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Subject:RE: TW and QA From:eric -dot- dunn -at- ca -dot- transport -dot- bombardier -dot- com To:"TECHWR-L" <techwr-l -at- lists -dot- techwr-l -dot- com> Date:Wed, 20 Oct 2004 10:23:27 -0400
bounce-techwr-l-106467 -at- lists -dot- techwr-l -dot- com wrote on 10/20/2004 08:50:51 AM:
> The article described a stunning gap in QA. A failure of the gravity
> switches would (and did) lead to the total loss of the
> $264 million capsule.
> Was there no way to test their functioning when installed
> according to the drawings?
The article showed not one gap, but many. Instead of their processes and
testing resembling the "Swiss cheese" model (where there can be many
holes/gaps but they don't line up to form a clear path), their processes
and testing clearly had many critical paths to disaster and inadequate
monitoring of those paths.
The design of the switch should have indicated "this way up", the designer
of the craft should have designed the mounting in such a way the switch
couldn't be installed upside down or clearly indicated it in the design
drawings, the manufacturing engineer (or Industrial or Methods Engineer,
all overpaid techwriters for a portion of their duties) should have been
savvy/technical enough to realise that such switches have an Up and
written the procedure and created the assembly drawing accordingly, the
procedures should have been reviewed and tested, inventory control should
have noticed if the switches were packaged with documentation and brought
it to the attention of engineering, the assemblers (which in that industry
are probably more savvy than your average assembly line type worker)
should have noticed that the switch didn't have a clear mounting method,
the test engineers/QA should have designed a test based on manufacturers
information to test the orientation of the switch, project management
should have been in charge to ensure that the lists and management
required were in place to ensure that all components were tested and all
manufacturers information and tolerances were communicated correctly.
The OEM, system design, manufacturing/methods, shipping/receiving,
assembly, Tests/QA all had primary roles in the ignorance of the problem
and the eventual failure. Management had an important secondary role.
Unless it can be shown that someone DID speak up, but was ignored, this is
not a single point failure. It should be impossible for it to be a single
point failure (and if it was a single point failure, it is actually two
failures. Management has to shoulder as much, or more, blame as the
A technical writer or someone tasked with focusing procedure writing may
have caught the problem. But considering that none of the other job
functions I've mentioned seemed in the least bit interested in the
technical side of what they were doing, would the corporate culture have
been broken by one more person on the team?
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