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But what if there's absolutely no documented process involving those bolts at all? Its perfectly reasonable to ask what the process is and who is responsible. B

But what if there's absolutely no documented process involving those bolts at all? Its perfectly reasonable to ask what the process is and who is responsible. Boeing acknowledges they don't have an answer here. Is it because they never had a process for those bolts to begin with? You can't document following a process (or not following one) when there is no process at all.

wbl 3y ago
Then Boeing management is responsible for not realizing the process was missing. Peoples lives were at stake here.
dv_dt 3y ago
The process to do something undocumented could be to plan and write down what you are about to do, record the before during and after states file the documents. Alternately the process should be to do nothing until the system studies the action and defines the process. But even then you have a proofing run where you probably should have extra documentation. And arguably in a high safety environment- this would be preferred.
- ethbr1 3y ago
  Back upstream to the source of the problem, too much rework was already being required by the time the components got to the Boeing assembly plant (i.e. the Spirit techs onsite doing repairs). In an environment where process exceptions are the norm, people begin to deprioritize handling exceptions properly. Everything can't be critical or emergency all the time. And once that deprioritization happens, safety critical process exceptions begin being treated like all other exceptions. Because they're all exceptions, and there are so many. And eventually normalization of out of bounds situations via repeated team exposure leads to catastrophe. NASA lost two shuttles via the same organizational problem.
  - dv_dt 3y ago
    That’s all very true, but just a casual opinion, I think Boeing's process problem is more one driven by prioritization of profits with management corroding the safety culture vs nasa procedural breakdown missing risks because of routine complacency of many previous launches.

wbl 3y ago

Then Boeing management is responsible for not realizing the process was missing. Peoples lives were at stake here.

dv_dt 3y ago

The process to do something undocumented could be to plan and write down what you are about to do, record the before during and after states file the documents. Alternately the process should be to do nothing until the system studies the action and defines the process. But even then you have a proofing run where you probably should have extra documentation. And arguably in a high safety environment- this would be preferred.

ethbr1 3y ago
Back upstream to the source of the problem, too much rework was already being required by the time the components got to the Boeing assembly plant (i.e. the Spirit techs onsite doing repairs). In an environment where process exceptions are the norm, people begin to deprioritize handling exceptions properly. Everything can't be critical or emergency all the time. And once that deprioritization happens, safety critical process exceptions begin being treated like all other exceptions. Because they're all exceptions, and there are so many. And eventually normalization of out of bounds situations via repeated team exposure leads to catastrophe. NASA lost two shuttles via the same organizational problem.
- dv_dt 3y ago
  That’s all very true, but just a casual opinion, I think Boeing's process problem is more one driven by prioritization of profits with management corroding the safety culture vs nasa procedural breakdown missing risks because of routine complacency of many previous launches.