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Boeing 777 landing-gear incident, who is to “blame”?

Written on:juni 6, 2011
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Boeing 777

Boeing and the Federal Aviation Administration are investigating why a landing gear was improperly installed on a new Boeing 777 jet. This technical deficiency led to an emergency landing at Paine Field in May. This flight was fortunately a test flight.

According to the aircraft manufacturer, incorrect rigging of the landing gear during final assembly caused the incident. Boeing believes that the root cause lies with “workmanship issues”. Mechanics did not follow instructions for proper assembly and they indicated that there was time pressure involved. It was a case of hurry up and get it done. So, the mechanic is to blame?

The internal system of inspections and quality control failed. Mechanics were more and more performing self inspections and no quality inspectors were signing off the independently performed work on the landing gear? So, is the Quality System to blame?

If human errors like these occur and the individual was forced to deviate from standard work instructions due to time pressure, the blame lies with the organization and not the mechanic or the Quality System. It’s culture is wrong and indirectly allows these deviations, by imposing pressure. If you blame the individual, you will develop a blame culture within the organization. Next time when mistakes like these happen, mechanics will not report human errors, and may hide them, lie about it or even worse, blame others.

The organizational culture should support that when mistakes are made, that they need to be reported with the intention to learn and prevent them form happening again.

A safety first mentality, instead of a sales first mentality is needed to support a good and Human Factors healthy organizational culture. With this, the number of internal human factors related incidents, should go done, and the organization’s safety level should go up.

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