Replacing the Baby Boomers

“Shut it down! Shut it down!” Every alarm on the $9 Billion engine was going off. Oil was seeping from every visible seal on the crankshaft. The building was filling with a hazy cloud of oil smelling smoke. “Shut it down! Shut it down!”

A $9 billion engine almost destroyed before it was even installed on its ship. Estimated cost of repairs will total over $3.5 million, not to mention 3 ½ months of extensive labor. How could this happen? What could have possible went wrong. This was the 54th engine in that series; there were no engineering changes; everything was to be manufactured and assembled as all the previous engines. Could it have been a new and inexperienced assembler on the test stand? Someone who was following procedures exactly as trained; but was missing the extensive experience and tribal knowledge?

“Bob,” who was an inexperienced assembler, but very knowledgeable, did his job exactly as trained, but didn’t match the correct covers with the correct block. This is a procedure that the previous retired assembler always did just as a double check. There is no documentation nor is there any quality requirement to do this. It was just something the “retired” assembler would do as a precaution.

When the engine blocks arrived at the facility, they were inspected and signed off. What was not noticed was “Gene” the senior employee, kept a manual journal of all the serial numbers for the blocks so that when the covering caps arrived at a later date, he could make sure that they matched and were assembled on the right engine block. It just so happened that for some strange and bizarre reason, engine block 4 of this set arrived prior to engine block 3. The covers arrived in the proper order. “Gene” the senior employee had retired before the covers arrived. No verification of serial numbers was made at the time of assembly. This little procedure was not noted anywhere. The small error in attention to detail has cost the company millions...