there was apparently two (identical) procedures -- one for "removing" the door plug and one for "opening" the door plug -- but only one of them actually called for paper-work and quality inspection after it is done.
It seems they decided to "open" the door plug instead of "remove" it to work on the sealing issue? -- and thereefore documentary record of the work performed and inspection thereafter is lacking.
It would be useful IMO to explore what led the team to prefer "opening" versus "removing" -- and if the subtle difference in documentation requirement was a consideration in preferring one over the other -- and if that points to deeper pervasive culture issues that leans towards less work rather than give safety and quality the primary importance.
I doubt this was intentional? It sounds more like mistakenly applying the procedure for opening a normal door, which requires no followup, to opening a door plug, which does.
what the Spirit mechanics had to do was a RMV, they knew this, because the Boeing eng rep told them so, but they didn’t like this, so they marked it in the system as an OPEN but performed the work of a RMV, to avoid the additional quality checks a RMV would require. And then they fucked up the RMV but didn’t know and no one else did because it was marked as an OPEN so no one checked the bolts.
this was very intentional. the Spirit mechanics thought they were hot shit and didn’t need to follow the stupid, slow process. and they abused the system to allow them to file the work as more innocuous than it was. because they didn’t need anyone checking their work, or whatever they were thinking.
My experience in across a range of technical and consulting roles has been that junior folk understand the need gor their work to be reviewed and checked, because they know that they are inexperienced. Good senior folk want their work to be checked because they are experienced enough to know that they are fallible. It is the mid level folks (especially those who are promoted above their competence to senior roles) who think that they are good enough not to need hheir work reviewing.
This is my experience as well, but it’s usually not those promoted above their capability but those who were passed over and then grow resentful that end up causing the issue. An otherwise competent, but now bitter, middle aged guy on the third shift (or otherwise with less supervision than usual) who is going through a divorce or some other major life stress is the scenario I see most often. They fall behind, they come in to catch up, they have to leave unexpectedly for a family medical crisis, they fall further behind, and so on and so on and before you know it, a perfectly rational person is doing stuff like half-assing the QA checks and it seems almost normal.
But you’re right. It’s not the black belts you have to watch out for it, it’s the browns.
there was apparently two (identical) procedures -- one for "removing" the door plug and one for "opening" the door plug -- but only one of them actually called for paper-work and quality inspection after it is done.
It seems they decided to "open" the door plug instead of "remove" it to work on the sealing issue? -- and thereefore documentary record of the work performed and inspection thereafter is lacking.
It would be useful IMO to explore what led the team to prefer "opening" versus "removing" -- and if the subtle difference in documentation requirement was a consideration in preferring one over the other -- and if that points to deeper pervasive culture issues that leans towards less work rather than give safety and quality the primary importance.