Sidney Vianna said:
ISO 9001 has a requirement that is overlooked most of the time, but I believe, very relevant to this scenario:
6.2.2 Competence, awareness and training
The organization shall
d) ensure that its personnel are aware of the relevance and importance of their activities and ....
It is hard for us to accept that someone would be negligent with flight safety issues, spacecraft integrity, critical checks but, let's remember that we are dealing with human nature. I agree that there should be checks in place to make sure such critical operations were being properly carried out.
Human nature...snort!
This sort of thing makes me foam up. It provides a clear picture of why I have been career challenged since I left the Navy in 1995.
I inspected U.S. Navy submarine repairs in oxygen and salt water systems, plus high pressure steam systems in surface ships. Our human nature was to take personal pride and ownership in the fact that systems under our reponsibility were always properly repaired, inspected and tested before that ship went anywhere. Our customers' lives depended on us. We were always aware of that, especially in the Quality Departments.
The U.S. Navy has not lost any submarines from repair problems since the USS Thresher in 1963, whereupon the quality program was completely reworked to include the proper checks and balances.
But there was also accountability. If negligence was found, or even suspected, it would happen soon because there was frequent process examination by following servicemembers. Each one had the responsibility to report if something was amiss from the previous shift. If they did not, they shared liability.
If NASA management placed the same priority on life and system safety as it has on deadlines, we would not be finding this mess. Nor would we have expoding space shuttles from things like the o-ring fuel leak while launching when it was too cold out.
And just look at the expense of these problems! The cash registers in my head sound like those old fashioned pinball machines when I think of it. The unmeasurable cost is loss of public confidence.
Management steers the organizational ship. Management is responsible for ensuring systems are designed, implemented and followed through. Management is responsible to ensure inspection records are checked, audits are done and that the %(*# thing doesn't sail until it's right. Management is responsible for establishing the sense of responsibility, ethics and pride in workmanship in an organization. When management is seen to be preoccupied with marketing and deadlines, when management is perceived to not care about quality, even the lowest member may be severely challenged to compensate out of personal pride.
Now, let's also consider that NASA has been consistently underfunded. Here, top management (our government members) is responsible for providing the needed resources to accomplish a mission. But our (their) penchant is to make sweeping, grand plans and then ask for them to be implemented and maintained with 40-70% of the recommended funds. The front line personnel, including inspectors, are probably aware of this too, plus the bloated salaries of top staff, and may find it hard to give with all their hearts.
Then, they may have any one of many potentially debilitating issues to deal with. If the problem lies with personnel failure at low levels, it can often be resolved by finding and approaching the reason for poor performance.
For example, poor performance through financial pressures is quite common. The Navy realizes that credit problems can distract its workers. So they have financial specialists available, very often on the ships (I was one) to assist through liaison and counsel. This is much cheaper to do than fire an otherwise good worker and replace him or her...and worse, to undo the damage he or she has wrought. Management is responsible for recognizing this.
We have heard inspections were found not done--we have not heard why, nor shall we I'll bet.