and we bitch when Luigi makes a mistake

[redrider90]

Investigators have concluded that a $22 million US Air Force F-16 fighter jet crashed near Joint Base Andrews, Maryland earlier this year because its engine was improperly assembled and was missing key parts, the service announced Thursday.
http://www.cnn.com/2017/10/26/politics/f-16-crash-engine-investigation/index.html

[Socalrob]

On a related note, my dad sold aluminum on an industrial basis to aircraft companies like Lockheed and Boeing.  The documentation of aircraft parts, even before computers, was extrodinary.  Every single part on an aircraft was documented all they way back to the mixing of the alloy in the forge.    All done on file cards.

So I imagine they know exactly who assembled that part of the engine in question.

[Lannis]

Investigators have concluded that a $22 million US Air Force F-16 fighter jet crashed near Joint Base Andrews, Maryland earlier this year because its engine was improperly assembled and was missing key parts, the service announced Thursday.
http://www.cnn.com/2017/10/26/politics/f-16-crash-engine-investigation/index.html

I'm getting ready to get on an overseas BA flight ... and I realize it's a shame that I've studied and analyzed so many airline crashes.

Engines rip off the wing because Maintenance short-cutted the engine replacement procedure (FL 191), or the plane goes out of control because someone used the wrong, out of spec lubricant on a jackscrew (Alaska Airlines), or a radio altimeter fails and misdirects the autopilot and crashes the plane because it wasn't replaced on schedule .... Hard to eliminate human failure.   Robots and computers can't fix that ....

Lannis

[troyhamilton]

I dont fly because you cant pull over on a cloud and make a repair....

[KiwiKev]

Still a lot safer to fly than riding a motorcycle they say lol.


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[normzone]

(QA war story ....)

 Back in the previous century when I was more naive than I am now, and thought that quality control would be a good idea, I accepted an entry level inspection position in a forging house. It was a dungeon, with the QA department managed by a person who had all the resistance beaten out of her long ago.

Among my duties I used an optical temp measuring tool to verify ovens were within temperature tolerance, and was instructed that there was an additional informal tolerance added to that value as a company policy.

I lasted about two months. One day I told an operator that his oven was over temp even considering the informal house tolerance add-on. He told me I was full of it, and he had two thermocouples that showed he was in tolerance.

I went and got an old hand who was in his working retirement and didn't give a hoot about pushback. He brought another optical temp measuring device and confirmed that the material was way over target. Last I saw the oven was being emptied and the material was on it's way to the lab for analysis. The product in question was jet engine blades - I like to think that I may have helped keep a plane in the sky.

The next day a repair guy was working on the thermocouples. A week later I was shown the door. The documentation said " ineffective job performance "

Willy Nelson said it best when he sang " Mama, please don't let your babies grow up to inspect things .... "

[oldbike54]

 We refer to this as doing "A Brian Bosworth" in Oklahoma 

 Dusty

[Zoom Zoom]

It's very sad Norm when companies find ways to deal with people for doing the right thing.

ZZ

[ITSec]

I've always thought that the air force base involved may be ironically named... 'tinker'. Hmmmm! 

[Chuck in Indiana]

QA department managed by a person who had all the resistance beaten out of her long ago.

"The beatings will continue until morale improves.."

Dorcia was QA, too. There was a "material reclamation area" where all the rejected parts went. Until they ran out of good parts..then the bad parts were "reclaimed." 
"Quality is our most important product.. until it interferes with our 10000 parts a day quota.." 
Yeah, I worked for morons, too..

[Two Checks]

My son just lost a job for following safety protocol. And he had been warned it was going to happen, they just didnt know when or how.
He saw another supervisor at a grocery store a week later and was told he was set up. Why? He followed procedure rather than risk someones life for a production bonus.

[ARGuz]

We refer to this as doing "A Brian Bosworth" in Oklahoma 

 Dusty

Boz...Enough said!

[normzone]

It's very sad Norm when companies find ways to deal with people for doing the right thing. ZZ

Thanks for the sympathy [ZZ], but I kept on and have since managed to get fired by better companies than that one .... for doing the right thing. It's an acknowledged occupational hazard in my field.

After a while it becomes a game to see how much and how far you can grow the organization without stepping on the land mine that blows you up. These days I relish process improvement and fire prevention - fire fighting is boring. I got into this gig because I was tired of seeing employees take the heat for normal process variation, and because I was concerned about the customer. That's not usually part of my interviewing pitch though 

[charlie b]

Process improvement.  Wish it were all it is supposed to be.

As an engineer I watched management bring in QA experts to propose a 'process improvement' to fix a problem that could have been fixed with a simple mechanical upgrade.  We ended up with two procedures that had to be inspected and signed off during each shift, none of which prevented the same mistake being made at least once a week.

But, we did end up hiring three more QA people to oversee the processes.  They did provide the finger pointing to say who screwed up each time (which was already on the production sheet).  After a year we could have paid for the simple upgrades ten times over.

Most QA people in companies I have been in were in a completely different chain of command, all the way up to the CEO.  Some used that to their advantage when they would halt a process just to tick off the production manager.  Or, they would wait a day or two to inspect a product, which meant any issues delayed delivery.

Goes right up to the govt/union/company folks who failed to properly inspect the oil rigs or all the coal mine incidents.  After each incident you find that the company tried to 'get by', inspectors overlooked or didn't look, and bad things happen.

It is too bad that many companies do not just do the thing right in the first place.

[normzone]

Process improvement.  Wish it were all it is supposed to be.
....

It is too bad that many companies do not just do the thing right in the first place.

Well, as in all things it depends on who you're working with. Often it's just a matter of asking the guys doing the work what they think and then convincing management that they thought of it first.

You do have lazy inspectors, but in an organization with responsible competent management (oxymoron?) they get weeded out. Rule of thumb, if your inspection crew is lame it's a direct reflection of the guys at the top.

In this field you start at the bottom and learn to find product problems - then if you're lucky you get to focus on the top and find process problems. I get no thrill from looking at manufacturing and inspection - I'm much more interested in sales and design. If those folks do it right it's harder to fail on down the line.

Back to the original topic, an incorrectly assembled engine? Somebody didn't vet the assembly instructions properly. That should all be poke yoke (polite japanese for idiot proof)

[redrider90]

Back to the original topic, an incorrectly assembled engine? Somebody didn't vet the assembly instructions properly. That should all be poke yoke (polite japanese for idiot proof)

HOW MANY PEOPLE DO YOU THINK MISSED/OVERLOOKED THE PROBLEM AND LET THE ENGINE PASS? I'D BET THERE HAD TO BE AT LEAST 3 OR MORE PEOPLE WHO SCREWED UP ON THIS ONE. THIS WAS NOT A REPAIR, IT WAS A NEW ENGINE. GOOD PILOT SAVE HIMSELF AND KILLED NO ONE ON THE GROUND BUT $22 MILLION GONE. WHO PAYS THE BILL?

[roadscum]

At least Luigi's consistent. You can count on him to screw up on a regular basis. 


perhaps his brother is working at the Air Logistics Complex in Oklahoma City, Oklahoma.
Paul

[normzone]

HOW MANY PEOPLE DO YOU THINK MISSED/OVERLOOKED THE PROBLEM AND LET THE ENGINE PASS? I'D BET THERE HAD TO BE AT LEAST 3 OR MORE PEOPLE WHO SCREWED UP ON THIS ONE. THIS WAS NOT A REPAIR, IT WAS A NEW ENGINE. GOOD PILOT SAVE HIMSELF AND KILLED NO ONE ON THE GROUND BUT $22 MILLION GONE. WHO PAYS THE BILL? 

No need to shout, I can hear you just fine.

I wasn't there, and perhaps my standards are too high, but if it was my party:

The engine would be designed so that it could not go together unless all the parts were both THERE and CORRECTLY INSTALLED - I know, not always possible. In this case, apparently the damn thing passed testing like this, so the test process also needs to be improved.

The assembly instructions and build record would have an inspection step each time a "layer of the sandwich" was added. Whenever something is about to get covered up, an inspection is required before that happens. That probably existed and either it was flawed or somebody falsified it. Not likely a falsification - people take their work seriously, and aircraft people more so than most.

And if a step was skipped in the build AND in the build paperwork, whoever reviews that before it leaves the building is on the hook. No fun for anybody.

[Chuck in Indiana] should be along any moment to instruct us on how it really works.

Who pays for it? Well, I estimate my share of it comes to $314,000. I'll have to make installments.

[cloudbase]

Goes right up to the govt/union/company folks who failed to properly inspect the oil rigs or all the coal mine incidents.  After each incident you find that the company tried to 'get by', inspectors overlooked or didn't look, and bad things happen.

It is too bad that many companies do not just do the thing right in the first place.

Absolutely.

I lost friends on the Marine Electric and the Poet.

That doing the right thing often costs money.  Sometimes lots of money.
Watch for more in the current regulatory environment.

[normzone]

Ooh, I just read up on the Marine Electric - thank you [cloudbase]. Falsified inspection records - that's a hanging offense in my book.

I've made people disassemble stuff when I found at final inspection that an inspection step was skipped.

As with any good QC guy, I look under my car for new wires and such before I start it up    I worked with an inspector who had his car windows shot out. We're popular people. 

[twhitaker]

I've always thought that the air force base involved may be ironically named... 'tinker'. Hmmmm! 

We did work for Tinker about 20 years ago

[LowRyter]

what a shame, the problem occurred right here at Tinker (where I used to work).  It's perplexing to me to think how the part got out and that it was installed and the engine passed test.

[Chesterfield]

Boz...Enough said!

Watched an ESPN documentary on him. I found myself really liking the guy. He`s grown up considerably. I don`t think any one of us would not have done the same in his surroundings.

[LowRyter]

HOW MANY PEOPLE DO YOU THINK MISSED/OVERLOOKED THE PROBLEM AND LET THE ENGINE PASS? I'D BET THERE HAD TO BE AT LEAST 3 OR MORE PEOPLE WHO SCREWED UP ON THIS ONE. THIS WAS NOT A REPAIR, IT WAS A NEW ENGINE. GOOD PILOT SAVE HIMSELF AND KILLED NO ONE ON THE GROUND BUT $22 MILLION GONE. WHO PAYS THE BILL?

the engine was depot level repaired or overhauled.   The control system was repaired and assembled in the back shop.  It was installed on the repaired engine, the engine was run in the test cell, passed and sent to the field.

Sad day.

[ITSec]

We did work for Tinker about 20 years ago

I used to visit there in the 70s, when my grandfather had the contract to supply the tooling for their milling machines and such - Kennemetal and Sandvik.

[nc43bsa]

Engines rip off the wing because Maintenance short-cutted the engine replacement procedure (FL 191)
Lannis

Damn, it blows my mind that AA191 was almost 40 years ago.

[KiwiKev]

Never mind, the article says they have 1000 of them so no big loss. At least the pilot got out alive.

Watching the airline disaster shows on tv it’s amazing what simple things can bring a plane down. Like the pitot tube covers being left on or in Canada when they filled up with  XXXX liters instead of XXXX I gallons after going metric.


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[Ncdan]

I dont fly because you cant pull over on a cloud and make a repair....

I’m with you Troy

[wavedog]

QA- got a little familiar with it while in the submarine service. Subsafe programs etc. Good stuff. One time a young A-ganger was doing a manual line up to blow the ballast tanks and did not follow established procedure and the aft tanks blew but not the forward group. A little excitement for a few moments. Everyone was to blame for allowing that to happen. Either we all make it to the surface or no one does.
 A lifetime ago I was working a fire in Oregon and the turbine engine on the Airtanker I was flying went into auto destruct mode because, as it was later determined, a mechanic had cross threaded a lubrication line onto the engine casing. Not wanting to replace the entire casing he just jammed it on and it worked for a while until it didn't. That was cause for a few exciting moments also. QA in that shop? I guess that's why my former boss now owns that company, the aircraft, the land, the buildings and the airstrip that it sat on also. Nice settlement.

[LowRyter]

Watched an ESPN documentary on him. I found myself really liking the guy. He`s grown up considerably. I don`t think any one of us would not have done the same in his surroundings.

I think Dusty was referring to Boz's job at the local GM plant and the "quality" of the work he produced there.  Inso far as pulling a "Boz".

A twist of irony:  The plant closed 10 years ago and you know, it's now part of Tinker Field (AFB).



I will say that Boz was a helluva player.   I've never seen a harder fought football game than OU beating Penn State for the National Title in the Orange Bowl.   That game was a war.