As if we didn’t need another expensive example of why standard work is critical.
The Air Force said the first crash of a B-2 stealth bomber was caused by moisture in sensors and estimated the loss of the aircraft at $1.4 billion.
The Air Force stopped flying B-2 stealth bombers for two months after the crash.The crash probably could have been avoided if knowledge of a technique to evaporate the moisture had been disseminated throughout the B-2 program, Maj. Gen. Floyd L. Carpenter, who headed an accident investigation board, said Thursday.
Carpenter said the pilots and crew followed procedures and "the
aircraft actually performed as it was designed. In other words, all the
systems were functioning normally."However, a technique learned
by some two years ago that had gone widely unknown and unadopted
probably would have prevented the crash, Carpenter said. The technique
essentially heats the sensors and evaporates any moisture before data
calibrations."This technique was never formalized in a technical order change or
captured in ‘lessons learned’ reports. Hence, only some pilots and some
maintenance technicians knew of the suggestion," according to
Carpenter’s executive summary of the accident.The report said, "The human factor of communicating critical information was a contributing factor to this mishap."
Enough said.
