Examples of major problems caused by Poor document control

S

Squiggy

#1
Hi,
Has anyone an example of where poor control of documents has caused a major problem?
I'm hoping someone can give an example e.g where a military battle was lost or a major construction project failed etc.
This is to be used in a training presentation to get the message across to those within my organisation who do not understand the basic need to control documentation.
The funnier the better!
Cheers
Squiggy
 
Elsmar Forum Sponsor
#2
Re: Poor document control

Back in 1993 I had to complete a ton of forms to get life insurance with Prudential. Spending an evening with an insurance sales manager is not my idea of well spent time! So, imagine my frustration when I was (joyfully) told we'd have to do it over, because the salesman had picked up the 'wrong form' - it had been recently updated!

I told him (as a small, 'inside joke') that I wanted to audit their office and that he'd be better off if he was out meeting a new client instead of spending time with me (again)! He didn't quite see it that way!

Well, I thought it was funny, even if not earth shattering.....:notme:
 

Wes Bucey

Quite Involved in Discussions
#3
Re: Poor document control

Hi,
Has anyone an example of where poor control of documents has caused a major problem?
I'm hoping someone can give an example e.g where a military battle was lost or a major construction project failed etc.
This is to be used in a training presentation to get the message across to those within my organisation who do not understand the basic need to control documentation.
The funnier the better!
Cheers
Squiggy
In my experience, it isn't the BIG SNAFUs with Document Control, but the countless small ones which insidiously erode the efficiency of the organization, often making the difference between a successful, profitable one and the hopelessly ineffectual, bankrupt one.

If it takes ten minutes to retrieve a document instead of five, what profit-making activity could be performed in the accumulated segments of five minutes over a week? a month? a year? Multiply by the number of documents and the number of folks and you may just have the AHA! moment you request as your audience gets the impact of the trite aphorism:
The Devil is in the details!
 
S

Sean Kelley

#4
Re: Poor document control

I worked for a stainless steel mill that had a document control problem concerning drawings. Purchasing ordered hot mill reduction rolls to an out of date specification because no one updated the drawings to the updates and when the rolls came in and needed to be replaced they would not work. This was huge because it takes 6 months to order these special rolls and they are incredibly expensive. This cost them millions of dollars because they had to baby the mill along at 40% capacity in order to ensure not breaking the roll and the rolls that were ordered were unable to be used or modified for use. All this over an out of date drawing which made a very big issue. No one was ever disciplined and the system remianed the same. This certainly was a lesson to be learned and just became a faint memory.
 

Caster

An Early Cover
Trusted Information Resource
#5
Re: Poor document control

I.. Purchasing ordered hot mill reduction rolls to an out of date specification because no one updated the drawings to the updates ...This cost them millions of dollars
Wow, you win? with that one.

We once had a customer call and ask if we could send them a copy of THEIR blueprints because they were undergoing an ISO audit and they had lost control of their own drawings.

We also had to buy an x-ray system in a rush because Sales was going to "work their magic" and make that requirement go away. The customer engineers drank our beer and appreciated the "entertainment" but kept the x-ray requirement once they got back to the office. If I recall, there were no repercussions for Sales, but we sure were busy for quite a while cleaning up their mess.
 

Randy

Super Moderator
#6
Yep, a big messy one.

In 1973-74 the city where I lived was having a water tower built (about 1 million gallons). Somebody like an engineer or draftsman inadvertantly modified the plans with some kind of mark that meant to eliminate certain aspects of the tower during construction. While the tower was being filled and during the celebration of its opening the tower burst at the seams and over 300,000 gallons of water flooded the area including some homes:mg:

Some re-inforcing bracing and a walkway had been eliminated because of the change and the integrity of the tower had been compromised because of the "document revision" without review and approval.
 
D

Duke Okes

#7
Hi,
Has anyone an example of where poor control of documents has caused a major problem? I'm hoping someone can give an example e.g where a military battle was lost or a major construction project failed etc.
This is to be used in a training presentation to get the message across to those within my organisation who do not understand the basic need to control documentation.The funnier the better!Cheers Squiggy
I prefer to use examples people can personally relate to, such as not having your drivers license with you when pulled over by a state trooper, not putting the new expiration sticker on your license plate (which can result in your getting pulled over), ...
 
M

MIREGMGR

#8
The US Coast Guard recently launched the "first article" of a new generation of coastal patrol ships, designed by a low-bid outside contractor with minimized oversight and control by USCG personnel in order to lower project costs. One of the intended design features is a modular "power pack" for the ship's engines and closely related equipment, intended to be able to be hoisted vertically into and out of the ship's lowermost hull extent at overhaul time and quickly replaced with a second power pack so that overhaul time can be minimized and therefore the ship's duty-availability days/year can be maximized. This hoisting is to occur through a hoistway that is cleared by temporarily unbolting and lifting out modular sections of the ship's internal structure and upper-hull functional equipment.

Ships are built with internal "frames", lateral structural elements sort of like human ribs that reinforce the hull. These are spaced every 25 feet or so in this case. Ships' internal design features are always considered in regard to which frames will structurally support them, and between which they must fit.

My understanding is that one team of outside contractor engineers was responsible for design and functionality of upper-amidships hull functionality and structures, and another team the corresponding lower-amidships functionality and structures. Due to a design/document control mistake, the powerpack location and corresponding lower-hull hoistway were mis-aligned with the upper-hull hoistway by one frame...and this wasn't discovered until the ship costs were essentially 100% committed, with subcontractor elements of the ship already built, delivered to the final assembly shipyard, and partly assembled.

For cost reasons they built the first ship anyway. My understanding is that the revised intent is that when the time comes for the first powerpack maintenance cycle, they will tear the ship apart and rebuild it per a revised design yet to be created that will make engine access possible.
 
Z

zancky

#9
once I was told about a real fact happened some Year before.

once the design department needed some basket to collect big drawing, so it was decided to design a wooden one as there was nothing that fits the big drawing dimensions.

The purchasing dept found a supplier

A design made the drawing and sent to the supplier but nobody has reviewed / approved the drawing (poor document control).

The supplier asked if the dimensions on the drawing were right as they looked too big, but the designer said "our drawing are very big indeed".

The problem was evident when the basket were delivered at the design department:

the designer has supposed the dimension in mm but the standard for basket maker/shop was cm (i.e. 10 times bigger)

A 1 meter intended diameter basket was actually 10 meter large and so on.

The baskets can not even go inside the building as they were too big for any door
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
#10
Hi,
Has anyone an example of where poor control of documents has caused a major problem?
I'm hoping someone can give an example e.g where a military battle was lost or a major construction project failed etc.
This is to be used in a training presentation to get the message across to those within my organisation who do not understand the basic need to control documentation.
The funnier the better!
Cheers
Squiggy
Funny is better, huh? Well, I'm inclined to disagree on that one, even though I perfectly agree that humor is among the best teachers. My only worry is that it's so easy to continue not taking document control seriously enough - as has been shown (great examples from Randy, Sean Kelley and MIREGMGR) - even after the disasters occurred!

But I dug deep and thought of an example: sending your old girlfriend's Valentine's card to your new girlfriend - with the old girlfriend's name on the inside. Okay, not so funny...
 
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