I Get the Can
I Set Up Manufacturing
A friend, Steve “Bookem” Danno, helped me find a contract manufacturing plant in Santa Ana, California to assemble the Vision-DS2. I had written a large and very detailed manual with CAD drawings of each part, and how they should be assembled. It also included all wiring diagrams. I worked feverishly for several months helping the company get set up. They had an illegal alien from Mexico named Angel Rodriguez as project manager. (right in the photo at left) Angel was a very intelligent and hard working twenty-five year old who was in charge of two other illegal aliens from Vietnam, who were older, and not quite as competent. Angel spoke excellent English, and was a terrific worker. I would have hired him myself in a minute. The older workers had a bit of a problem taking orders from Angel because of his youth, which was a constant problem during manufacture. It was really amazing how almost every plant that I worked with was manned by “illegals”. I really wonder how businesses could exist without them. The manufacturer began assembling twenty-five units. I had to keep a pretty close eye on them as they worked to make sure parts were being put together correctly. The two Vietnamese workers tended to pick up any screw that would work rather than following the exact directions in the manual. Once I caught one of them using an incorrect and too long of a screw in the dryer-blower mechanism. The screw would have broken the fan, which would have caused the coil to overheat and burn out. Overall the company seemed to be doing a pretty good job, initially at least, but not perfect. Perfect was required.
Flatley Fires Me
Late in 2002, Jude asked me to a meeting there where he told me that since the Vision-DS2 design is complete, my services would no longer be needed at Flatley Dental. They had hired a new head engineer, Mike Smitz, who would be taking over the project. I was introduced to Mike. I asked him what his experience was with film processors. He said none, but he is a fast learner. Jude asked that I continue to support Mike so we can get the project to market. I agreed, but was completely puzzled as to why they would release the most knowledgeable person the world on the Vision-DS2, me, and replace him with a completely inexperienced “engineer”. I always have my doubts about people in this field who say they are engineers, as the vast majority who do are really nothing more than modestly trained technicians. But it seems that everybody in this field says they are an “engineer”. I gave Mike an instruction manual that I had put together, and told him that he should read it thoroughly. Mike was asked by Flatley Dental to install a Vision-DS2 unit at the Navy Dental Center in San Diego. A couple of days after installing the unit, he got a frantic call from the techs there that “it was overflowing! You’ve got to get down here right away!” Mike went down there and, sure enough there was chemical all over the counter-top. He called me, so I could help him figure out what had happened. After a bit of discussion, I realized that Mike had not read the instruction manual at all! He had absolutely no knowledge on how to run the processor. The instruction manual said, in very big bold type, and in several places, that the processor should be filled with only one gallon of chemical in each tank; that the tanks should be half full, and no more. When Mike filled the tanks with one gallon, he noticed that they seemed to be only half full. So he added another gallon into each tank so they would be completely full! Arrrgh! So when the Navy techs ran the Vision-DS2, it overflowed the reaction tank and flooded the darkroom. Luckily Flatley Dental took Mike off of this project, and a short time later he was gone. I guess he was fired, or quit, but I never saw him again at Flatley Dental.
Moe Takes Over
I was asked to another meeting at Flatley Dental. I kind of figured that they would see that they needed me to head up this project, and they were going to tender me a job offer. Wrong! At that meeting I was introduced to Moe Bush, who was to be the new project head. I was asked to be available for Moe for consultation. I was stunned. I asked Moe what his experience was with film processors. He said none, but he is “a fast learner”. I think I heard that before. I was more stunned; shocked would be the word. Why would they hire another completely inexperienced “engineer” to run this project, and again ignore me? Moe asked me to forward all of my materials to him. I gave him copies of the numerous manuals that I had put together, and a copy of the Bill of Materials. The BOM is an important list of all of the parts for the unit. Every screw, bolt, and wire has to be accounted for. There can be no errors. The company that assembles the units orders parts from this list. If even one screw is missing or incorrect, it is very time consuming to have to stop assembly so the missing part can be procured. And if there are several errors, the time loss and expense are compounded.
The first job Moe wanted to accomplish was to rewrite the instruction manual that I had spent hundreds of hours writing. I had made numerous very clear CAD drawings, and what I think was an excellent and very clear manual. Why would he rewrite the manual? Why would he waste all of that time? Here are the emails that he sent me requesting a digital version of the manual. This may give you an idea of how Moe’s new version might look:
Steve,
All what I need is the instruction manual in a word format with the drawing so I can modify/change. The words in the manual (clean it up). That’s all what I am looking for. Do you have that?
Moe
Steve
This is not clear. What do you mean by that?
What is means is:
Moe
Steve,
Thank you so much.
I have copied the drawings to the word file (user manual) and picture is it clear or focus.
Moe
Yes, the person that wrote these emails, the head of the Vision-DS2 project, was going to rewrite the instruction manual! Moe appeared to be born foreign born as he had a very slight accent, however he spoke excellent English. I have no idea why he couldn’t write, or why he didn’t realize that he couldn’t. As soon as I saw these emails, I knew that this project was dead. I decided to play along as if I still had hope, but, as far as I was concerned, all hope was lost. Moe spent several months rewriting the instruction manual. The result was an abomination, as would be expected. Moe replaced my very clear CAD drawings with the most horrendous digital pictures imaginable. The “manual” was replete with misspelled words (didn’t Moe know about spell-check?). The grammar was atrocious; not third grade level. Yes, this project was dead as a doornail.
Moe’s next “project” was to update the Bill of Materials. Each time a part was changed, I would make a new BOM showing that change. Each new “generation” of BOM was numbered so that all who use it would not make the mistake of using an old version. I sent each new version to Fred, the vice-president, Moe, and the head of the assembly plant via email. I continued testing and working on the project, even though I had been released by Flatley Dental I still wanted it to succeed, even though, deep down inside, I knew it wouldn’t. The assemblers had been contracted to assemble 25 units. Moe was in the process reviewing the BOM. On September 12, 2003 I received this email from Moe:
Steve,
The BOM you have given me has a lot of errors, such as vendors name or part numbers.
I have been working on this BOM for the last 2 weeks trying to fix it and contacting all suppliers. I have attached an excel file which the vendors do NOT recognize the part number or description of the part. I need to have the correct info. in order to start purchasing parts.
Moe
Of course Moe sent copies of this email to both Jude and Fred, the goal here to make me look bad, and him good; very transparent. I was shocked that there were so many errors in something that I put together! I prided myself on being very accurate in everything that I did on this or any project. I couldn’t believe I could make so many errors! I began going over the errors, calling vendors, and trying to make corrections. I spent several hours working. Things just didn’t add up. Belatedly, I checked the version of the BOM he was working with, and Moe had been using an eight generation old version! He had completely ignored all of the new versions that I had sent him. I couldn’t believe it. I sent Moe the following email, of course with copies to Fred and Jude:
Moe:
I spent several hours going over your list of errors. I was amazed to find that there were these errors. I reviewed all of the parts on your list, and made corrections; several hours of work. I then went to my current BOM (090803) to check a few items, and none of information matched yours. The numbers and vendors on my current BOM were all off. Conclusion: You are working with a very old version (at least 6 months). Have you spent the last two weeks “correcting” a very obsolete BOM?? I certainly hope not.
Steve
Now, if this was my company, and I had seen Moe’s emails regarding his manual corrections, and his spending two weeks working on an obsolete BOM, that would be the end of Moe. But it wasn’t. Flatley Dental kept Moe right where he was, at the head of the Vision-DS2 project. And things never got better.
Moe informed me in an email that he wanted to learn how to assemble the units.
Steve,
Please the attached mail.
Plus, I want to learn from how to assemble the unit.
Moe
Steve,
Do you have the BOM for the day light loader?
DO you have assembly instructions for the day light loader?
How do we use the day light loader?
Moe
Unthinkable that the head engineer for the Vision-DS2 had no idea how to use the daylight loader, a very commonly used “box” that allows assistants to utilize the processor outside of a darkroom. How could this “university graduate” engineer write such incredibly bad emails? How could Flatley Dental allow this guy to represent them? I sent Fred the following email:
Fred:
I am concerned about Moe. Is he heading up the processor project, as well as editing the user manual? Please read the emails that I have received from him. (I forwarded them.) Disturbing. I would appreciate it if you would keep this email confidential, as I must keep a working relationship with him.
Stv
Incredibly Flatley Supports Moe
I was told to basically mind my own business, and not to worry about Moe. With Moe at the head of the project, there was absolutely no knowledgeable oversight for the assemblers. Moe had no idea what he was doing, and he was completely incapable of checking for mistakes. Flatley Dental sent out Moe’s instruction manual with developers that they sold. The grammar and spelling was about the same as his emails. To me it was a complete embarrassment, and it should have been to Flatley. Above is a picture from Moe’s manual showing how the replenisher should be connected. Notice that the developer on the right is squashed. The hoses are the incorrect hoses. The image that says “Recommended” is the incorrect. The bottles need to be at the same level with the developer or the chemical won’t vacuum into the storage tank. The left developer has the correct position for the bottles and should have been the “Recommended” image. I really can’t imagine how any purchaser could use Moe’s instruction manual and be able to work the processor. The pencil corrections are mine. The embarrassment is also mine.
I went by the assembly plant on several occasions to see how things were going. Sitting on a table there was an apparently used unit that had a broken storage tank nozzle. It looked like the nozzle broke in use, which would cause the chemical to dump out on the counter! I’m sure there was an angry dentist out there somewhere. I did some observing of how these nozzles were being put together. The techs had to tap threads into the nozzle, then twist on a plastic “L” shaped pipe. The “L” had to tighten down against an “O” ring. The techs were tapping the threads crooked. When the “L” was tightened down, one side compressed the “O” ring, while the other side didn’t. The techs would then take a large pliers, and crank the “L” down incredibly hard so that both sides pressed on the ring, which caused great pressure on the nozzle. When the soon to fail unit was shipped out, a crack opened after a few days use. I took a look at all of the storage tanks that were ready for assembly, and the assembly techs had tapped all of them crooked! This is a potential catastrophic problem. I notified Moe of my discovery, and he said, “The crack was from shipping. The processor got bumped, and don’t worry about it.” Of course I argued the point, but he wasn’t interested in hearing. I redesigned the nozzle and mold so that tapping wasn’t necessary, to remove human error from the equation, and forwarded the new design to Fred and Moe. I met with Fred and told him the storage tanks absolutely had to be trashed, and a new set made with the modification that I had designed. Otherwise there would be big problems on a large percent of the units. Fred said OK, but I could tell he wasn’t very interested. The cost of redoing all the tanks was only about $600. The cost of one failure would be immense, and there was the possibility of many failures.
The mold was not modified, and the tanks were not changed. And, Flatley Dental continued to send out units with the flawed tank nozzles. One went to a dentist in Boston. After a few days use, the nozzle cracked, and dumped a gallon of chemical in their darkroom. Takeo, one of the Flatley Dental techs, was flown back to Boston to fix the problem. On his return, I ran into him at Flatley Dental He told me of the failure, and that he was flown back there to do the fix. Takeo had no experience on film processors, specifically the Vision-DS2. I could not believe that they didn’t at least call me and ask me what kind of fix was necessary; stunning. I never ceased to be shocked when dealing with Flatley Dental. Takeo proudly showed me pictures of his fix. He tapped the broken nozzle. He then had taken a brass threaded nipple and threaded it into the tank, and he used silicone glue as a sealer. I couldn’t believe what I was seeing in his pictures. The brass nipple would corrode horribly in that chemical environment. The Silicone sealer would be eaten by the chemical. I told Takeo that the unit will “leak in a week”. Takeo said, “No way! It was sealed perfectly.” Coincidentally, I happened to be at Flatley Dental a week later. Takeo was there in the werehouse, and getting ready for another trip to Boston. The unit started leaking exactly a week after he did his repair. What a prediction! Takeo flew back to Boston, and with no more knowledge than he had on the first trip, and without consultation with me, he did another repair. I have no idea how that came out, and I never heard, but I can imagine. I only heard Jude complain to me about how he had to fly a technician back to Boston TWICE to make a repair on one of my units.
Another time I visited the assembly plant and I found an obsolete gasket that I had eliminated from the BOM because it was too thin and caused a light leak which ruined film in one of the beta sites. I had redesigned a thicker gasket, which would do a much better job of sealing light out. I couldn’t believe that the obsolete gaskets were on the assembly table where an assembler could pick them up and install them. I took the whole bag of gaskets, about $75 worth, and tossed them in the trash. I didn’t want them even near an assembly line. I then received the following email from Moe:
Steve,
You took all the gaskets from I/O (153pcs).These are JMA inventory parts. Please drop off these parts at JMA and I would really appreciate if you let usKnow ahead of time of what you are planning to do. This will screw up my inventory and production.I need to keep track of what I/O has and what needs to be ordered. Thank you for your corporation..
Moe
Thank me for my CORPORATION? My reply to Moe:
Moe
I removed those door gaskets from I/O because they are obsolete and defective and must not be used. We discussed that at our last meeting, and I communicated that fact by email. I do not want obsolete parts at the assembly plant, otherwise they will be used to the great detriment of this project. You need to order new door gaskets per the new drawings that I gave you. I am certain that JM would not want defective parts used on this project.
Steve
I then received this email from Fred:
Steve,
You cannot just take our inventory without permission. We have recorded all items into our system, and the procedures for inventory movement must be followed by our personnel who are responsible for that inventory, in this case it is Moe.
You claim that the gaskets are defective. How are they defective? Regarding their obsolescence, I think we decided to proceed with the first run of units using those gaskets that were part of the final design, final BOM and specifications submitted by yourself, which we used as a basis to start production. At our meeting we discussed making that change in the next run of units with all other necessary changes that will be required based on our continuous monitoring of the units in the field. These gaskets have only been a problem in one location, so it is not considered a major concern at this time.
Please remember that these changes must be controlled based on our internal procedures that we must follow. I am sorry to burden you with the bureaucracy that we must follow, but this is a must. So, please work through Moe on any pending, current or future proposed changes. I appreciate your cooperation.
Thanks,
Fred
Again I was beyond amazed. They would actually put out processors with parts that could fail? Isn’t that “manufacturing Russian roulette”? The potential disasters just kept getting worse. Good manufacturing practices dictate that parts that can create failure should never be used. But I couldn’t seem to get Flatley Dental to understand that very important and simple principle. And, with a brand new device, there are always minor modifications that need to be made. These gaskets were only a few cents apiece. Would Flatley Dental actually risk thousands of dollars, and egg on their faces for a few cents? Answer: yes!
Another visit to the plant produced another unbelievable incident. I had made changes in the assembly manual where there might have been a mistake on my part, or a part improvement or correction. Each change was carefully documented by me, and a new generation number was assigned to the modified manual. Of course, it is extremely important that Flatley, manufacturing, and I are on the same “page” using the same generation manual. I would forward the modifications to Moe, who was then supposed to forward to manufacturing. A couple of months after Moe started, I went to manufacturing to see how things were coming. Moe had never forwarded the new manual corrections! They were working with generation two when generation twelve was the current manual. I was exasperated. I started ignoring Moe, and forwarding any modifications directly to Angel at manufacturing. I informed Fred of this, but, as was the usual case, I got the blank stare, and nothing was ever done to correct this very big problem.
Eighteen months after I placed the fourth beta site processor, I got a call from one of the users. The assistant said that their processor wasn’t developing the film at the top of the holder. I went to check it, and the storage tanks were full, so there was no leakage. I emptied the unit, and took it apart to see what was happening. I had designed a small check valve to let the chemicals out of the tanks. A check valve has a small flap that lets liquid flow in only one direction. When the chemical returned, the flap would close, making the chemical flow up through another pipe. On this unit, the check valve flap had been sucked into the opening and stuck, so on the next cycle the chemical couldn’t come out of that opening. The reaction tank would not fill, and the film on the top rows of the holder wouldn’t process. This was a real engineering surprise, because when I designed the check valve, I placed a full force vacuum near the flap to see if it could be sucked back into the opening. It worked perfectly, and didn’t get sucked back in. Apparently, the constant soaking of the rubber flap made it more loosely flexible, which eventually led to this failure. In my experience, if there is one failure on one unit, that same failure can and will happen to others. I designed a very minor modification to resolve the problem. I took a small piece of stainless steel wire and placed it across the opening through a tiny hole, which would make it impossible for the flap to wedge back into the opening.
I notified Moe and Fred of this very important change. It would take only a few minutes to modify each unit. I told them they must not send any units out without making this change. I went to all of the beta sites and modified the opening on each unit. Well, guess what? I was completely ignored on this one too; not shocking anymore. Units were sent to Mexico City, Venezuela, and Kuwait. (Moe’s horrible manuals and Vision-DS2 displays weren’t even translated into Spanish or Arabic, so why?) It would be good common sense to send the first twenty-five to fifty units to offices close to home, so if any manufacturing problems or glitches showed up, they could be easily corrected. Vision-DS2 units should only be sent to international locations when assembly is near perfect, and when we were sure that all possible glitches have been discovered. When six units are running in offices like my beta-sites were, most glitches will show up. But, in all probability, it will take twenty-five to fifty units to really make sure all glitches and manufacturing errors have been exposed. The Vision-DS2 was not even close to being ready for international sales. But that’s what took place. The unit in Mexico City had a stuck check valve. Flatley Dental sent another untrained technician there. Not having any idea what was wrong, he figured that if he raised the reaction tank, it would allow more chemical to flow in, and that would solve the problem. So he took the unit apart and drilled holes in the reaction tank bracket, and raised the tank. In reality, his “solution” would only increase the problem. And, again, a tech was sent to resolve a problem that he knew nothing about solving, without consultation with me. He returned from Mexico City proudly victorious, only to hear my laments. The unit in Kuwait also had a stuck valve; amazing they stuck so quickly when it took eighteen months for the problem to show on my six beta sites. However, that is very typical of engineering. Nobody in Kuwait had any idea how to fix the unit, so it was decided to trash it. Jude said it would cost $2,000 to send the unit back; simply not worth the cost. Jude frequently reminded me of the failed units in Kuwait and Boston. No amount of discussion on my part would be paid attention to. It was like talking to a room of the deaf; no expression, no reaction to anything I said.
