Examples of major problems caused by Poor document control

J

joe098

#11
During an Third Party Audit there was a condition form not filled out correctly because of a mistake in the form. A fellow employee tried to show a different form for a newer appliction and it had the same mistake. :notme:
 
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Wes Bucey

Quite Involved in Discussions
#12
I generally think of Document Control as what happens to a "good" document (documents are the "plans" for performing an action versus a "record" which is a special kind of document which "records" the action taking place.) in the time from approval to actual production and after initial production (or action) if circumstances indicate a change is required. Documents may be revised from time to time by a systematic method (some folks have a "document change" or "engineering change" process.)

"Control" means determining who may
  • see
  • copy
  • revise
  • store
  • use
a document.

If you have a good document control system, you can still have BAD documents, like some of the examples above, simply because a typographical error or an error in judgment can slip through ANY system, no matter how many checks and balances are in place.

The frequency and egregiousness of the errors increases when one or more of the folks who are supposed to perform the checks and balances are ill-prepared and ill-motivated to perform those tasks in a competent manner.

The incident described above with the ship poorly designed to make the "power pack change out" procedure impossible to perform as intended is really a failure to truly follow a Configuration Management system as part of the overall Document Management and Control System.

At its simplest level, Configuration Management is intended to assure an obsolete document is not used on a current project. As envisioned and practiced by the aerospace industry for decades, Configuration Management is ALSO supposed to entail ensuring all Associated Documents are reviewed and checked to determine they will jibe with the revised document and with each other.

Elsewhere, here in the Cove, I outlined a relatively simple array of things which need to be checked and possibly ALSO modified as a result of one tiny change in a product design (changing a fastener from Phillips head to Torx.)

Analyzing a change and reviewing Associated Documents is not a simple clerk's job - it requires knowledge of the entire process and ability to spot how each change may affect form, fit, and function of other parts of a process, some of which may be subtle, while others can have catastrophic consequences.

My point in the first post I made in this thread is that it is not necessarily the catastrophic lapses which cause the headaches in industry, because they are relatively few and far between. Far worse are the nickel and dime lapses which add up to far greater overall damage.

Consider a weak analogy between the number of American casualties in Iraq over the last four years (about 5,000) [source: http://www.icasualties.org/oif/USbyYear.aspx ]
and the number of deaths due to automobile accidents in 2007 alone (about 41,000) [source: http://en.wikipedia.org/wiki/List_of_motor_vehicle_deaths_in_U.S._by_year]

My local paper lists the death toll in Iraq (thousands of miles away) every day, but it doesn't list the deaths (about 24,000) in California each year due to air pollution
A state report (.pdf) to be presented today [May 22, 2008] says that "as many as 24,000 deaths annually in California are linked to chronic exposure to fine particulate pollution," according to the LA Times.
[source: http://laist.com/2008/05/22/24000_californi.php]

My point being the relatively unnewsworthy events wreak more damage than the newsworthy ones.
 
S

szohar

#13
I am not naming names, but I do have a story:

Company X and Company Y have a partnership. Company X manages the production of the product that Company Y is ultimately responsible for testing and storing. If the product is not produced, tested, and stored to spec, the results could literally be lethal. Multiple regulatory and accrediting bodies are involved in the industry, and the product is used globally.

When Company Y is testing and storing Company X's product, Company Y must follow Company X's latest SOPs.

What happens when Company Y mishandles its paper copies of the Company X SOPs, and ends up working with a prior version that was rewritten due to regulatory changes?

Hint: It's not pretty. Thank goodness the problem was caught before anyone could be harmed. However, both companies had to go to great expense to resolve the debacle, valuable product had to be destroyed, and then significant training had to happen on both sides to prevent a recurrence.

Names have been changed to protect the not-so-innocent... :notme:
 
D

ddunn

#14
I came across this problem when I worked for the DoD. While some may say it is not a document control problem (change approvals were obtained and the drawing properly revised (sort of)) it is a Configuration Management problem and a violation of the rules of interchangeability.

Company X made a fuel cell feed-through RF connector for use on military aircraft. Since the connector came in contact with the fuel it was replaced often as part of regular maintenance. The connector was a square flanged, 90 deg. N type feed-through RF connector. Company X revised the drawing with no part number change to make the connector a triangular flanged, 90 deg. BNC non-feed-through RF connector. Company X reason for the change – they had a new application and didn’t want to generate a new part number.

The result, many aircraft were grounded for several months until a new source could make the correct connector.
 

Randy

Super Moderator
#15
OK guys there is no intent to input politics into this discussion, the material I'm attaching is very relevant to the subject of Document Control and problems that can come from not having it.

This was recently in many news reports and articles and attribute to API I believe.

What are some of the problems that can happen because of the document this photo is an extract from?
 

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