RE: The 6-million-dollar documentation mistake

Subject: RE: The 6-million-dollar documentation mistake
From: "Joe Malin" <jmalin -at- tuvox -dot- com>
To: "Paul Pehrson" <paulpehrson -at- gmail -dot- com>, "TECHWR-L" <techwr-l -at- lists -dot- techwr-l -dot- com>
Date: Fri, 24 Mar 2006 13:11:13 -0800

Hmmm.

I notice that the article doesn't explain what the "streamer" was. If it
was one of those red "remove before takeoff" streamers I see on pictures
of aircraft, then blaming the documentation isn't exactly fair. Someone
on this list with military experience may have to correct me, but I
think that the general rule is that the red streamers come off before
you start up. Or maybe it's just they come off before you roll?

This goes back to the whole idea of "quality", that oft-abused word. In
my previous life as a SW engineer, I was part of a pioneer HP software
total quality control project. I read *a lot* of books about statistical
quality control, total quality control, Deming, etc. From that I
actually learned some rules of thumb about preventing errors.

Some of them you have heard already, perhaps, like defining your
process, measuring it, and so forth. But, one thing I learned almost
immediately is that you can design the errors *out* of a product or
process by watching where they occur and why.

An example from hardware comes to mind. I worked in tech support for a
multimedia hardware company. They shipped out (without the knowledge of
tech support) a combination sound card and CD-ROM drive controller that
connected to the CD-ROM drive with a thin cable. The cable connectors
were symmetrical, meaning you could plug the socket in upside down and
not know it. Furthermore, if you *did* plug it in upside down, you
burned out the board the moment you powered up your computer!

The company either believed they were saving money by using a generic
socket, or just didn't notice.

If you look at a typical computer of any type today, you'll be
hard-pressed to find a perfectly symmetrical connector. PCs these days
come with color-coded connectors for monitors, keyboards, mice, and
sound, and the connectors (except for the RCA-style plugs) have specific
orientations.

That's a way to design errors out of the product.

Don't ever forget that documentation is a backup for designing out the
errors. As a tech writer, I have to remember that if I have to put a
note or caution into the documentation, I'm covering for something that
may be a design flaw.


Joe Malin
Technical Writer
(408)625-1623
jmalin -at- tuvox -dot- com
www.tuvox.com
The views expressed in this document are those of the sender, and do not
necessarily reflect those of TuVox, Inc.

-----Original Message-----
From: techwr-l-bounces+jmalin=tuvox -dot- com -at- lists -dot- techwr-l -dot- com
[mailto:techwr-l-bounces+jmalin=tuvox -dot- com -at- lists -dot- techwr-l -dot- com] On Behalf
Of Paul Pehrson
Sent: Thursday, March 23, 2006 11:11 AM
To: TECHWR-L
Subject: The 6-million-dollar documentation mistake

The following article was published in today's Salt Lake Tribune. It
details an incident where a mistake by a mechanic caused over 6 million
dollars in damage to an aircraft engine. A contribuiting factor? A lack
of proper documentation for removing landing gear pins after performing
maintenance on the planes.

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