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What if the inspector isn't inspecting? NASA inspector indicted

#1
A former NASA quality inspector tasked with checking maintenance work on parts for the space shuttle Discovery will be arraigned Friday on federal charges that he failed to conduct 83 "critical" inspections in late 2002 and 2003, federal prosecutors announced Wednesday.
NASA Inspector Indicted

This raises a question: If an inspector is not doing his stuff, how do we find out? In this example, it seems to have taken NASA a while to catch on.

/Claes
 
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J

Jim Howe

#2
Where are the checks and balances? where is the supervisor? where is management? No audits? Finan was right NASA is a crap shoot! :mad:
 

Wes Bucey

Prophet of Profit
#3
Golly. I'm just a poor Demingite, howling in the wilderness, crying "blame the processes and the managers who created them!"

I won't bother to read through the case and yet my "cold read" of the situation is that Life, Health, Safety characteristics should have a system (even sampling) of review to assure everything is in conformance. The cold read part is that someone looked the other way when this inspector seemed to have time on his hands and clean clothes when other inspectors were pressed to finish and had smudged or rumpled clothing at the end of a shift.

I recall an instance when I was still in college and took a part-time job at the post office in downtown Chicago during the Christmas holidays. The supervisor in charge of my orientation made a special side trip to show off a room of people hand sorting mail. He took special pride in pointing out one woman of indeterminate age (20 to 30 years old, I guessed) whose hands were a blur as she threw mail unerringly into little cubby holes.

"You're only going to be here two weeks," he said to me. "She's only been here 4 weeks and she's my best worker."

Before I finished my two week stint (shuffling canvas carts of mail one block from the commuter train station to the sorting center), both the woman and the supervisor had been fired.

She turned out to be only 15 and illiterate, using her aunt's ID to get the job. She was having sex with the supervisor regularly during the lunch hour in one of the seldom-visited storage rooms. All the mail she "threw" was just random, since she couldn't read one word and "drew" her name to sign employment papers.

Postal officials didn't catch that she was illiterate until after they were fired. They were only fired because the supervisor's previous "girlfriend" was jealous and snitched them out for having sex. The supervisor admitted having sex, but claimed he had no clue she was underage nor that she was illiterate. He claimed he really thought she was a good worker. So did most of her fellow workers!

So - who was the NASA inspector's supervisor? What processes were in place for him/her to confirm the adequacy and competence of the inspector?
 

Sidney Vianna

Post Responsibly
Staff member
Admin
#4
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.
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
#5
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! :blowup:

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.
 
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C

cruiser0407

#6
NASA Requirements for QA

It is good to see individuals out there with good Quality minds who take pride in their work. I have been in the Quality world for 25 years and take pride in my work. I've seen individuals "railroaded" out because of their pride in their work. This may be that situation. I am going to research all the QA requirements that NASA has out on the net to try to find the true picture about this subject. :applause:
 

Wes Bucey

Prophet of Profit
#7
cruiser0407 said:
It is good to see individuals out there with good Quality minds who take pride in their work. I have been in the Quality world for 25 years and take pride in my work. I've seen individuals "railroaded" out because of their pride in their work. This may be that situation. I am going to research all the QA requirements that NASA has out on the net to try to find the true picture about this subject. :applause:
I'm looking forward to a report on the results of your research. Welcome to the Cove!:bigwave:
 
#8
Wes Bucey said:
I'm looking forward to a report on the results of your research. Welcome to the Cove!:bigwave:
Yep. Very welcome:bigwave: , and I'm looking forward to hear the outcome too. Particularly interesting in the light of the two swapped instruments in the Mars Rovers.

/Claes
 
A

Al Dyer

#9
This situation is probably the worst scenario of incompetance on all levels!! From setting goals to management, funding, planning, training and execution... the entire system failed with the ultimate effect (PFMEA 10) being death.

In this instance there should be consequences, from impeachments in Congress??? down to actions against lower level personnel with diminishing levels of accountability.

Harsh opinion, Yes!!! But a bit of venting is appropriate.

Al...
 

Jim Wynne

Staff member
Admin
#10
Claes Gefvenberg said:
NASA Inspector Indicted

This raises a question: If an inspector is not doing his stuff, how do we find out? In this example, it seems to have taken NASA a while to catch on.

/Claes
In this case, the strategy was to wait for something to blow up. The generally accepted--but misbegotten, imo-- definition of "corrective action" is "action taken to prevent recurrence." Hence the witchhunt referred to in the quote. I personally think it's too much to expect that you can continually put people on top of huge incendiary devices and shoot them into space without expecting that you're going to kill someone sooner or later. To think otherwise is either naive or disingenuous. A successful space shuttle mission is nothing short of miraculous when one considers the number of things that can go wrong, and there's simply no way to always account for all of them. In order to keep the carnage to a minimum it's necessary to adopt a policy of leadership and prevention (Deming said, "adopt the new philosophy"). The alternative is to accept the status quo, which means that politics and budget considerations ("business decisions") become a cause of death above and beyond all of the possibilities inherent in the activity.

We'll never know what the inspectors are doing (or not doing) until they don't do it and something bad happens. That's because intensive inspection is built into the design, and into job descriptions and also because inspection snafus are a convenient scapegoat for the bureaucrats when something explodes.
 
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