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Sadly a lot of systemic breakdowns in the maintenance system according to the report. These days the feds are relentless on training and record keeping.
As they probably should.
I am reminded when USAF in the 90's tried to go all TQM (Total Quality Management) and did away with Quality Assurance programs/units. Maintenance practices quickly went into the crapper and unsafe acts skyrocketed. It didn't help that this was during the Clinton years and defense budgets were slashed and parts were really hard to get. I can remember flying with two dozen pages of open discrepancies on an aircraft because parts weren't available. Even something as simple as lightbulbs... the cargo area on a -141 often had more than 1/2 the light bulbs burned out. There were a few airframes I was truly frightened to fly on due to their condition. Of course the messaging was simply "don't bitch about it... you need to lean forward and get the mission done."
Sorry for the off tangent... I am truly saddened by the end result for the Foundation.
ISO9000 can work, just not without a complete change of thinking, and that includes the C-suite. you visit a Toyota factory in Japan, and every work station has the ability to shut down the production line if they discovered a problem. This way, any problems found were a top priority for the whole company to fix - not 'someone else's problem'I was in the thick of TQM when it first entered the scene. IMO it was an attempt to take simple maintenance practices and turn them into complex analytical tracking and compliance processes so costs could be tracked to the penny. Although a great concept, many of the people who tried to implement these processes never turned a wrench on an aircraft. Additionally the certification process was (and still is) a giant scam IMO. I had two bosses during the 1990s who were both TQM and later ISO 9000 self proclaimed gurus who turned out to be two of the dumbest SOBs I've ever worked for and ultimately caused more harm than good to our company. I was the Chief Inspector at a repair station where the other arm of the company was ISO 9000 approved (pre ISO 9001/ AS9100 days) and I refused to hang a copy of the ISO 9000/ TQM certificates on the same wall as my FAR 145 Repair Station Certificate and ops spec. When challenged by one of my bosses I told them their ISO/ TQM certificates were meaningless in the "real world" and the only place worthy of display was in the toilets! "FAR 145 was the sole bible here." After a while they left me alone and stayed away from Repair Station activities.
ISO9000 can work, just not without a complete change of thinking, and that includes the C-suite. you visit a Toyota factory in Japan, and every work station has the ability to shut down the production line if they discovered a problem. This way, any problems found were a top priority for the whole company to fix - not 'someone else's problem'
How many U.S. manufacturer's would accept that?
It's a bit like lean manufacturing, it requires the whole supply chain to operate to the same principles.
Thing is, AS9100 mandates some things that were optional in the ISO standard, at least when I did my lead auditor training. I think a lot of hte problem was that companies were getting advice from manufacturing experts, not anyone whit aviation experience. They didn't identify what the 'product' was correctly i.e. a safe aircraft, rather than an adequately maintained aircraft. As soon as you inset safety as part of your product description, then it works a lot better.Agree to a point but this was in a day before AS 9100. ISO 9000/9001 is tailored for manufacturing, not aircraft maintenance, especially when troubleshooting a 25 year old aircraft, that's why AS9100 was created.
Agree 100% and that's exactly what I dealt with. All the ISO auditors and "experts" were from manufacturing and knew nothing about maintaining an aircraft once it was in operation.Thing is, AS9100 mandates some things that were optional in the ISO standard, at least when I did my lead auditor training. I think a lot of hte problem was that companies were getting advice from manufacturing experts, not anyone whit aviation experience. They didn't identify what the 'product' was correctly i.e. a safe aircraft, rather than an adequately maintained aircraft. As soon as you inset safety as part of your product description, then it works a lot better.
In my experience, I wouldn't say higher...The Space Shuttle Columbia Mishap Investigation board said that there was no reason to think that ISO 9000 had any applicability to a vehicle like the Space Shuttle conducting manned spaceflight. It may be a great way to organize a spare parts warehouse for lawnmowers, but aviation and space are on another, higher, level.