RE: The 6-million-dollar documentation mistake

Subject: RE: The 6-million-dollar documentation mistake
From: "Johnson, Tom" <TJohnson -at- starcutter -dot- com>
To: "TECHWR-L" <techwr-l -at- lists -dot- techwr-l -dot- com>
Date: Fri, 24 Mar 2006 09:59:01 -0500

You know what, when a red ribbon that says, "Remove before flight" is hanging from an airplane, it's somebody's responsibility to make sure it is removed safely before flight whether or not it is in the procedures. That ribbon trumps procedures. The mechanic that worked on the plane, the pilot that started the engines, and the ground crewman that was in charge of the plane all bear some responsibility. Everyone knows that bad things happen if ribbons are hanging from the plane. That's why they are there. Procedures are important, but they are fallible. In this situation, I would bet the plea "It wasn't in the procedure" isn't going to cut it.

Lastly, Geoff is right, the people who wrote the procedure and those that verified the procedure are also to blame.

No matter how hard we try to make our instructions idiotproof, someone is going to design a better idiot. I'm going to write the "Preflight Inspections for Dummies" book this weekend.

Tom Johnson
Technical Writer
tjohnson -at- starcutter -dot- com

-----Original Message-----
From: techwr-l-bounces+tjohnson=starcutter -dot- com -at- lists -dot- techwr-l -dot- com
[mailto:techwr-l-bounces+tjohnson=starcutter -dot- com -at- lists -dot- techwr-l -dot- com]On
Behalf Of Geoff Lane
Sent: Friday, March 24, 2006 9:39 AM
Subject: Re: The 6-million-dollar documentation mistake

On Friday, March 24, 2006, Edwin Skau wrote;

> I don't think this is as much a tribute to the importance of documentation
> as passing the buck to poor documentation. It is an effective way of
> sweeping the blame under the carpet, or lynching an unidentifiable someone.

> I don't know if absence of a documented procedure is a good excuse for not
> removing landing gear pins. I'm not sure if you'd excuse your mechanic or
> plumber of shoddy work because the procedures were inaccurate, or "well,
> that's how the manual says it is done..."

That said, don't most procedures in aviation have to be verified
before use? If that's so, surely any blame must pass to the person who
missed the pins during the verification process? After all, anyone can
make a mistake - which is the whole point of procedure verification
and procedure acceptance groups!

Just a thought ...


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