scope:

Description of Driving Event:

A manufacturing engineer found that sixteen fasteners were not installed on Flight Wing 1 (Solar Array Assembly) two (2) days prior to shipment. Investigation revealed deficiencies and/or breakdowns in several discrete process.

Root cause:

1. Engineering design error; fastener was too short.

2. Failure to adhere to manufacturing control processes:

a. Fasteners were not installed and informal notification of fastener size error was done in lieu of formal discrepancy report (DR) documenting incorrect fastener size and lack of fastener installation.

b. Inspection/Manufacturing failure to verify completion of operation at documentation buyoff (Inspection buyoff indicated bolts were installed, but bolts were not actually installed). Operation had Operator & inspection stamps indicating installations actually occurred, which is a process violation.

3. Planning incorrectly posted a Manufacturing Change Notice; the design change adoption process was not followed. When an engineering change initiated to correct the fastener size was processed, planner did not flow the change down to the initial assembly, only subsequent assemblies.

4. Subsequent Engineering/Manufacturing/Quality Assurance hardware reviews ("shakes") failed to identify missing bolts: "Shakedown" verification process inadequate.