RE: TW and QA

[eric -dot- dunn -at- ca -dot- transport -dot- bombardier -dot- com]

bounce-techwr-l-106467 -at- lists -dot- techwr-l -dot- com wrote on 10/20/2004 08:50:51 AM:
> The article described a stunning gap in QA. A failure of the gravity
> switches would (and did) lead to the total loss of the 
> $264 million capsule.
> Was there no way to test their functioning when installed 
> according to the drawings?

The article showed not one gap, but many. Instead of their processes and 
testing resembling the "Swiss cheese" model (where there can be many 
holes/gaps but they don't line up to form a clear path), their processes 
and testing clearly had many critical paths to disaster and inadequate 
monitoring of those paths.

The design of the switch should have indicated "this way up", the designer 
of the craft should have designed the mounting in such a way the switch 
couldn't be installed upside down or clearly indicated it in the design 
drawings, the manufacturing engineer (or Industrial or Methods Engineer, 
all overpaid techwriters for a portion of their duties) should have been 
savvy/technical enough to realise that such switches have an Up and 
written the procedure and created the assembly drawing accordingly, the 
procedures should have been reviewed and tested, inventory control should 
have noticed if the switches were packaged with documentation and brought 
it to the attention of engineering, the assemblers (which in that industry 
are probably more savvy than your average assembly line type worker) 
should have noticed that the switch didn't have a clear mounting method, 
the test engineers/QA should have designed a test based on manufacturers 
information to test the orientation of the switch, project management 
should have been in charge to ensure that the lists and management 
required were in place to ensure that all components were tested and all 
manufacturers information and tolerances were communicated correctly.

The OEM, system design, manufacturing/methods, shipping/receiving, 
assembly, Tests/QA all had primary roles in the ignorance of the problem 
and the eventual failure. Management had an important secondary role. 
Unless it can be shown that someone DID speak up, but was ignored, this is 
not a single point failure. It should be impossible for it to be a single 
point failure (and if it was a single point failure, it is actually two 
failures. Management has to shoulder as much, or more, blame as the 
failure point).

A technical writer or someone tasked with focusing procedure writing may 
have caught the problem. But considering that none of the other job 
functions I've mentioned seemed in the least bit interested in the 
technical side of what they were doing, would the corporate culture have 
been broken by one more person on the team?

Eric L. Dunn
Senior Technical Writer

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

ROBOHELP X5: Featuring Word 2003 support, Content Management, Multi-Author
support, PDF and XML support and much more!
TRY IT TODAY at http://www.macromedia.com/go/techwrl

WEBWORKS FINALDRAFT: New! Document review system for Word and FrameMaker
authors. Automatic browser-based drafts with unlimited reviewers. Full
online discussions -- no Web server needed! http://www.webworks.com/techwr-l 

---
You are currently subscribed to techwr-l as:
archiver -at- techwr-l -dot- com
To unsubscribe send a blank email to leave-techwr-l-obscured -at- lists -dot- techwr-l -dot- com
Send administrative questions to lisa -at- techwr-l -dot- com -dot-  Visit
http://www.techwr-l.com/techwhirl/ for more resources and info.