JF Mezei wrote on Sat, 13 Oct 2018
15:56:38 -0400:

On 2018-10-13 09:43, Jeff Findley wrote:

They know WHAT happened. What they don't know is WHY it happened.


Agreed. And the fact that Russia is still planning on launching the
next Soyuz on time, presumably with a crew on board, is indicative of
how they handle these investigations.


If NASA's methods wee applied to car travel, there would be no cars
travelling because with each accident, NASA would convene a 3 year
investigation to ensure there are no safety defficiencies or design
problems at GM, even if the accident was caused by a car driver going
through a red light and hitting another car.


Mostly bull****.


It is ironic that you are quick to believe that they found out exactly
what happened, but then criticise the Russians for not cancelling plans
for another launch.


It's ironic that you'd lie.


Once they know what happened, then they can check the next rocket to
ensure all the parts in that area of rocket were assembled properly and
launch. Once they know it was human error and not a design flaw, the
need to ground the fleet until the design flaw has been isolated is reduced.


Except they won't know that just from knowing 'what happened'. They
need to figure out WHY and HOW it happened, and that's the hard part.


Same with that hole in the Soyuz. Once they find out that it was human
error, they know where to check on the upcoming ships to ensure same
error not present and allow it to launch.


The Russians are constantly trying to 'inspect out' problems rather
than figuring out root causes and fixing those to prevent the problems
in the first place. It's a very 1960's approach and it simply doesn't
work very well.


That doesn't mean that they stop looking at why that emnployee made that
mistake, why he was handed the wrong tenmplate, why he didn't notice it,
and why he didn't warn anyone after he realized he drilled hole in wrong
place.


Of course it does. They punish that guy and move on. Again, a very
1960's approach.


Having a 3 year long commission to conclude what they already know about
a cultural problem that lacks full quality assurance mentality wouldn't
do much since they already know that.

My guess is that the drilling and now this accident will cause whatever
relaxation in quality assurance to be undone to return to a stricter
quality assurance.


For a little while. And that's the whole problem with 'inspect in the
quality'. It's just not sustainable in the long term. Your guess is
wrong. I'd bet they didn't 'relax' or change anything at all, so
there's nothing to 'undo' and nothing different to 'return to'.


There is a huge difference between a problem that has already happened
(loose bolt) that you can check for, and a problem that hasn't happened
yet but could happen due to design flaw (battery issues on 787 for
instance). In the later case, you want to ground the fleet because you
can't predict/check when it will happen next.


But why was that particular bolt loose? Design flaw? Bad
manufacturing? Lack of retainer? Bad maintenance procedure? Higher
than predicted vibration levels? You need to know and just inspecting
that particular bolt just adds to the inspection load without solving
the potential problem.


But if an employee didn't tighten bols sufficiently it is easy to tell
airlines to check their aircraft for loose bolts. (and once rectified,
there is no fear of a problem so you can fly safely).


Until the next plane goes down because of the next bolt...


--
"Ignorance is preferable to error, and he is less remote from the
truth who believes nothing than he who believes what is wrong."
-- Thomas Jefferson