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Re: Re: Arcjet Motor (or tell me which person is responsible)



The fault does not lie with one individual who may have made a mistake and 
forgot to check the removal of one preflight safety cap.

The fault lies with the Team management who established the flight ready 
safety inspection procedures.  There should have been at least a 3 member 
team of inspectors who would have had to inspect every single safety 
removal item prior to flight ... who would have had to sign their name to a 
piece of paper for every single item, stating that they had inspected the 
item, that the item had been removed and the item was flight ready. Three 
people having to eyeball and sign off would have prevented this accident. 
Hopefully we will use such procedures on future satellites.

W4SCO




At 06:34 PM 6/8/2001 , you wrote:
>The AMSAT-NA board, which represents its members, initiated an investigation
>by people who understood the process of building and launching satellites
>and published a report (see
>http://www.amsat.org/amsat/news/ans2001/ans01077.html#01). I'm sure that
>whoever forgot to remove the cap on the valve exhaust port had to explain it
>to 20 of his peers. There is no reason that the rest of the world needs to
>know his or her name.
>
>I've had people working for me make mistakes. They had to admit them in
>weekly project review meetings and fix them. However, I would never make
>them go to the customer to have them humiliated and no customer ever asked
>me to do that. Usually, anyone in the project team could have made the same
>mistake. Singling out one person would only make everyone less willing to
>admit mistakes and future product quality would suffer. If a person didn't
>learn and kept making mistakes then he or she had to be moved to a more
>suitable job. Standing in front of the customer and having them tell me that
>we were a buch of creeps was my job since I was management. After venting
>their anger, the customer would usually accept our plan to fix the problem.
>
>73,
>
>John
>KD6OZH
>
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