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.
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.
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.
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.
"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 surgical
instruments are left in patients, 5 percent of prescriptions contain
errors, and 1 percent of these are potentially fatal.
