Classic Mistakes

F117 Crash Blamed on Missing Bolts

When an F117 pilot complained about vibrations, the flight crew inspected the aircraft, but didn't find any problems. The pilot ejected safely on September 14, 1996 when vibrations became extreme. Subsequent investigations showed that four of five 1 inch diameter bolts holding a wing to the airplane were missing! A cover plate not removed during inspection concealed the missing bolts. The $42 million dollar plane was destroyed.

Mislabeled Fluid Costs Saturn $5B

In the Saturn automobile startup, because fluids were mislabeled the wrong fluid was used in production. When the problem was discovered, corporate leaders recognized that the fluids would destroy seals in the vehicle. Since Saturn's reputation was on the line, the company decided to replace all vehicles that might contain the wrong fluid by delivering new vehicles to the owner. The replacement cost Saturn an estimated 5 billion dollars.

Hatch Size Makes Aircraft a Deathtrap

During WWII, pilots in one British aircraft would enter the plane by throwing their parachute through the hatch, and then climbing aboard. Part way through the war, it was realized that the death rate was significantly higher in this aircraft. It was discovered that the pilots could not bail out of the aircraft through the hatch with the parachute attached. Due to the urgency of war, the problem was not corrected.

Blunder Burst KC -135

The outflow valves used to regulate aircraft pressure on a KC 135 were capped off during a 5 year overhaul and not reopened. During a pressure check, a depot technician used a homemade pressure gauge without procedures. The gauge did not have a "max" peg. The technician missed the fact that the needle had gone around once, and on the second trip around the plane ruptured with a boom. Thankfully, no one was injured.

Boy Loses Cancer Battle

"The boy's life turned into a chain of medical visits....that...led to one mistake after another." "One error cost him several ribs that were mistakenly removed during surgery. ...Daniel had to go under the knife again to have the correct ribs removed." –The Record, March 1998

Think this is an isolated incident? It is estimated that 44,000 to 98,000 people die each year in hospitals due to errors. Each year, 1500 sponges and surgial instruments are left in patients, 5 percent of prescriptions contain errors, and 1 percent of these are potentially fatal.