Collins Foundation B-17 crashed at Bradley

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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.
 
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.
 

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.
 
The Air Force was big time into Demming's Statistical analysis in the 1980's. It may be wonderful for cars but makes little sense for airplanes and represents utter insanity for space launch vehicles.

I recall some stupid Asst Undersecretary of Defense or some such visiting the B-2 production line and fuming that there was no statistical process quality control going on and they had to do something about that. That flaming idiot! You are building a whole freaking TWENTY very very expensive airplanes at a rate of 2 or 3 a year and you want to use statistical process quality control?

That was, if anything, even dumber than Space Command's "We're going to use operational people and treat this space booster like it was an F-16 or Minuteman III and things will go much better!" We only built 39 Titan IV's and in 1998-1999 they lost three out of four of them by being careful to look the other way when it came to anomalies and instead focus on meeting the schedule. .
 

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. Trying to explain to an ISO 9000 auditor why you can't get corrective action for a burnt out electrical motor that was made 20 years ago by a manufacturer that's no longer in business is like wiping your butt with sandpaper! On many occasions I tossed the ISO folks out of my shop. Nothing wrong with continual improvement and established processes, its another thing when these folks wanted to count "Meaningless Beans."
 
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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.
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.
 
Man, I don't know much about the Collings foundation, but that doesn't sound good for them, and I admit, if you're going to be responsible for 80 year old airplanes that are getting very rare, I'd think you'd have your sh!t together better than this report seems to say.

Also, I understand about experienced pilots but come on, 75 and 71? Not trying to judge but between that and poor maintenance and safety protocols I have no problem with them not being able to take passengers at this time. I'm sure they have good intentions but jeez man, these planes ain't getting any younger and there are damned few of them left. I'd say you better be effing top notch in every category before you take one of these off the ground anymore.
 
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.
 
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.
 
In my experience, I wouldn't say higher...
 
My 4 years in aircraft depot maintenance and 34 years in space launch, including support to various aircraft mishap investigations and service on two space launch mishap boards would indicate aircraft are a whole different situation than ground equipment and space is at least another order of magnitude above that.
 
There's nothing wrong with an analytical process to track performance and quality within an aircraft maintenance environment (and seek ways for continual improvement), but the program has to be implemented and maintained by individuals who understand the environment and track data that is not only reasonably attainable but meaningful to the operation. At the end it is desired to have an operation that operates safely and is cost effective. Regulators sometimes throw a wrench into this, but it is achievable.

In the case of this incident there seems to be breakdowns in compliance that ultimately broke links in the safety chain. There were several documents that the Collings Foundation submitted to the FAA to show operational compliance, but in the aftermath it seems many portions of these documents were not complied with, either intentionally or out of ignorance (and I don't mean that to sound insultave). I also question why these system breakdowns weren't captured at an earlier date by FAA inspectors who are usually "all over" warbird operations (at least in my experience). It's obvious that in the aftermath, all warbird operations will be heavily scrutinized.
 

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