Don’t Make a $1.4 Billion Mistake
An Air Force Accident Investigation Board said the crash probably could have been avoided if knowledge of a technique to evaporate this moisture was disseminated to those responsible for the B-2 Program Maintenance.
Both pilots followed procedures, and were able to eject safely. Unfortunately the aircraft was not as fortunate. A technique that heats the sensors and evaporates any moisture before calibration was known by some for two years; however this was never formalized in a Technical Order Change or “Lessons Learned” Reports.
The report stated failure to communicate critical information was a contributing factor. This incident was Aerospace specific; however human performance issues are not industry specific.A formal communication and distribution program can help preclude a similar event from happening in your industry, or more importantly to your company. Do you have such a program? If not, you should put one in place. Consider utilizing an audit consultant to assist your team, or perform this for you, so that you can focus on what’s most important to you - your customers.
At Storti Quality Consulting, we take pride in helping our customers use quality management practices to enhance results and increase profits. If you’d like to talk about Quality, please call us at 215.657.0837, send an email to ralph.storti@storticonsulting.net, or visit our website, www.storticonsulting.net.
