Three Boeing employees failed to follow the rules and created a dangerous fire hazard aboard the world’s most recognizable jet. To read the complete informative article please click here.
So yes, this happened, TO AIR FORCE ONE! It was human error so we investigated.
Read below the root cause codes and recommendations from our end.
Description of event: fire hazard detected, parts contaminated.
– Root Cause Code #1: B3e05
– Near Cause: Product/Material Controls NI
– Description: Shelf Life Exceeded
Comment: Possible holding time exceeded, creating conditions for contamination.
Evaluation: All or most product Expiration date is exceeded and continue to be used.
Recommendation: Make sure to have a good life cycle practices in place. Move or discard any material that have exceeded shelf/holding life. Plan in order to prevent the shipment of expired product or it’s use.
– Root Cause Code #2: C4a03
– Near Cause: Procedures Not Used
– Description: Use Not Required but Should Be
Comment: Not Enough Data. Nevertheless, the procedures where not followed twice (holding time and “stopwork”) suggesting an acceptable unspoken practice to deviate.
Evaluation: Procedures exist but use is not required. It is an acceptable practice to execute without procedure or checklist.
Recommendation: Provide training to the employees on required task prior to execution. Enforce the use. Improve supervision.
– Root Cause Code #3: C10a04
– Near Cause: Documentation NI
– Description: Signatures practices, instructions on documentation NI
Comment: No documentation of employees responsible for the task (as per article).
Evaluation: Spaces provided for signatures are inconsistent (i.e….spaces for signature area similar format in all pages, enough space, be sure to distinguish between initials andfull signature etc… ). Spaces for signatures cannot be consolidated in 1 (one) space for multiple entries. Clear instructions are not given nor available for documenting signatures (i.e… . execute by, approved by,review by, witness by, etc.).
Recommendation: Provide a clear and easy to follow signature spaces throughout documents. Clearly establish when a signature/ Initials are required. Design/ implement a procedure to define: execute by, reviewed by, witness by,approved by, verified by, among others. Define the meaning of the signature, the legal aspects, the responsibilities and who can sign on each definition.
– Root Cause Code # 4: C9b00
– Near Cause: Mistake (intentional; failure injudgment / interferential process. No harm intended.
Comment: Decision making mistake. Intentional error of commission. Even though the contamination was detected after first installation, a decision was made to continue with the process, cleaning the contaminated parts with a non-unauthorized cleaning process. This could also lead to violation or reaction due to extreme stress levels.
Evaluation: Evaluate cognitive load. Needs to be evaluated on the floor.
Recommendation: Evaluate knowledge based decisions opportunities and take proper actions. Format documents to include conditional statements. Knowledge based decision assessment tools can be incorporated to manage this situation.