![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
I read today about a recall of birth control pills. The detail that caught my attention was this:
Buddha wept, this is Industrial Design 101. If you have an integration process where orientation is important, you avoid this kind of disaster by enforcing orientation through asymmetry. You can't plug a USB cable in upside down because the plug is asymmetrical along the critical axis. You shouldn't be able to load unlabeled blister packs into a machine upside down, nor should it be possible to fill and label those blister packs. All it would take is a notch in one corner to ensure orientation.
I'm sure press people would assure me "it's more complicated than that." No, it's not. I could be wrong about the mechanical particulars, but issues like this represent a systems design error of a real-world artifact: somewhere along the way a physical template, die, guide, measure, or clamp that could have been designed to prevent this from happening was not.
Blister packs of the birth control pills were rotated 180 degrees, which reverses the weekly tablet distribution. This packaging error could cause women to take pills in the incorrect order and could lead to unintended pregnancy.I suspect this means someone at the factory put the empty blister packs into the packaging machine upside down.
Buddha wept, this is Industrial Design 101. If you have an integration process where orientation is important, you avoid this kind of disaster by enforcing orientation through asymmetry. You can't plug a USB cable in upside down because the plug is asymmetrical along the critical axis. You shouldn't be able to load unlabeled blister packs into a machine upside down, nor should it be possible to fill and label those blister packs. All it would take is a notch in one corner to ensure orientation.
I'm sure press people would assure me "it's more complicated than that." No, it's not. I could be wrong about the mechanical particulars, but issues like this represent a systems design error of a real-world artifact: somewhere along the way a physical template, die, guide, measure, or clamp that could have been designed to prevent this from happening was not.
no subject
Date: 2011-09-17 05:21 pm (UTC)In addition, computer-based vision systems are incredibly cheap these days. It costs very little to provide automated visual inspection of 100% of product, with automated checks for size, shape, discolouration, cracking, orientation, and even OCR of markings. If there was any visible difference between the different pills, a vision system would have flagged the error before product left the packaging facility.
https://secure.wikimedia.org/wikipedia/en/wiki/Poka-yoke
no subject
Date: 2011-09-17 08:45 pm (UTC)I agree with Elf, this was probably human error allowed for by poor design decisions.
no subject
Date: 2011-09-18 09:04 am (UTC)no subject
Date: 2011-09-18 05:08 am (UTC)no subject
Date: 2011-09-17 11:56 pm (UTC)no subject
Date: 2011-09-18 12:19 am (UTC)Though I will say, USB ports annoy me. If I can't see the side with the symbol on it, it takes me half a dozen or more tries to get the thing into the port.
no subject
Date: 2011-09-18 06:11 am (UTC)A related failure mode may be that - even if the blister packs are 'keyed' - the machine that holds the dies and the dies themselves may not be. A maintenance job may have put a catcher in backwards. Still, it's the same damn thing - key it!
Complicated is PR for "They're cheap SOBs."
Date: 2011-09-18 12:03 pm (UTC)And they are the same color because they don't want to pay for a different coloring agent.
Color me surprised that they don't opt to ship 21 pills and the instructions "Take one pill a day starting at next full moon." I mean it worked for India.