is often regarded as a post event activity. i.e. a means of detecting whether quality has been achieved and taking action to correct any deficiencies. However, one can control results by installing sensors before, during or after the results are created. It all depends on where you install the sensor, what you measure and the consequences of failure. Some failures cannot be allowed to occur and so must be prevented from happening through rigorous planning and design. Other failures are not so critical but must be corrected immediately using automatic controls or fool proofing. Where the consequences are less severe or where other types of sensor are not practical or possible, human inspection and test can be used as a means of detecting failure. Where failure cannot be measured without observing trends over longer periods, one can use information controls. They do not stop immediate operations but may well be used to stop further operations when limits are exceeded. If you have no controls then quality products are produced by chance and not design. The more controls you install the more certain you are of producing products of consistent quality but there is balance to be achieved. Beware of the law of diminishing returns. It is often deemed that quality assurance serves prevention and quality control detection, but a control installed to detect failure before it occurs serves prevention such as reducing the tolerance band to well within the specification limits. So quality control can prevent failure. Assurance is the result of an examination whereas control produces the result. Quality Assurance does not change the product, Quality Control does. Quality Control is also a term used as a name of a department. In most cases Quality Control Departments perform inspection and test activities and the name derives from the authority that such departments have been given. They sort good products from bad products and authorize the release of the good products. It is also common to find that Quality Control Departments perform supplier control activities which are called Supplier Quality Assurance

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or Vendor Control. In this respect they are authorized to release products from suppliers into the organization either from the supplier's premises or on receipt in the organization. Since to control anything requires the ability to effect change, the title Quality Control Department is in fact a misuse of the term since such departments do not in fact control quality. They do act as a regulator if given the authority to stop release of product, but this is control of supply and not of quality. Authority to change product usually remains in the hands of the producing departments. It is interesting to note that similar activities within a Design Department are not called quality control but Design Assurance or some similar term. Quality Control has for decades been a term applied primarily in the manufacturing areas of an organization and hence it is difficult to change peoples perceptions after so many years of the terms incorrect use. In recent times the inspection and test activities have been transferred into the production departments of organizations, sometimes retaining the labels and sometimes reverting to the inspection and test labels. Control of quality, or anything else for that matter, can be accomplished by the following steps: Determine what parameter is to be controlled. Establish its criticality and whether you need to control before, during or after results are produced. Establish a specification for the parameter to be controlled which provides limits of acceptability and units of measure. Produce plans for control which specify the means by which the characteristics will be achieved and variation detected and removed. Organize resources to implement the plans for quality control. Install a sensor at an appropriate point in the process to sense variance from specification. Collect and transmit data to a place for analysis. Verify the results and diagnose the cause of variance. Propose remedies and decide on the action needed to restore the status quo. Take the agreed action and check that the variance has been corrected 2.5 Quality Assurance The ISO definition states that quality assurance is all those planned and systematic actions necessary to provide adequate confidence that an entity will fulfill requirements for quality. Both customers and managers have a need for quality assurance as they cannot oversee operations for themselves. They need to place trust in the producing operations, thus avoid constant intervention. Customers and managers need: Knowledge of what is to be supplied (This may be gained from the sales literature, contract or agreement) Knowledge of how the product or service is intended to be supplied (This may be gained from the supplier’s proposal or offer) Knowledge that the declared intentions will satisfy customer requirements if met (This may be gained from personal assessment or reliance on independent certifications)
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Knowledge that the declared intentions are actually being followed (This may be gained by personal assessment or reliance on independent audits) Knowledge that the products and services meet your requirements (This may be gained by personal assessment or reliance on independent audits) You can gain an assurance of quality by testing the product/service against prescribed standards to establish its capability to meet them. However, this only gives confidence in the specific product or service purchased and not in its continuity or consistency during subsequent supply. Another way is to assess the organization which supplies the products/services against prescribed standards to establish its capability to produce products of a certain standard. This approach may provide assurance of continuity and consistency of supply Quality assurance activities do not control quality, they establish the extent to which quality will be, is being or has been controlled. This is born out by ISO 8402 1994 where it is stated that quality control concerns the operational means to fulfill quality requirements and quality assurance aims at providing confidence in this fulfillment both within the organization and externally to customers and authorities. All quality assurance activities are post event activities and off line and serve to build confidence in results, in claims, in predictions etc. If a person tells you they will do a certain job for a certain price in a certain time, can you trust them or will they be late, overspent and under spec?. The only way to find out is to gain confidence in their operations and that is what quality assurance activities are designed to do. Quite often, the means to provide the assurance need to be built into the process such as creating records, documenting plans, specifications, reviews etc. Such documents and activities also serve to control quality as well as assure it (see also ISO 8402 ). ISO 9001 provides a means for obtaining an assurance of quality, if you are the customer, and a means for controlling quality, if you are the supplier. Quality assurance is often perceived as the means to prevent problems but this is not consistent with the definition in ISO 8402. In one case the misconception arises due to people limiting their perception of quality control to control during the event and not appreciating that you can control an outcome before the event by installing mechanisms to prevent failure such as automation, mistake-proofing, failure prediction etc. Juran provides a very lucid analysis of control before, during and after the event in Managerial Breakthrough. In another case, the misconception arises due to the label attached to the ISO 9000 series of standards. They are sometimes known as the Quality Assurance standards when in fact, as a family of standards, they are Quality System standards. The requirements within the standards do aim to prevent problems and hence the association with the term Quality Assurance. Only ISO 9001, ISO 9002 and ISO 9003 are strictly Quality Assurance Standards. It is true that by installing a quality system, you will gain an assurance of quality, but assurance comes about through knowledge of what will be, is being or has been done, rather than by doing it. Assurance is not an action but a result. It results from obtaining reliable information that testifies the accuracy or validity of some event or product. Labelling the prevention activities as Quality Assurance activities may have a negative effect particularly if you have a Quality Assurance Department. It could send out signals that the aim of the Quality Assurance Department is to prevents things from happening! Such a label could unintentionally give the department a law enforcement role.

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Quality Assurance Departments are often formed to provide both customer and management with confidence that quality will be, is being and has been achieved. However, another way of looking upon Quality Assurance departments is as Corporate Quality Control. Instead of measuring the quality of products they are measuring the quality of the business and by doing so are able to assure management and customers of the quality of products and services. Assurance of quality can be gained by the following steps illustrated diagrammatically in the Figure below: Acquire the documents which declare the organization’s plans for achieving quality. Produce a plan which defines how an assurance of quality will be obtained i.e. a quality assurance plan. Organize the resources to implement the plans for quality assurance. Establish whether the organization’s proposed product or service possesses characteristics which will satisfy customer needs. Assess operations, products and services of the organization and determine where and what the quality risks are. Establish whether the organization’s plans make adequate provision for the control, elimination or reduction of the identified risks. Determine the extent to which the organization’s plans are being implemented and risks contained. Establish whether the product or service being supplied has the prescribed characteristics. In judging the adequacy of provisions you will need to apply the relevant standards, legislation, codes of practices and other agreed measures for the type of operation, application and business. These activities are quality assurance activities and may be subdivided into design assurance, procurement assurance, manufacturing assurance etc. Auditing, planning, analysis, inspection and test are some of techniques which may be used. ISO-9000 is a quality assurance standard, designed for use in assuring customers that suppliers have the capability of meeting their requirements 2.6 Quality Improvement The ISO definition of quality improvement states that it is the actions taken throughout the organization to increase the effectiveness of activities and processes to provide added benefits to both the organization and its customers. In simple terms, quality improvement is anything which causes a beneficial change in quality performance. There are two basic ways of bringing about improvement in quality performance. One is by better control and the other by raising standards. We don't have suitable words to define these two concepts. Doing better what you already do is improvement but so is doing something new. Juran uses the term control for maintaining standards and the term breakthrough for achieving new standards. Imai uses the term Improvement when change is gradual and Innovation when it is radical. Hammer uses the term Reengineering for the radical changes. All beneficial change results in improvement whether gradual or radical so we really need a word which means gradual change or incremental change. The Japanese have the word Kaizen but there is no English equivalent that I know of other than the word improvement. Quality improvement (for better control) is a process for changing standards. It is not a process for maintaining or creating new standards. Standards are changed through a process of selection, analysis, corrective action on the standard or process, education and training. The standards which emerge from this process are an improvement from those used

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previously. A typical quality improvement might be to increase the achieved reliability of a range of products from 1 failure every 1000 hours to meet the specified target of 1 every 5000 hours. Another might be to reduce service call-out response time from an average of 38 hours to the maximum of 36 hours specified. Another might be simply to correct the weaknesses in the registered quality system so that it will pass re-assessment. Quality improvement (raising standards or Innovation), is a process for creating new standards. It is not a process for maintaining or improving existing standards. Standards are created through a process which starts at a feasibility stage and progresses through research and development to result in a new standard proven for repeatable applications. Such standards result from innovations in technology, marketing and management. A typical quality improvement might be to redesign a range of products to increase the achieved reliability from 1 failure every 5000 hours to 1 failure every 10,000 hours. Another example might be to improve the efficiency of the service organization so as to reduce the guaranteed call-out time from the specified 36 hours to 24 hours. A further example might be to design and install a quality system which complies with ISO 9001. The transition between where quality improvement stops and quality control begins is where the level has been set and the mechanisms are in place to keep quality on or above the set level. In simple terms if quality improvement reduces quality costs from 25% of turnover to 10% of turnover, the objective of quality control is to prevent the quality costs rising above 10% of turnover. This is illustrated below. Improvement by better control is achieved through the corrective action mechanisms and by raising standards that requires a different process. A process which results in new standards which is improving quality by raising standards can be accomplished by the following steps illustrated diagrammatically in the figure below Determine the objective to be achieved. e.g. new markets, products or technologies or new levels of organizational efficiency or managerial effectiveness, new national standards or government legislation. These provide the reasons for needing change. Determine the policies needed for improvement. i.e. the broad guidelines to enable management to cause or stimulate the improvement. Conduct a feasibility study. This should discover whether accomplishment of the objective is feasible and propose several strategies or conceptual solutions for consideration. If feasible, approval to proceed should be secured. Produce plans for the improvement which specify the means by which the objective will be achieved. Organize the resources to implement the plan. Carry out research, analysis and design to define a possible solution and credible alternatives. Model and develop the best solution and carry out tests to prove it fulfils the objective. Identify and overcome any resistance to the change in standards. Implement the change i.e. putting new products into production and new services into operation. Put in place the controls to hold the new level of performance.

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This improvement process will require controls to keep improvement projects on course towards their objectives. The controls applied should be designed in the manner described previously. The inherent characteristics of a product or service created to satisfy customer needs, expectations and requirements are quality characteristics. Physical and functional characteristics such as weight, shape, speed, capacity, reliability, portability, taste etc. Price and delivery are assigned characteristics and not inherent characteristics of a product or service and are both transient features whereas the impact of quality is sustained long after the attraction or the pain of price and delivery has subsided. Quality characteristics that are defined in a specification are quality requirements and hence any technical specification for a product or service that is intended to reflect customer expectations, needs and requirements is a quality requirement, Most people simply regard such requirements as product or service requirements and calling them 'quality' requirements introduces potential for misunderstanding.

3 IMPLEMENTATION OF QUALITY CONTROL Dr. Ishikawa attempted to standardize the procedure of implementing quality control by setting guidelines for implementation: 1. Engage in quality control with the goal of manufacturing products with the quality, which can satisfy the requirements of consumers. Just meeting the standards or specifications of national organizations is not the answer. These standards and specifications are not perfect and do not always satisfy customer requirements. Customers change their requirements often as the market and consumers dictate and national organizations do not set standards that keep up with customer requirements. 2. Companies must emphasize consumer orientation. Companies aim to develop the best products and then think that they are doing everyone a favor by providing quality products. This approach should be changed to take into account customer requirements and preferences during the design, production, and sale of products .“The customer is always right” should factor into these decisions.

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3. Interpret quality in the broad sense to take into account all departments of the company versus concentrating solely on the production department. 4. Maintaining a competitive price regardless of how high the level of quality is .Despite the quality, customers will not purchase excessively expensive products. Companies cannot implement quality that ignores price, profit, and cost control. These companies should aim to produce a product with just quality, just price, and just amount. 3.1. Proceeding with Quality Control Proceeding with quality control involves several steps first described by the American, Dr. Fredrick W. Taylor. Taylor used the following to describe control, “plan-do-see. ”Dr. Ishikawa further developed this approach by rewording the method, plan-do-check-action. This involves several steps: 1. 2. 3. 4. 5. 6. Determine goals and targets Determine methods of reaching goals Engage in education and training Implement work Check the effects of implementation Take appropriate action (59)

Those six steps follow the plan-do-check-action approach modified by Dr. Ishikawa. The first two steps involve the planning aspect, steps three and four follow the doing aspect, step five is the checking step, and step six is the action portion of the method. Each of these steps involves a great detail of work. Unless top management determines standardized policies, the company will not reach its goals. These policies need mutual understanding and adherence by all subordinates at every level in the hierarchical tree. Direct subordinates need to full understand these policies in order to implement and enforce them in their individual departments. The mutual understanding by all employees puts everyone on the same page. This allows the company to proceed towards accomplishing its goals. Companies should set goals based on their problems at a company level and set specific limits on the goals. This makes the goals more explicit to everyone striving to attain them. With that said, top management should take into account the feelings and opinions of their subordinates when setting these guidelines. Determining the methods of reaching the goals set forth by top management involves the standardization of work. An idea can work for an individual, but if those around him do not adopt it confusion will arise, hence, defeating the purpose of standardized work. The mangers should again take the subordinates input into account for more effective implementation of the standardized procedures. This approach looks at potential problems and the standardization solves and eliminates these problems before they ever surface. Engaging in education and training eliminates many human errors before they occur. Good goals and planning are useless unless the workers understand what they need to do and exactly how to do it. This does not mean classroom work exclusively. This step involves everything from one-on-one meetings between management and subordinates to classroom work to hands-on training with equipment and machinery. This step also involves the personal nurturing of every employee. Building a mutual trust between management and subordinates is vital to a cooperative team effort.

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If management follows the previous three steps, implementation should not pose any significant, unfixable problems. Problems will arise at every step in the process, but management should solve these problems immediately as they surface. The last two steps involve observing any negative effects that implementation presents and taking appropriate action to correct them. These steps involve finding the root or cause of any problem and then systematically solve them in a standardized manner. Solutions presented must not only solve the problem, but must also prevent the recurrence of this problem. 3.2. Total Quality Control In short, Total Quality Control (TQC) is the management of control itself. First suggested by Feigenbaum, TQC referred to the job of management in maintaining and managing their subordinates and their quality control system. The Japanese approach to TQC differs from Dr. Feigenbaum’s approach in that the Japanese involve this type of management at all levels of the company. The Japanese encourage all employees in every department to involve themselves in studying and promoting quality control. This Japanese designate their approach by the name company-wide quality control. Companies all have different goals for TQC and reasons for implementing it; however, they all have similar purposes summarized by Dr. Ishikawa: 1. Improve the corporate health and character of the company 2. Combine the efforts of every employee, achieving participation by all, and establishing a cooperative system 3. Establish a quality assurance system and obtain the confidence of customers and consumers 4. Aspire to achieve the highest quality in the world and develop new products for that purpose alone 5. Show respect for humanity, nurture human resources, consider employee happiness, provide cheerful workplaces, and pass the torch to the next generation 6. Establish a management system that can secure profit in times of slow growth and can meet various challenges 7. Utilize quality control techniques (97)

4. THE JAPANESE ADVANTAGE It is well known in industry on a global level that the Japanese are the industry leaders in TQC. There are several reasons for their advantage .It begins, however, with the differences in Japanese quality control from that of the West. In 1967, the seventh Quality Control Symposium determined six distinguishing characteristics of Japanese quality control: 1. 2. 3. 4. 5. 6. Company-wide quality control Education and training in quality control QC circle activities QC audits Utilization of statistical methods Nationwide quality control promotion activities

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There also exist several societal and work related differences in attitude and practice that provide the Japanese with a significant advantage over their Western counterparts. The differences in professionalism provide the Japanese with an advantage. Professionalism and specialization is common and encouraged in Western cultures. QC specialists run the quality departments in companies and make the decisions regarding those issues .In Japan, companies rotate workers through all divisions to give them experience in many different departments of the company. This allows a broader understanding of quality control and what it takes to achieve TQC. The vertical integration of Japanese companies provides management with a better working relationship with their subordinates. Subordinates are less apprehensive about approaching management with suggestions and ideas .On the other hand, most Western companies have distinct gaps between each level of employee, which allows a communication gap to persevere. This poses many problems for Western companies when trying to get all team members on the same page aiming towards a common goal. Labor unions influence many company decisions in the West. The unions organize themselves along functional lines. Therefore, if the welders or the machinists decide to strike, a whole company will shut down. Japanese labor unions organize themselves across an entire enterprise. These unions cross-train workers to be multi-functional. The Japanese companies nurture this type of worker, which provides greater cohesion in the team effort. Western cultures rely too heavily on the Taylor method. This method is one of management by specialists. These specialists develop standards and specification requirements. In contrast, as previously mentioned, Japanese cross-train their workers to educate them in many facets of company operation. They also work more as a team to develop these standards and requirements. In Japan, most workers stay with a single company for their whole working careers. This makes the workers familiar with the company and develops more of a family atmosphere. This enhances the cohesion between workers previously mentioned. In Western cultures, the job turnover rate is much higher. Workers change companies looking for pay raises and personal career development. This brings a “me” attitude to many companies, which can take away from company productivity. There are many other cultural differences between Japan and the West that also facilitate the gap that sets Japanese companies apart from their global competition.

5. QUALITY AS A VALUE The ad men are on it daily; government agencies are asking for quality control manuals; some seek no less than total quality management; yes, the chances are you have some form of quality strategy working or planned. Quality management is a wildly popular merit badge.

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Whose Shoes? Give popularity a look askance; it runs on a sidetrack. What is constructive about a thing is seldom known by its popularity. Take running shoes. They are good shoes and mostly trustworthy. The people who wore the first running shoes probably were runners, but the shoes got popular. Now, mostly, the people who wear them don't run in them. On the question of who runs, the wearing of running shoes is untrustworthy information. If everyone showed up tomorrow in running shoes, don't bet on the winner by the wardrobe. You Run in Borrowed Shoes? There isn't a quality control manual in here. You checked, didn't you? No person in the world can give you quality from a manual. Some mighty impressive quality control manuals can be found, and they say things finer than the rest of us even know. Still, the people wrapped in them sometimes must stand naked for their appointments in reality. The quality paradigm explained and applied here is not a manual for following. It is a focal point for reflecting on yourself in many mirrors. Quality comes from there. We pay too dear a price for experience that we should ever be permitted to waste it. A number of the payments we are making to that account are considered here. They were drawn from the public record that we may each recognize our own time and place in them. IS QUALITY CONTROLLED? I'm not at ease with this "control" business when it comes to quality. Quality Control sounds entirely too self-congratulatory. Quality assurance and quality management unsettle me, as well. They are close-ended terms, and, when I listen to people speaking them, I hear a finality in their voices that says they have it under control. But quality is an elusive prize. I can't get easy with terms that hint we can directly control it. Think that, and you could lose the richness of the quest for quality in the same way moon shot loses the sustained exhilaration of a lunar rendezvous. The seekers of rendezvous move to choreography with complex steps, breathtaking leaps, and music; they have harmony and are open to secret possibilities. Astronauts ventured to the moon in the embrace of that. And you will be closer to quality in a rendezvous and more likely to touch and be touched by it. The quality paradigm sounds a chord of notes to help you find the steps in quality's choreography and hear the music it plays on the strings of your consciousness. THE PARADlGM The connection with quality is made by decoding the human behavior of conscious beings and preparation of the individual consciousness for quality results. The paradigm is rooted in the conviction that quality is the result of conscious judgments made to achieve it, and our failures are traceable to dysfunctions in our consciousness. Within our consciousness, values are gate keepers-opening for some choices, closing for others, and providing "just squeeze by" space for some. They are standards for choices.

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Controls are the tools we design to manage and inform us of our progress along settled goals. We understand and act on their messages in the context of all the information in our consciousness, which is open to possibilities broadly or narrowly depending on our construction and conservation of information and our individual selves. THE VALUE STATEMENT Management is widely charged with setting the goals for the firm, including the quality goals. We stand, but do not rest with that. Goals and values are uttered in the same breath with such nonchalance that I wonder: Do we practice conservation of values separately from goals? We should. Goals are never closer than derivatives of values, and in practice may not support professed values at all. We throw goals ahead of us to march in their direction, but why goals land where they do and why people march to those places and not others is distinguished by values. Goals yield no common sense, and wisdom cannot be gained from their achievement or failure without knowledge and conservation of the value premises. Absent wisdom ordered by values, our marches make the picture of pachinko balls dropped into reality to score points or not in a noisy descent. The racket we make does not accumulate to our wisdom. Value premises are distinct from goals by their formation. Goals are settlements. Both individual and organizational goals settle competition over the questions: What shall we do? What will we forego? And, what resources shall be committed? People speak easily of established organizational values and goals. You should not glide easily over that. As settlements of the choices open to a group, organizations can be said to have common goals. But a common value premise does not arise by any such settlement. Certainly, a number of people can agree that they hold similar value premises, but that is close correlation of what value is held rather than settlement among values open for choice. You could settle with me that to achieve the goal of a 10% productivity increase, our partnership will allocate 15% of its cash resources to computer-aided drafting equipment, and we will be bound by our goal settlement. But could I settle with you that I am bound by your value premise: Business growth is good? If we agreed already, that is a correlation. In fact, however, I would spend the increased productivity not on building our business, but on time to kayak the river every Friday. My value premise is: Confrontation with the object of man's desiring is good. If you insisted, and I agreed with your value premise as a condition to buying the equipment, I would conclude that, by making the value "settlement," the value premise nearest that is: Agreement with you is good. The river is still in the lead, and you would find me there every Friday. Does that help answer why organizations do not have values per se and suggest where to look for values? Value premises are important to the pursuit of quality, because what is steadily valued (if experienced as wisdom) is the rail that keeps an individual locked onto the prize. Otherwise, a professional does not pore as thoughtfully over the one hundred and first shop drawing at seven thirty tonight as over the first at eight o'clock this morning, or does not faithfully complete a job awash in budget overruns. Of course, an assumption of the value held was

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made for those statements, and, if the rails are set on a side track, they run a different course to another destination. How high or low you place the value note determines the tone of the paradigm chord. Some chords are played on the high register; others play lower. The Settlement of Goals All quality goals are settlements. The settlement of goals for quality is a management task; however, it is not a solitary task. Professional service is advice for the guidance of others. Clients purchase advice, and, in the price paid, they largely settle the quality goals whether spoken or not. I call it a settlement to draw specific attention to the fact that the level of quality is an issue between the design professional and client. It must be specifically settled, else the financial resources to deliver the quality expected will not be provided. The first chance, and perhaps the only chance to settle quality, is the negotiation of the contract for services. Left unsettled, the client's expectations for quality will likely be quite high (or will be so stated when goals conflict), while the professional's quality goal will tend to center on the fee available to pay for it. In other cases, the prospective client's quality target may be so low that the legal minimum standard of care should preclude settlement. If you aspire to design quality projects, seek quality in both your clients and yourself. Settle the goals specifically, and determine that they are matched. When they are mismatched, test what values they derive from and learn what tone the project will sound. You cannot play on the high register if the client is intent on other notes. The Controls Controls serve three primary purposes: First, a control communicates what management expects the firm's professionals will do to achieve a goal; second, a control provides information to management and the working professionals about progress toward the goal; the third purpose is to raise the stock of people who obtain quality results, which is proof manifested in people of the value held for quality. Controls, like the goals before them, are derived. How the notes of the paradigm play a chord is important to staying in step with quality. The value statement says what ought to be. The goal is management's settlement of its aspirations to the value stated by its commitment of resources to it. The control is information about how to achieve the goal and the progress made along the path to it. If values are not firmly held, goals will be confused, inconsistent, and ill defined. Then, controls on those goals will be pointed in the wrong direction, or whatever information they

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offer will go unheeded. Light will not cleanly separate the quality achievers from those in the shadows. You will miss the complex steps; your leaps will be into empty space; and your music will sound discordant notes. Finally, the value premises will be exposed by behavior tested in reality. Quality strategies are typically chock full of procedures, forms, standard design details, and checklists. Particular quality management procedures, for example, a design peer review, a mock-up and test of a structural connection, the common checklist, quality performance evaluation, and the budget to do any of them are examples of controls. Typically, much stock is put in them because they are demonstrations of headway toward quality, but listing them here is not a recommendation for them. I have a different point. Any strategy for quality is destined to fail utterly, unless controls give the opportunity and the time to act. The initiation of effective controls requires the foresight waiting for you a few pages ahead in "The Freedom to Act" and beyond. Controls are tools for anticipating hazardsthat we shall have the opportunity to act in time. Do not get snagged on gadgets here; the most effective controls are those which provide information needed at critical times. You might get that just by listening to what the client is telling you (or what is left unsaid). Controls are deliberate potentials for disquieting news. They are not the lights on the right seat vanity mirror. Controls are your lasers piercing the night you go into uneasily, sending back the information you need. We move directly, then, to information.

INFORMATION Information is everywhere in the paradigm. Without it, we are conscious beings on perpetual standby waiting for data in grave doubt about our next move. So vital is information that theorists include it with matter and energy as an essential concept to interpret nature. Design professionals are in particular need of an information theory, because information is exactly the component they add to the building process. Principles are needed to encode information that will empower others to act in predictable ways. No complete theory is handed to us; however, there are tools. a. Probability Probability is the linking theory between the sender and the receiver of information. We have need of probability, because the transfer of useful information always involves uncertainty. The measure of that uncertainty figures in the difference between the sender's and receiver's knowledge and the skill of the information encoding. You can readily see why this is the case. If your knowledge and mine are the same, a transfer of information between us has little uncertainty, but what we exchange adds little to our knowledge. The exchange would become completely predictable, and we would end it. Ratso Rizzo put it bluntest in Midnight Cowboy by saying, "There's no use talking to you. Talking to you is just like talking to me." The prime purpose of communication is to exchange messages that are not predictable, which is to say we want to send missing information. The outcome is always uncertain. The greater the missing information, the greater is the inherent uncertainty of the outcome, but the potential exchange is all the richer for it.
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The rich potential will not be achieved if inept encoding decreases the probability of the intended outcome. Probability will be low if the message cannot be understood. The information will not empower the receiver to act, and actions that follow may be based on information gathered from other sources. You will not have influenced the probability of the outcome (affected, yes; influenced, no). Probability will also be low if the message can be understood in so many ways that the receiver is empowered for numerous possible outcomes. When information is structured to achieve an acceptable probability of its intended outcome, we come closest to getting something useful from our communications. Point one is your knowledge that professional advice (drawings, specifications, letters, and conversation) supplies missing information, whose probability of intended consequences is made acceptable, if at all, by skilled encoding. Seeking an acceptable probability focuses the sender's consciousness to the receiver's missing knowledge so that the obligation to fill that gap will be assumed. Success is not measured by what is said. "I made my point!" misses the relevant investment. Dividends are paid on the action taken in response to the message received. Uncertainty forces us to encode information in ways meaningful to the receiver: Use vocabulary already commonly understood; order information in logical blocks which prepare the receiver for complex missing information; test the possible outcomes empowered by the information beforehand; use redundancies to limit the possible outcomes. I hear a few readers barely able to suppress a rejoinder. "Doesn't the receiver have an obligation to comprehend and tell me when there is a confusion about my information?" There is, and, when you are a receiver, you should honor the attendant obligations. The decision will be yours then, but the decision is another's when receiving from you. Do you see? You should aim to influence probability. You cannot pitch poorly on the premise that you are owed good catching. b. Redundancy Redundancy makes complexity more predictable. The possibility of error in complex tasks is great, because there are many possible outcomes from their attempt. You can test this by operating a transcontinental car ferry for a few minutes. Traveling by road from New York to San Francisco is complex to begin with, because there are so many possible roads. When you instruct one hundred drivers in New York to drive to San Francisco, unpredictable arrival times are likely. The system of instructions needs redundancy to enhance its predictability, which can be achieved by internal rules. More stability is achieved if only paved roads are allowed. That rule is, strictly speaking, unnecessary information for getting to San Francisco. It is redundant, and it increases order by reducing the number of possible routes. Greater order is achieved by progressively greater redundancy: Use only U.S. interstate highways; use only U.S. Interstate 80. We could go on by adding internal rules on speed, check points, and place and length of rest stops until the reduced number of possible outcomes constrained by redundancy yields acceptable predictability. One of the reasons both drawings and specifications are issued is to surround a thing with redundancy in a way that makes the result intended more probable. Detail drawings serve a similar function. Redundancy makes the complex system of construction more predictable.

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Information theory instructs you to test the probability of your information by anticipating the number of possible outcomes from its use. Too many possible outcomes indicates unpredictability, which calls for more skillful encoding, including, perhaps, greater redundancy. Finally, an acceptable probability requires knowledge that no communication is ever completely secure. Settled understandings are disordered over time. That is the reason we move on to entropy. c. Entropy: From the Greek Root Meaning Transformation Entropy is an additional concept needed to figure the probability that information will have the desired outcome. Entropy describes the tendency of all things to become less orderly when left to themselves. It is the measure of disorder in systems of matter, energy, and information. Entropy has highly predictable applications in natural systems. For example, in a corollary to the second law of thermodynamics, energy does not alter its total quantity, but it may lose quality. A fully fired steam engine left unattended ceases to function not because total energy is less, but because its energy is dissipated from a highly regulated form in the boiler to a randomly organized form in the atmosphere. When cold, the engine's energy system is at maximum entropy. Claud Shannon's work on information theory at Bell Telephone Laboratories, published in the July and October 1948 issues of the Bell System Technical Journal, is the prototype scientific application of entropy to information systems. Shannon theorized that information in a system tends to lose quality over time by progressive transformation from an organized form to an eventual random order. At maximum entropy, the information has so many possible arrangements that nothing useful or predictable can be made of it. Missing information is then at its maximum; outcomes are highly uncertain, and predictability is very low. For example, a beaker of seawater in one hand and a beaker of distilled water in the other represent a highly ordered system of information about their contents. The information is significantly disordered when I mix them together in a single beaker. When the mixed beaker is drained into the ocean, complete entropy of the information is reached. The order of matter and information is completely random, and no use can be made of it. Entropy is ubiquitous. You likely discovered its consequences when you first remarked, "When did we start doing things that way? Whatever happened to our practice on doing things this way? Who gave them the idea they could do that?" The when, whatever, and who is entropy. Entropy is systemic. A firm with many branch offices is headed for disorder in numerous systems, which will account for some of the confusion among them. The decision to set up a new department is a decision to risk entropy in a new system. A decision to locate one firm in two buildings is just asking for trouble. Entropy, you see, is also a concern of effective architecture. Let's check in on our car ferry business. Shannon's corollary predicts that over time our highly ordered way of getting reliable arrival times in San Francisco will fall apart: Our drivers will seek scenic diversion; they will ignore the route rules; they will overstay at

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Jesse's Highway Diner; Jesse may add new diversionary information; some maverick drivers will break the rules and chance acceptable arrival times; replacement drivers will ignore our rules and try the maverick routes. Left unattended, missing information will tend to grow, the possible outcomes will increase, predictability will decrease, and, at some point, total entropy will be reached when all arrival times are equally likely. There will be no information in the system we can do anything useful with. d. Open and Closed Information Systems Theorists postulate two fundamentally different kinds of energy, matter, and information systems. Open systems grow in complexity despite the demonstrable effects of entropy, while closed systems wind down on the entropy clock to eventual randomness. The cosmic scale of this notion makes a delightfully heady place to romp. Don't miss the opportunity. Solar systems that can exchange matter and energy with other systems grow, while a solar system closed to exchanges will collapse. Worlds are made and lost here. One fate or the other awaits people orbiting within information systems. A closed information system resists exchanges. It busies itself with cybernetic enforcement of the system extant. Closed to disruptive outside influence, it may be thought stable, but the apparent stability carries the seeds of self destruction. The closed system will not change, but the surroundings do not stand still. New possibilities are unwelcome and do not spin off as innovative systems of greater complexity. Information missing in the closed system will approach maximum. The entropy alarm will sound; no one will hear. The Soviet Union is a deliberate, real life laboratory of that-with consequences. It is not by information gathered from coincidence alone that glasnost sounds at least a quarter note in the trumpeted Soviet economic reform. An open information system is very nearly the opposite. It thrives on exchanges. While entropy is running the clock down, an open system busily spins out new subsystems of greater complexity. The clock will run on them, but they are replaced by higher orders of complexity. Open system characteristics predominate in the system that encircles the design professions and construction industry. But you might be tempted to believe the entropy clock has run quite far if you compared sets of drawings for yesteryear's grand old buildings with a set for an ordinary recent building. The grand and old may have been built several hundred years ago from a dozen drawing sheets, while even the quick and dirty model today takes several times that. Is there that much more missing information today? Is the difference in those drawing sets the measure of entropy in the system? It probably is not. If the design and construction information system was a closed system, then I would answer, yes, that entropy was greatly advanced. In a closed system, we would be constructing basically the same building today as a century earlier in substantially the same way, and, if it took triple the number of drawings, that would be clear indication of enormous missing information. You would expect a highly disorganized industry. None of that is the case. The construction industry today is more highly organized than a century earlier, and its projects are increasingly complex. In its open system, load bearing masonry got transformed into structural steel or reinforced concrete, both with curtain walls, on to geodesic domes, onward to space frames, and out, we might predict, to delicately webbed cities sailing in orbit.

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Did I answer why there are more drawings? There are more because greater complexity has multiplied the potential outcomes, which design professionals endeavor to regulate by greater redundancy. Your chore is to battle against entropy (and other sinister opponents) within a worldwide construction information system busily spinning out ever greater complexities. And it all happens not in glacial time, but so luckily that the greatest complexity has developed in your lifetime. It must be very exciting for you. e. Something Profoundly Optimistic Ilya Prigogine, Nobel chemistry laureate in 1977 (nonequilibrium thermodynamics), theorized that (despite entropy) ordered information can arise out of disorganization in complex open systems, and he observed in 1979 to The New York Times: This is something completely new, something that yields a new scientific intuition about the nature of our universe. It is totally against the classical thermodynamic view that information must always degrade. It is, if you will, something profoundly optimistic. We will want to find a personal entrance for you into the profoundly optimistic behavior of complex open systems. Your entrance is not in the size or complexity of organizations providing architectural or engineering services taken either separately or combined. That system is minuscule in isolation. But complexity on the significant order required for profound optimism can be found. It is in the complex being that you are. Look for the door in the cognitive capacity of each person for billions of potential connections multiplied by the junctions possible with every other person. Your entrance is in the fields of mixed flowers discussed very near your next destination in Consciousness. f. Points of Information Information is everywhere in the paradigm, and, strategically, it is just before our time in the Consciousness. Information theory is the probability of your supplying missing information. Your consciousness embraces the capacity to see the measure of that and the many other uncertainties you face. The approach to quality is made when you act on your measurements of all the uncertainties you see to affect reality with careful, harmonious, conscious choreography. CONCIOUSNESS a. The Place of It The music in the quality paradigm is all single notes until they are written in a chord. The place of consciousness is to order the notes, record them, and sing the chord. If you would hear music from stone, steel, and glass, stand before a building you admire and ponder: Why does it stand? Why does it endure? What in it stirs my admiration? An explanation for its standing might be all laws of physics, its endurance all properties of materials, and the stir in you the emotive power of elegance or grace. In Departures, a journal ended by his death from cancer, Paul Zweig wrote that we live in a "double sphere of consciousness." The near shell is occupied with our immediate needs, "full
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of urgency, heavy with the flesh of our lives," but the outer sphere takes us, "into the future where we pretend there is time." Time in the outer sphere is our "experiment with immortality without which books would not be written and buildings would not be erected to last centuries." Pause here and listen. The human music is playing all around you. The building you admire stands and endures because it stood first and endured first in the consciousness of its designers and builders. The building was an experiment with immortality that has lasted long enough to capture you, and it was made into art within the private estate of your own consciousness. Between you and some remarkable people, perhaps now gone, a great building has been created. It is exquisite work. It might not have been great at all. A different consciousness by any one of you, and the building could have been ugly, dilapidated, or collapsed, but I thought you should be fortified first by beautiful music. b. The Working Parts Consciousness has the function to show us information inside and outside of our bodies, so we can order and evaluate it and instruct our bodies to act on it. Control over information is the hallmark of conscious beings. The leaves of the Silphium laciniatum plant line up in a north-south direction to catch the morning and late afternoon sunshine, while avoiding the damaging mid-day sun. It is known as the compass plant for its reliability at reading sunlight and answering its genetic code. The human nervous system has evolved more complex capacities. We are conscious not only of a perception of light, but also of the sensation of its intensity and color, the fact of the speed of light, the memory of a nap we once had in the light of a winter's day, anger at being awakened prematurely, the intention to install shades, the value of eyesight, the desire to write an ode to light. All these (perception, sensation, fact, memory, anger, intention, value, desire) are additional bits of information available to the conscious mind Consciousness exists when specific mental phenomena are occurring and you have powers to direct the intended courses. Intentions are bits of information which order other information in the consciousness. Intentions profoundly affect other information. Their effect is to reject information, rank it, interpret, synthesize, and order our bodies to action along particular paths. As a result, our consciousness is filled and continues to grow with intentionally ordered information.

c. The Self: Fields of Mixed Flowers All compass flowers will, in obedience to their genetic code, align their leaves on the light source. A field of them has no dissidents and, as a result, limited potential; however, each conscious being has the capacity to intentionally order information differently. The behavior that results may be quite dissimilar among individuals. There is danger in that, of course, when managed unwisely, but the potential combinations of thought and action can yield complexity on the scale of cosmic numbers. Here is your personal door to the profound optimism of complex open systems. The management of it is the key to its opening or its closing.

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Each human being carries an ordered set of information termed the self. It is the ordered set that tells you who you are. If a self set was read aloud in a crowd, someone would likely respond, "That's me, my identity! Where did you get all my private stuff?" That is how we would know whose set it was. The self is a private estate and by far the most luxurious you can construct. It offers you command over billions of potential mental phenomena, and, when opened to connections with others, you have immense potential. The self is a potent set. It is loaded with a lifetime of experiences: passions and pains, goals, values, convictions, and intentions. Information in that set is potent because it was ordered for the survival of the self ("That's you!"). If you do not remember ordering your potent set, it is because you had a great deal of help (some useful, some inhibiting) from family, school, society, and a very long, recorded genetic code of homo sapiens' experience on this planet. Information that threatens the self will set off a quake in the consciousness. Adaptive strategies are quickly implemented; consequences can be ruinous and range far. The threatened self has but a few possibilities and they are urgent, heavy with the flesh of life. Information that suppresses the self will cause a range of adaptations from passivity, resentment, to rebellion. We restrict our own opportunity when we initiate limitations in others, or when we fail to petition their potential. A thwarted self may find its final revenge in conformity. The point/counter-point between the proletariat and the withering state is: They pretend to pay us; we pretend to work. We are more at risk from another point and counter: They pretend to hear us; we pretend to think. d. Mixed Flowers: Our Door to Profound Optimism The door to profoundly optimistic complex systems is opened on the hinge of a consciousness free to act. If you think something very simple was just said, I join in your thought, but its simplicity gives no clue to the stubborn determination of people to confound it. The picture they make is a room full of them dutifully closing doors with one hand on the fingers of the other in their grim determination to discover what characteristic of doors is responsible for such excruciating pain. General Electric caught itself in a door of its own making when it decided in 1983 to massproduce rotary refrigerator compressors. The story is told on the front page of the May 7, 1990, Wall Street Journal. The reporter found that the product development phase was under severe time pressure to gain advantages over foreign manufacturers. Based on the lab test of about 600 compressors in 1984, mass production was commenced in March, 1986. Field testing was cut from a planned twenty-four months to nine. User failure reports commenced in December, 1987, about 21 months after production. By March, 1989, defective compressors had compelled GE to take a $450 million pretax charge for about 1.3 million compressor replacements. The lab testing had consisted of running prototypes under harsh conditions for two months. It was intended to simulate five years of normal operation. One GE testing technician of 30 years experience had repeatedly told his direct supervisors that he doubted the test conclusions. Although the units had not failed, there were visible indications of heat related distress: discolored motor windings, bearing wear, and black, crusted oil. None of the

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warnings to his supervisors (three supervisors in four years) were passed on to higher management. An independent engineer urged more severe testing, because there had been only one failure in two years. That was suspiciously low; the news was too good, but he was overruled. Examination of failed field units disclosed a design error responsible for the early wearing of two metal parts that, you guessed it, caused excessive heat buildup leading to failure. GE had declined to walk in the field of many flowers. It wanted an early success with every head turned the same direction, and it got that. But key cognitive connections were lost: GE had declined an offer of help from the engineer, who in the 1950s had designed the GE rotary air conditioner compressor; the testing technicians and independent engineer were not heard; no one dared insist on the longer field tests desired, because, "It would have taken a lot of courage to tell (the GE Chairman) that we had slipped off schedule." The senior executives, walking in the field of silent flowers, petitioned only good news. Lessons at GE were paid in money and prestige. The replacement GE Chief of Technology and Manufacturing was quoted on the lesson he took from his predecessor's experience: "I'd have gone and found the lowest damn level people we had...and just sat down in their little cubbyholes and asked them, 'How are things today?"' Well, everybody has a story to tell. Don't you wonder what is low and little about that place? Do you wonder who is damned there? After all that passed, do you suppose "please" is too lavish an offering for the door to profound optimism? e. Back on Our Drawing Boards Design professionals should mark well every door to the consciousness and install freely swinging hinges in both directions. You make your services out of judgments formed in the consciousness. The primary "things" that demonstrate their worth (the drawings, specifications, your advice) cannot be better than they are in the consciousness. I will allow that drawings and such can be checked. They could get better by checking; however, I hold to my point on the consciousness, because checking drawings is not like checking any other "thing." If you made ball bearings, all the information about their quality could be quickly known. Metallurgy would give the properties of the steel, laser measurement would test thousands of them as fast as they rolled by, maybe test a sample to destruction, and a bucket of bearings would be right to specification. But the quality of designs is not tested that way. Obviously, it is impractical to rely on a check of the final construction for proof that the design was good. A twenty-four month field test would have helped GE, but is an untimely control for you. Instead, a drawing checker looks for indications apparent on the drawing and in key calculations, perhaps, that the preparer met the standards for design. One consciousness checks what another has revealed about itself on paper. It helps. Two heads can be better than one here, but it remains a fundamentally different check and pass than you get on ball bearings. A laser sees every ball bearing the same way. One consciousness will not see the same drawing another consciousness sees. There is both benefit and mischief in that. Judgments in design develop one on another until what appears on paper may mask deficient work many steps back. The indications become less clear. Designs are not dismembered step

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by step when they are checked. Construction documents are not checked by duplicating the work any more than the knots in a Persian rug are tested by untying all of them. The point is, all that you do is tied in your private estate on strings of consciousness. You have the first and best chance at quality there. No one after you will have a slate as clean and clear. We will visit inside your private estate later in Putting the Paradigm in Motion: Learning to See, where we can explore what you might mark on your slate. Summing the Paradigm We readily and correctly credit glorious design and elegant engineering achievements to the finest work of our most able design professionals-to the most effective consciousness. To find the causes of failure in services that are based on judgment, we will reach closest to their roots in the dysfunction of the consciousness, where information, and the values, goals, and controls of the paradigm are ordered. THE FREEDOM TO ACT Reading the Race Reports The human species is a physically weak contender, but it has taken planetary leadership by exploiting, among other things, an enriched brain. Much is owed to the brain, yet our use of it is a paradox. Only a part of it is applied to outrun the surrounding Chaos. With that, we bravely pick our way through indifferent forces and cosmic coincidence. Another part we give over to constructing comforting race reports about the absolute security of our pack-leading position in the food chain. Entire firms, indeed whole cultures, issue themselves favorable race reports. We believe ours. We believe each other's when quite convenient. Smug satisfaction with our own race reports is unwarranted self-congratulation. By listening to them, we lose the freedom to act creatively, decisively, and effectively. We surrender to entropy in our information system by disabling our consciousness. We stun exactly the faculty needed for agility and proficiency. We are overtaken, outmaneuvered, and the prize is lost. a. X On the Reef And we can lose woefully. Those who are captains of firms take a lesson! Before there was the agony wrought by the Exxon Valdez, there was an opportunity to determine its rules of operation. The reasoning against allowing passage of super tankers from Valdez, Alaska, through Prince William Sound was to many minds convincing, but it was finally silenced under a thick blanket of government and oil industry assurances of extreme safety, profound expertise, and good intentions. There was to be virtual "air traffic" quality control over the sea lanes beginning in 1977. Why that was a comfort at the time remains a mystery. Years without fatal incident were sweet succor. Every player, from ship's captain, Exxon president, Alyeska, and the State of Alaska to the Coast Guard, readily accepted obliging race reports. Bligh Reef wasn't one meter further out of harm's way, but the consciousness had new information: The shoals near Bligh Reef had been passed hundreds of times without incident; no oil tanker had been holed in Prince William Sound; the oil fields drained into

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Valdez, Alaska, had peaked, and the campaign was on the down slope side of economic maturity. At Exxon and Alyeska, that information was ordered by intentions to improve profits. Equipment and manpower were cut, safety and cleanup systems were disabled, and the surplus was siphoned to a thickening, black bottom line. The Exxon Valdez had clear sailing as far behind as the eye could see. Bligh Reef waited. If the cosmos played at tag, its mechanics must have watched rapt, while, on March 24, 1989, Bligh's prize was delivered by current, wind, and human fallibility heavily laden and hard aground. The Exxon Valdez, gorged with obliging race reports, belched sickening defeat. Are we unfair to Exxon and the Exxon Valdez? Couldn't they, after passing Bligh Reef and clearing Prince William Sound safely time after time, prudently lower their concerns and preparations? They could not, because each passage was an independent event. The conditions on one passage were not the same as the next. Variables of sea, weather, and crew preparedness were different for each, and they were different on March 24th. Only Bligh Reef was unchanged. Belief in Exxon's race reports was no more prudent than your using the same soils report for all projects on Main Street. Repeated success with similar independent tasks enhances the qualifications for the next attempt, but it does not suspend the hazards encountered. Architects and engineers, who have designed this or that project type dozens of times, may have paramount qualifications for the work; however, they have not suspended the hazards. Success talks, but it can speak praise we should not honor. b. Controls for the Barely Conscious What sort of controls are expected from people slowed by their own race reports? People intent on the rear view mirror need a great deal of time to act in response to controls. They do, but they don't know it. They are cozy in a closed information system, free from the perception of uncertainty and blind to the possibilities. Aboard the Exxon Valdez, it was a control that the crew shall: "Call the Captain's quarters for instructions abaft Bligh Reef." As a control, it was designed to give the Captain notice of the approaching reef and an opportunity to give his instructions. The goal was apparently to pass Bligh Reef without bloody running hard up the back of it. How do you rate it? Some use a similar control: "Check the drawings before release to construction." That is a point on your chart just abaft Release Reef. The control increased the Captain's time and opportunity to act in one way. It gave him a single point in time to check where the Valdez was in relation to Bligh Reef and the same single opportunity to correct his course. Next stop: Bligh Reef. It was not a wise choice among so many better ones. For example, "The captain shall remain on the bridge until Bligh Reef is cleared." The time and opportunity to act is increased, and there are bonuses here: The price for a captain on the bridge is the same as a captain in his quarters; a captain at the helm more likely has a consciousness alive to the hazards than a captain on the bunk.

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Would you add a ship's pilot to Exxon's quality program? An expense authorization from Exxon is needed for that. The time for it was in 1977, when the goals were settled. It is too late now, of course. Quality is built into a project at its beginning, if at all. c. Summing the Entropy Oblige Cosmic machinations made Bligh Reef the winner by patient waiting, but not you and me. Humankind is competition against Chaos only as the eager, agile beneficiary of a remarkable ability to remake itself by adaptation. The ability to add experience to the consciousness, indeed, to add gainful adaptations to a flexible genetic code, are qualifications for planetary leadership. We are not obliged to listen to the siren's song of numbing contentment. We race against the sands of time. The freedom to act is power to our legs and mind. Powers absorbed in issuing and receiving obliging race reports collect sand. Silica petrifies us; we slow, then we die. Shaking the High Wire a. Entrustment of Judgment Workers The manager aiming for quality results needs to take care with the people entrusted to the project. We speak carefully here. People are neither entrusted to the manager, nor is the manager to take care of them. Judgment workers are committed to the project, and they take care of themselves. Design professionals are judgment workers. They typify the workers fast dominating the kind of labor done in America. Specific qualities recommend them. Judgment workers are distinctively goal directed, highly motivated individuals, who have arrived where they are by selecting ever more demanding and specialized careers. Their paths were deliberately chosen, and the personal stake in them is high. They are the guardians of their own investment in values. Paths of action supporting personal goals and values are beneficiaries of their personal stake. Contrary paths clash strongly with the potent set, which can initiate conflict and ultimately threaten the self. Unclear or conflicting goals can create conditions of siege. Care was justifiably taken to say that judgment workers are more likely committed to a project than a "boss," and they take care not of themselves. Please note: That statement is not in the least equivalent to, "They look out for Number One." More often, the people I describe will inflict substantial penalties on Number One for the benefit of the project. Whether management receives the benefit it seeks from their work depends on the care management takes in its tasks. A firm of consistently and skillfully managed judgment workers can achieve wonders. A firm managed with discrepant values, goals at cross-purpose, or with conflicting information can set loose its own Golem. b. Seventy-four Seconds in Tribal Time The seminal experience in failed engineered systems was thrust on the world by a project honored with stunning successes. The launch disaster of the space shuttle Challenger on January 28,1986, the twenty-fifth shuttle program launch, was all the more shocking because of its management and engineering reputation. The presidential commission convened to

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investigate the Challenger disaster concluded that both the launch decision process and critical rocket hardware were flawed. The facts showed that, while Challenger was fueled, manned, and ready on the launch pad, Morton Thiokol booster rocket engineers raised a launch safety issue with Thiokol management. They had observed on previous launches that the synthetic rubber O-rings sealing the joint between two lower sections of the solid rocket booster had been damaged by hot gases escaping from gaps around the O-rings. The damage was most pronounced on cold weather launches. If launched as scheduled, Challenger would make the coldest test yet; there was potential for disaster. The position of the dissenting Thiokol engineers can be well appreciated. NASA launch safety procedures required a "Go" for launch from Thiokol. The issue raised by the engineers had consequences, not only for the immediate launch but also for the safety assessment of all prior launches, future launches, and Thiokol's reputation. The commission disclosed that there was debate. There was consideration of information. Ultimately, the engineers would report experiencing a shift that put them on the defensive. They would say it was as if the rules had changed. Previously, the control on "Go" for launch was, "Prove it is safe, or do not launch." The Thiokol engineers in the Challenger launch circumstances perceived a new control: "Prove it is unsafe to launch, or we launch." The consciousness of Thiokol's management was not swayed by the debate or by data that could be marshaled while Challenger waited. Finally, the engineers were asked by management to, "Take off your engineering hats, and put on your management hats." In only a short time, the engineers withdrew their safety issue, and the Thiokol "Go" for launch sent Challenger into space history. c. Obviously a Major Malfunction Just the thought of beginning the discussion is daunting. The events are close and emotional. This and all the cases here exacted tragic costs. Still, we are seeking lessons, and the learning of them is a small repayment to history. The strong intentions expected from goal driven specialists were evident in the Thiokol engineers. The space shuttle program is an ultimate specialty. There is one and one only. The information they had (previous cold temperature, O-ring damage, and it's even colder now! ) got channeled by strong intentions for safety right to the top of Thiokol. That could not have been pleasant. Playing the rock in the middle of the road resists other strong information in the self: intention to be loyal to the firm, intention to support coworkers, intention to advance one's career, and intention to support prior launch decisions (when no warning was given). After twenty-four successful launches, the potent self risked a considerable setback by speaking out. The warning was spoken, and, importantly, it was given in response to a perceived control: "Prove it is safe to launch, or do not launch." That was the discussion the engineers expected and were prepared to have. But the discussion and the control were reversed. The engineers would not likely win the case, "Prove it is unsafe," because the consciousness plainly did not prepare and order the information that way. You can hear the consciousness scream, "It's a little bloody late to change the rules here!"

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Management shook the high wire. Now, there were key judgment workers off balance. The Thiokol team had reduced effectiveness. Now, the Golem was set free. Changing the rules on the high wire has unsettling effects. There is new information in the consciousness: Management is inconsistent, management is unfair, management doesn't trust me, and I just might fall from here. The potent self gets punched hard when the rules are abruptly changed. When the O-rings were not proved unsafe, Thiokol's management asked the engineers to think it over, but, this time: Take off your engineering hat. Put on your management hat. We cannot pry open the engineers' consciousness to find the twisted metal memory of that moment, but we can analyze the conflict provoked by such an instruction. We honor a prohibition in arguing cases to the jury. The rule prohibits any attorney from arguing the Golden Rule. Counsel for plaintiff may not urge the jury to put itself in the plaintiff's shoes and decide for the plaintiff what the jury members would want decided for themselves. Defense counsel can't argue the Golden Rule in the defendant's shoes, either. Why it is a rule is easily tested on this whip lash case: Ladies and Gentlemen of the jury, if you would but put yourself in my client's shoes, paralyzed, numb to the world of feeling from the neck down, cut off from hope for any normal life, a tormented head condemned to ride a dead body to its death-if you would do that, then, this is the question I ask of you, "If you were this person, what would you want your jury to do for you today? How, from this position, shall a juror satisfy the duty to hear all the evidence and fairly decide the case bearing no prejudice to either side? I know I want the money, lots of it, and so do you! There may be saints (or are they brutes?) unaffected by the argument, but the system of justice does not chance it. Next try the fit of this: Engineer, take off your engineering hat and put on your management hat: If you were faced with aborting this space launch in front of the world today, and, if you would then be required to face the press, NASA, Congress, and the President of the United States to explain why the Thiokol rocket is unsafe, what would you want your rocket engineers to do for you today? These words, of course, were never spoken, but, under the circumstances (Challenger waiting at the "Go" line for a Thiokol release, the potentially embarrassing safety debate unresolved, the immediate need for a decision), prudent systems of management (like prudent systems of justice) do not chance the consequences of shaking the high wire in that way. Remember what is included in the potent self set. Here are the values, goals, hopes, loyalties, ambitions, and desires. Shaking a person there sets the high wire into wildly accelerating waves. The person either holds on against wave after wave, or he lets go of the position. And if the position is abandoned under pressure, what has management tested? Has it tested the merits of cold weather O-ring integrity? Does the question somehow clarify the

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understanding of any properties of O-rings and the behavior of combustion gases? Could it ever? If it couldn't, is it sensible to put the conflict into another's consciousness? And if the position is abandoned, is a new set of values installed that, because of a narrow reference as an engineer, could not be seen except by playing at management? Could it ever? The instruction does one thing: It abruptly tests whether or not a person for that moment valued agreement with management, the tribe, the hunting lodge, to such an extent that it would override confidence in a contested engineering judgment and the intentions that ordered it. That is galling in the extreme; hold on to it for the lesson taught in architecture and engineering. The control, "Prove it is safe to launch, or we do not launch," supports the goal, "Safety First," and the value premise in the lead of that is: Human life is good. Try that brief metaethical exercise yourself, beginning with the control, "Prove it is unsafe to launch, or we launch." Play the notes back from control to goal and search out the value premise in the lead of it. We will wait here for you. Are you back? Now, try it again with the control, "Prove it is unsafe to build, or we build." Did it take long this time? The test result in this instance was that Thiokol engineering did value more its agreement with Thiokol management, and it took momentary solace in that agreement from the 24 prior launches. A key engineer remarked later, "We may have gotten too comfortable with the design." You can hear silica replace key carbon cells in the registration of obliging race reports. Entropy unchecked had progressively disordered the boundary between a safe and an unsafe O-ring design. Framed in ghostly margins, a man pitching on the high wire could just make out a "safe enough" design in a thoroughly bad one. By all of that, Thiokol had progressively reduced its freedom to act. The opportunity to save Challenger was lost. d. Little Boxes, Bureaucrats, and Children The presidential commission was besieged by a NASA and Thiokol technical polemic on performance of the O-ring in cold weather. The seventy-four seconds was presented as indecipherable coincidence and accident, but Richard Feynman, Nobel physics laureate in 1965 (quantum electro-dynamics), finally cut to the chase. Feynman dunked a clamped piece of the synthetic rubber O-ring into a glass of ice water to simulate the preflight conditions. The material did not rebound; it could not fill gaps in the cold. Misjudgment had entered there through bare millimeters. Golem was Challenger's eighth and its fatal passenger. Test and hearings done, the commission concluded that NASA must rework its launch procedures to encourage a flow of additional information from more people directly into the launch decision.

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NASA broke up some of the little boxes. That helps. The DC-3 aeroplane was designed prior to 1936 in a hanger without walls between the engineers, wing, tail, instrument designers, or anyone else. When you wanted to know something, you walked over to the person doing it, and you displayed what you were doing. But there is a question bigger than little boxes: Whose stock was raised and whose fell by this quality disaster? The key engineer, who rose to answer the launch control, fell; he lost his job. The one and one only space shuttle program is over for him. Thiokol, however, is busy today making more NASA space shuttle rockets. Yes, everybody has a story to tell; it turns on a question of economics, they say. It turns there, but it twists and it contorts before us on the values exposed by behavior. Children can figure the lesson, and they do. e. But I Would Never Shake the High Wire Actually, I don't accept that, and you don't either. There is motion in all high wires. Some anxiety makes the trip interesting, and judgment workers will seek unsettled circumstances for the challenge in them. Challenger's circumstances are dramatic to the point of exhaustion, but the high wire sways for people in more ordinary circumstances: The project architect or engineer trying to meet a release date or a budget, leading the largest project ever, leading a project gone sour, managing the new department or profit center, opening a new market for the firm. All involve a critical test of the self. Although tests do build strength, time on the wire is taxing. An individual without options may implement self-protection plans harmful to quality: Ignore unfavorable facts that would draw criticism, leave problems unreported to avoid early judgment, end or abbreviate the professional service when the schedule or budget is exhausted just because it is too great a hassle not to. Problems may not surface until the freedom to act is largely lost. How to send a call for help with immunity from a self-damaging counterstrike is key to keeping people in balance on the wire. f. Getting Help on the High Wire Auto assembly line management uses a technique that I like. By it, management determines, with input from workers, what tasks can be done on the car at a "station" limited by two lines painted on the floor. That puts the worker on a wire. Auto carcasses are run between those particular start and goal lines, parts are lifted, placed, fitted, and fixed one after another. Ready to start? Action! Cars are rolling, and parts are fitting quickly, tightly. It's going well, and we are making good cars today, but what happens when the worker sees that a carcass might skid across the goal line before the assigned work is done? Are we going to lose another one off the wire? Will I get the leaky windshield, will you get the magic self-opening door? Not this time. The worker will hit a button that sounds a horn, and the horn will tell the floor section foreman to get on the line and start slinging parts. Bravo! What I like most about this is not that both management and workers contribute to goal settlement (one good idea); it is not that management pitches in (another good idea); what I

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like is that the horns go off routinely. People use them, and that says the people have trust. That's what I like! You are on a high wire. You will put other people on high wires. None are afraid of heights, and the view up here is exhilarating. You can see buildings from here that will last for centuries. And they will, too, if every high wire you construct has a safety valve people trust enough to use regularly. The Focus Filter The consciousness operates full time, unless it is turned off by sleep, injury, disease, or death. While we are conscious, we have the power to receive and order information. The raw potential of our consciousness is great, but it does not mark the boundaries of our actual consciousness at any particular time. In the 1930s, researcher Jacob Von Uexkull applied a technique in environmental studies for framing what the animal sees in the environment. Whereas, in oversight, we see the animal in the environment, the individual animal perceives the Umwelt or the self-world. As planetary leaders, we are accustomed to seeing the environment, and we easily assume that is our world. I think we do that because we claim a victory that allows us to survey from the top of the hill. In fact, we have the greatest need to see ourselves within our Umwelten. All the information an individual perceives about what is happening at a particular time is, for that moment, the individual's Umwelt. It is the world perceived, or the self-world. That you are in your Umwelt necessarily means that you do not see the environment. The self-world for one person differs from any other's. From place to place and culture to culture, the differences cause people to see separate worlds in the same space. The Inuit peoples hunt vast Arctic grounds without maps pasted to their sledges or kayaks, and they continue the hunt through the long winter even without a reliable sun fix to guide them. Take a long trek with a hunter, and figure how to return. While you and I are looking for North, East, or for Silphium laciniatum compass plants, the Inuit hunter has taken account of the direction of the wind monitored by the motion of it on his fur hood. He has noticed the ocean currents, memorized the color of the ice and ocean, the texture of the snow. You are lost in an Umwelt ended at the tip of your nose. The Inuit hunter wonders how you lived so long in your land and surmises everyone there is starving. Back home, your Umwelt is larger, but it is still a source of troublesome flux. You concentrate on one thing, and you miss a message on another. There are ten things on your mind, and your consciousness is busy swapping intentions to let some information in, ignoring other information, and misunderstanding the next message. Your focus filter is making efficient use of your attention, or so you think, if you are aware at all. Does your Umwelt for the critical instant encompass the clues you desperately need? You can't feel very confident. Just a minute ago you were as lost as a baby in the Arctic, and now there is something strange about your office.

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a. Do We Know What We are Doing? That question reverberated in the aftermath of the pedestrian bridge collapse at the Kansas City Hyatt Regency Hotel, and it tolls still. One hundred thirteen people died from it in July of 1981. Design professionals are urged to that particular question, because the infamous changed bridge hanger detail staring at us from an orphaned shop drawing is exactly the kind of puzzle they are deft at solving. Briefly, because it is everywhere reported, the design for suspension of the two stacked pedestrian bridges called for a hanger rod passing from the building roof trusses through the floor beams of the upper bridge, where the rod was connected, and continuing through to the floor beams of the lower bridge for connection there. Notice that the load on the upper bridge connection is the weight of the upper bridge. The load of the lower bridge is on the rod. Hold on to this: One rod means one load on the upper bridge connection, which we will call Connection "A". The lower bridge hangs on the rod and not on the upper bridge. A steel fabricator's shop drawing was generated, which changed the design by calling for two rods. The first rod passed through the upper bridge floor beams, where it was connected, and that is Connection "A". So far just like the first design and the same upper bridge Connection "A" has exactly the load put on it by the original design-one load. But, a second rod was started next to the rod just connected, and it was passed through the lower bridge deck beams where it was connected. Trace the load again. Now the lower bridge is connected to the upper bridge. The load that stayed in the rod on the original design was now hooked onto the upper bridge. As a consequence, there were two loads on the upper bridge Connection "A" and the bridges failed when the rod pulled through the upper bridge deck beams. That is the "Double Load" reason the bridges failed. b. Whose Umwelt and How Big? The original design was engineered by the project's structural engineer, but the shop drawing was produced by a steel fabricator, and it was not checked by the project structural engineer. You might expect a quick clear answer to, "Why not?" if you were from outside the industry. People in the profession know the answer doesn't come so quickly, and that is why the question applies, "Do we know what we are doing?" It is the practice that steel fabricators detail connections. I think that is because people believe it saves money. It is the practice that architects and engineers check fabricators' shop drawings for general compliance with the design concept, and that check is not always done by the original project structural engineer. I think that is because people believe it saves money. I also think it means that, in the rush and complexity of a design and construction project, there is a somebody who may not focus on the exact information needing attention in the precise way that will help. Our Umwelten all have different coverages. There are gaps in between, and the Golem hides in them. The size of our self-world denies our consciousness access to the signs that need reading, we miss the color of the ice, the wind confuses us, we lose our way, and the world comes down all around us. It would kill an Inuit hunter, and it kills us.
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Engineers and their advisors know that design changes are a major source of uncertainty. It is a place where one party's intentions acting on a design ordered by another's intentions may well block the objectives of both. Two heads are not better than one here. The engineer, fabricator, and contractor are not in the same DC-3 design hanger, so none has ready access to the others' consciousness. Their intentions order information differently, as they are not agreed on settled goals. The engineer, here, intended a hanger with simple, but specific load bearing characteristics, hence a one rod/one load system. The contractor may have perceived that stringing a long rod through two bridges was cumbersome. The fabricator and contractor may both have wondered how to thread a nut at the upper bridge connection, as you can't push a nut over the unthreaded part of the rod to its middle. The shop drawing intended to answer those issues by a two rod system. Right there in the gap was a two load Connection "A", which entered no party's consciousness. Had the information been ordered by consistent intentions acting on settled goals, construction could have been accomplished simply. Safe suspensions would have sustained life. All the two rod objectives could have been answered if the two rods had been joined together by a commonly available sleeve nut rod connector at or near Connection "A" to preserve the specific one rod/one load result intended by the engineer. c. You Will be Blind if You Look Where the Golem is Not You do not see the Golem unless you are looking for him-right now! When the Golem is outside your Umwelt, it is outside the world you know. Feel the limits here; rail bitterly against them; but the mischief is your own. Planetary leaders blind themselves by failing to anticipate the need to expand their self-worlds or by their immersion in an irrelevant field within them. All of our empathy begs for a second chance: (1) to express at the outset that design changes order information by different intentions along goals that are not uniformly settled, (2) that changes will mask neglected risks, (3) therefore, to install a control that all proposed changes shall be personally reviewed, rejected, or approved by the original engineer in whose consciousness we expect to find the intentions that will order information in time to give us the freedom to act. We can learn to read ice, and, if we expand our self-worlds to include reading ice when only the clues there will save us, we stand a chance at getting back home with some reliability.

Do We Bias Ourselves against the Future? We are more likely than not to scorn people who call out our errors. They have "20-20 hindsight," and it is easy for all to see what is apparent afterwards. Because we are all technically blind in the future, we exist in cramped empathy with people who are smacked hard by it. We are all in the same boat, I suppose, but should we be content to book passage through time with those who dare without proper preparation to affect reality for centuries?

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a. Markers in the Consciousness We are all time travelers in both directions. The past is our reservoir of experience; the future is our uncertain dominion. We travel a brief span of reality measured by the time we spend in it. No fare is collected, and no itinerary is posted. But you are not content with that. No reason for architecture or engineering exists, unless reality is changed by it. You are a traveler in reality bent on changing it. You are not alone. Before you, travelers bent on discovery of new lands made the legends we studied and admired in school. Who did not aspire to an explorer's life? Geographers know that exploration begins before the ship weighs anchor, and explorers never quite escape the exotic territory of the human mind. Exploration, teaches geographer J. Wreford Watson, is a process beginning in the imagination with preconceived ideas about the character and content of the lands to be found and explored. Explorers place imaginary markers on the land before one foot is set on it, and, once there, interpret what is seen to verify the markers sent conveniently ahead. What we observe in new lands, Watson teaches, is neither new nor correct. Rather, what we see is a distortion "compounded of what men hope to find, what they look to find, how they set about finding, how findings are fitted into their existing framework of thought, and how those findings are then expressed." The bodies of more than a few explorers are buried in a reality more strange and harsh than the one imagined or reported by the first to arrive. b. Claiming by Markers We carry our reservoirs of experience forward by placing markers ahead of our actions. Design professionals look ahead to the next project, and they imprint the expected reality of it with markers from their experience. I think explorers place markers for the want of courage to meet the unfamiliar with their lives. I think it is merely expedient for us at home. It is our way of fitting new realities into the garrison of the familiar. Whether the familiar will imprison our creativity or marshal a new and finer order depends on the preparation of our consciousness in that exact instance. If we send our imaginary markers, as Watson would warn us, compounded by what we hope to find, what we have decided to find, what within our existing framework of thought we are prepared to find, then, we will not claim new territory. There is no conclusive trepidation in that. The essential and cheerful point is that we can distinguish reality from our imaginary markers. The garrison of our experience will not acquit our comfortable conjecture if the consciousness is prepared to discover and reject all counterfeit reality.

PUTTING THE PARADlGM IN MOTION: LEARNING TO SEE What exceptional powers have the complex and wonderfully adaptable beings that we are. But how timid and awkward do we approach our potential. We are hunters who turn prey at our own hands. We build our own versions of a human consciousness by inventing our self,

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our self-worlds. To our great dismay, we do not always build wisely, and our maintenance can be shabby at best. The Self Estate If I have occasionally made the self sound troublesome, dispatch that notion. Thomas Edison said he grew tired of hearing people run down the future, as he intended to spend the rest of his life in it. Your time in the future is in the self and the consciousness you construct. You have need of a strong and orderly estate. The self has been much theorized, amplified, anesthetized, and penalized in philosophy, science, and society. We humans seem at times astonished at our capabilities and, alternatively, fearful of our potential. You may study the books yourself and draw your own conclusions about which ideology's sound you favor. We bark for no dogma here. We look instead for what will help us increase our freedom to act. For it is the freedom to act that powers the quality paradigm. To command that freedom, we need to know what labor our consciousness performs, collect the sweat of it on our faces, and feel its exertions as experience. We need to conserve our values and tie goals and controls in harmony with them. We need to chart the limits of our Umwelt, feel the weight of information and give good measure in it, and know the dysfunctions that inhibit our performance. Plainly, we will never complete the task of mastering all of that, but we can open our consciousness to secret possibilities and make at least a few breathtaking leaps through reality. a. Splendorous Estates Ours is first among all species for the time and energy spent in preparation, and our aspirations have propelled a pace of change that may predestine us all to a constant state of refitting. That would be a fine destiny, indeed, one well suited for planetary leaders. It is entirely suitable for any person bent on changing the planetary reality, even by adjusting a corner of it on Main Street. The point here acknowledges but moves across your constant technical preparation: The point lands in your private estate. There, you are made guardian of your values and goals, and you determine the paths you will follow; there, you install controls on your progress along settled paths; there, you experiment with immortality, and you plan to change reality, perhaps forever. Do you marvel at the splendorous potential of your private estate? Look at the rooms, the library shelves, secret passages, doors to cryptic codes unbroken, and the plans, dreams, the flying machines! No one else has an estate quite like it! It is no wonder Strauss has appeared suddenly to conduct Also Sprach Zarathustra just for you! Tell us Guardian: What will you build from all that wonderment in our shared reality? Concentrate! Strauss is on tiptoes; poised, baton waved high; the music soars here! This is your moment: Yours is the next breathtaking leap into reality leaving changes in stone, steel, and glass, perhaps forever! The doors to your estate fly open; the light from a billion possibilities is brilliant, but the music fails, it fades, and a critic looks back on you from your own shoulder. You can't stop it. Reality is sobering; there are doubts in the approach to it, and there ought rightfully to be. Reality is, finally, a splendorous place only for the people who are first prepared to leave their private estates and earn a place in it.

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b. The Concern of Self There is no single way of preparation, but none will escape the need to travel paths in that direction. I offer you a recommendation from my time spent visiting disappointed estates and on the grounds outside fitting back the pieces of broken realities. The classical Greeks postulated a self that held but the promise of attaining credentials fit to affect reality. The promise would be unfulfilled unless the individual undertook the obligation to prepare and care for the self that it would be made and remain qualified to venture into reality. The guiding, early Greek principle was, "Take care of yourself." Scholars teach that meant that you were to undertake the care of yourself as a central obligation. The philosophy obligated the individual to take guardianship over the self estate. To accomplish your care, you were necessarily required to see yourself as a figure of some central importance. Over time, that Greek principle got into the same kind of trouble the Sun had at the center of the solar system, and both lost ground in the fierce competition for the heart of mankind's proper concern. "Take care of yourself" and its corollary, "The concern of self," gave ground to the more accommodating, gnothi sauton, or "Know yourself." Scholars teach that "Know yourself" had a different point: It was ecclesiastical advice of the time meaning, "Do not presume yourself to be a god." Good advice for this time of day, as well. But, as the Sun was restored to a working position in the solar system, perhaps we may find useful employment in our time for the Greek concern with the self. Askesis Back to the Future The philosophy has technique. Askesis is a discipline to prepare the novice human being for reality. The techniques of askesis train the self. In the Greek, the objective pursued is paraskeuazo, "to get prepared." While adrift in a neophyte consciousness, you know neither yourself, nor do you know reality. You are unprepared to take your place in reality. But you become prepared by the acquisition and assimilation of the truth about yourself and about reality. All of that is knowledge necessary for you to take care of yourself. Do not draw the conclusion that the concern with self can be called self-centered as we use the term today. Askesis sought to train the ethical self. Its training led to the assimilation of truth, and its practice tested one's preparation for doing what should be done when confronted with reality. The first note of the paradigm, the value note, is everywhere evident in the askesis. Greece was to get a healthy Republic out of the healthful self. a. The First Discipline Melete: The Premeditatio Mallorum The askesis is a philosophical tradition in two parts. The first part is melete in the Greek or meditatio in the Latin. Melete is the progressive consideration of the self performed by contemplating anticipated situations, then engaging in a dialogue of useful responses, arguments, and courses of action.

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The meditatio is a "what if-then this" inquest of the self. Accomplished alone, it is a meditation; with another, it is Socratic exchange: I foresee something. What will you do? I will do this. Why? Because it will do some good. But, is that enough? I believe it is. But, I foresee something else. And on it goes. The meditatio is especially commended to judgment workers, whose thoughts (unlike ball bearings) cannot be readily measured and whose flaws, if not detected by themselves, may be unperceived by others. Judgment workers are the guardians of their own values and goals, but they are fiduciaries of precious parts of the reality we all share. Before our shared reality is changed forever by what is put there, people who bend it by their intentions should test the consequences first on themselves. You do not need more examples of that. Those who pursue the classic, premeditatio mallorum, pursue training of the ethical self. It is preparation that increases the freedom to act by forcing upon us images of the future misfortunes we will wish to avoid. It teaches us to see the Golem. The discipline develops three eidetic (cinegraphic) reductions of future misfortune: FIRST: Imagine your future, not as you believe it will be, but imagine the worst that can happen in your future. Do not temper the images with what "might be" or "how it happened once before," but make the worst case imaginable for yourself. SECOND: Imagine not that this will happen in the future, but that it is in the process of happening now. Imagine not that the shop drawing will change the design, but that the shop drawing is being drawn, that it has been drawn, that the steel is being fabricated, that the steel is being installed, that the building is occupied, that the connection has failed. THIRD: Engage in a dialogue to prepare your responses and actions, until you have reduced the cinegraph to an ethical resolution. Do not conclude the dialogue until you are prepared to do what should be done when faced with the reality of what you have imagined. Herein are tested the responses: I am not responsible for changes; someone else is responsible; they are supposed to tell me about any changes first and send me calculations; they are engineers, too; I wasn't hired for steel detailing; my review is only for general, not specific compliance; I look at every steel shop drawing they send me; there is only so much time and money for shop drawing reviews; the building department approved the building; I did what others would have done. Common precautions and plans may not allow an eidetic reduction of your future misfortune that can conserve your values and meet your goals. Perhaps, what you are about is not common, or, if common, it holds peril for many lives. Then, try repeated reductions with new precautions until a satisfactory resolution is achieved. This can be unsettling work, but

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harness the agitation you feel. It is an antagonist you call voluntarily to your cause. Feel the weight of that critic on your shoulder. People unwilling to deliberately disquiet themselves will refuse the proportions of a future misfortune or will dismiss it for an uncertainty of occurrence, but that is not an eidetic reduction. That is denial, and denial is not preparation. When you are prepared to affect reality, you will see the Golem, and you will be prepared to do what must be done. Your preparation will reveal the Golem wrapped in the twisted metal moment you cease conservation of your values. What you are permitted to access by the discipline is an unacceptable reality at no loss to life or property. It is an opportunity to check your values, settle your goals, install controls, and prepare yourself (including the potent set) with the intentions that will order and encode information and instruct actions thereafter to reduce future misfortune. As the result of living the premeditatio mallorum, a structural engineer might decide to review a steel shop drawing for each and every load-bearing connection in a suspension bridge, which he will check off on the structural sheets one by one. A design professional could discover that stacked, suspended, pedestrian bridge designs carry significant missing information and make the decision to increase the probability of the information furnished achieving the intended outcome. Drawings and specifications might encode copious redundant information to limit the possible outcomes. That might be done even for the absurdly simple design, because the consequences of a failure are too great to risk. Perhaps, the eidetic reduction of future misfortune can be handled in no other way. With this preparation, ice can be read and understood, and hunters will return to their families. b. The Second Discipline Gymnasia: To Train Melete is work in the imagination, and it prepares one to affect reality by fortifying the consciousness with information about intentions, anticipations, and future misfortunes. Gymnasia is work at the other end of the spectrum, where there is training in real situations. Training, as I believe you know, is not what is done in school. Students go to college to study for the same reason people go to banks for robbery. Money is kept in banks, and college is where theory is kept. If done at all, training is begun and continued in practicing firms actively affecting reality. New practitioners, if ready to work, are not prepared to affect reality. Gymnasia contemplates that training will be in real situations, even if they do not directly affect reality. That is one function of reviews by seniors and making experienced minds available to curious beginners. It is the business of finding and sustaining curiosity. Gymnasia teaches the premeditatio mallorum to give the novice a view, even if pessimistic, of the reality as it might be for a slow or careless apprentice. Take note that people who do not train at the premeditatio "if this-then what?" are frequently seen playing at the less effective self-care exercise, "If only we had-well then."

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THE CASE FOR OPTIMISM There are hard lessons for us and much work undone here, but even as we sit among the broken dreams and scattered flying machines, the case for optimism is at hand. Which Path is Chosen: Whose Fields are Crossed? Much stock is put in the individual here. Have you asked yourself what was done to teamwork along the way? Teamwork was not buried here. I think it was improved. People who are individually prepared for quality results are both candidates for leadership and worthy contributors to a team aiming in that direction. Prepared individuals can settle on team goals and the paths to them. They are more confident of their attainment, because they are individually and intelligently committed to the goals and paths traveled. The ideology of the submerged individual slogging along to forced songs fades now. The Internationale does not muffle the cries of people who will not bear repression. The fierce focus on the competition between ideologies is fading. You can read Winter and worry on the faces of the remaining ideologues. The immediate season is entrepreneurial Spring. And you can foresee the doors to profound optimism opening there on more hinges of consciousness free to act than ever before. The good of that is the better work our species does under those conditions. Abraham Lincoln knew that when he mused in a diary in 1861 on the success of the American experiment with the individual's freedom: Without the Constitution and the Union, we could not have attained the result; but even these, are not the primary cause of our great prosperity. There is something back of these, entwining itself more closely about the human heart. That something, is the principle of "Liberty to all"the principle that clears the path for all-gives hope to all-and, by consequence, enterprise, and industry to all. Basler, ed., Collected Works of Abraham Lincoln, IV, 168-69. The paradigm led to Greek philosophy and now to Mr. Lincoln by tracing the lineage of its subject. You have been our subject. When the path chosen starts there, its course passes through a philosophy that would put a piece of the Republic's fate in your estate and make you its guardian. We stand on good ground with that, because quality comes from there. Judgment Workers on the Path to Enterprise The attention to individuals and their achievements has given us insights into how some people get into step with the choreography of quality. Psychologists and researchers in this relatively new field have offered observations about the highest achievers: 1. They are able to transcend previous comfort zones, thereby opening themselves to new heights of achievement. 2. They are guided by compelling goals they set themselves. 3. They solve problems rather than place blame. 4. They confidently take risks after preparing their psyche for the worst consequences, and they are able to mentally rehearse anticipated actions or events beforehand. 5. They routinely issue "Catastrophic Expectations Reports" to themselves, against which they refine and rehearse countermeasures.
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6. They are able to imagine themselves exceeding previous achievements, and they issue themselves "Blue Sky Reports." 7. They do what they do for the art and beauty of accomplishment. There are other attributes of high achievers, I am sure, but this list is a fair mirror to reflect in. As you reflect, return to the askesis to test the durability of its traditions, and consider (with a nod to Mr. Lincoln's own reading list) whether the Greeks of antiquity were not correct after all to care for the self that the Republic might enjoy great health . Carry What You Think Will Last I hope you read more philosophy and art in the paradigm than procedure, for, unless you do, no good may come of it. Managers, who, by this time, may wonder how to get their judgment workers to rendevous with quality, are about to walk away from the philosophy of it altogether. The paradigm has space for all, but it has no separate rooms. Everyone must look to the care of the self that the firm may prosper. No one has permission to go blindly and unprepared into the reality of the next project. Not from the leading principal to the neophyte is anyone exempt from preparation to figure the probability of missing information and give good weight in it, to test false markers, or to lay first eye on the Golem. The philosophy of the paradigm is in the pursuit of quality as an ethical odyssey. Those who achieve and sustain high quality are in that chase. The art of it is in the happiness men and women attain from the work of architecture and engineering when they are prepared to affect reality in a way that has timeless beauty. Paper Tigers What place is there for the procedures, the checklists, and the standards that are the common mainstay of quality management? Yes, paper and recordings on it are required. But the purpose of all that paper is not to drive workers to quality goals. Rather, its purpose is to record the experience the firm has had in successfully affecting reality, and to communicate the wisdom gained. It is history; therefore, it can be guidance, and I like that. It is yesterday's news, and that worries me. That paper tools are made is not assurance that any user is alive to the hazards. Airlines believe in doing things by the book; pilots believe in doing things by the book; both mostly do. Yet wings are still ice coated and flaps set in wrong positions, and both occasionally stay that way right through the crash. I said earlier that controls are deliberate potentials for disquieting information, but what I know about checklists is that people frequently bounce through them seeking confirmation (or more likely, just documentation) that they have done right. None of that helps us return home from the hunt safely. The Inuit hunter learns the clues in ice for the love of life in him. Clues that have immense potential are not missed; they are immediate, intimate, and they solve the mystery of survival. You and I lose nearly every bit of the good in the paper tools we read. We are not disquieted, and we do not allow controls to make us deliberately so.
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The clues in paper tools will have immense potential only for people intent on their preparation for changing reality. People in that chase will compose their histories in comprehensive and precise checklists, procedures, and standards, and they will send them ahead armed with their tested insights of the perils in new projects. They will offer them for wisdom that is immediate, intimate and for their potential to solve mysteries in stone, steel, and glass. But they will not cast confident eyes over their paper tools. The quality is not in them. LAST WORDS We went looking for the roots of our failures and for any help there was to comprehend passages back from deep disappointment. I think we hoped to emerge with clues to our happiness. It turned out there were all around us everywhere waiting, clues. _________________

6. BIBLIOGRAPHICAL NOTES 1. To take your study into information and language theory, read much more about it in Jeremy Cambell's book, Grammatical Man, Information, Entropy, Language and Life, Simon & Schuster, Inc., 1982. Read, as well, in Chaos by James Gleick, Viking Penguin, Inc., 1987. 2. The structure of the consciousness is developed by Mihaly Csikszentmihalyi in Flow: The Psychology of Optimal Experience, Harper & Row, 1990. Flow is written for a wide audience by a serious researcher and scholar. It cannot be confused with a tenminute book on anything. 3. For a discourse on evolution of species, you cannot do better than Richard Dawkins' book, The Blind Watchmaker, W.W. Norton & Company, 1986. Mr. Dawkins offers for ten dollars to sell you his Macintosh "Biomorph" program, which will have you evolving on-screen life forms in minutes. See the coupon in the back of his book. As far as I know, it is the only way to get the program. 4. Peter F. Drucker is frequently your best source and often the only one you will need on management theory, including goals, controls, and the behavior of workers in an information era. Management Tasks, Responsibilities, Practices, Harper & Row, 1973, is comprehensive. 5. You can participate in a varied seminar on the self through the collection of papers in Technologies of the Self: A Seminar With Michel Foucault, University of Massachusetts Press, 1988. The editors are Luther H. Martin, Huck Gutman, and Patrick H. Hutton. 6. Two books adding to the study here through unique perspectives on life and the varied experience of it are: Departures by Paul Zweig, Harper Row, 1986, and Arctic Dreams: Imagination and Desire in a Northern Landscape, Charles Scribner's Sons, 1986, by Barry Lopez, who introduced us to the Inuit hunter, Jacob Von Uexkull, and J. Wreford Watson.

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