Raytheon Aegis missile part aluminum bending incident

Early 1980s. A worker straightened a bent aluminum bar with a handheld torch — destroying the heat treatment. Navy inspector caught the lack of procedure, shut down the 400-worker plant. Tom (after Mortensen begged off) called it a tempest in a teapot, wrote up the analysis, and the plant was back in operation by Friday. Used to illustrate Navy SUBSAFE-era documented-procedure enforcement.

Back in the 80s, I had been in Japan and just got back, and I got a phone call from Raytheon here in Massachusetts. They had a production facility making parts for the Aegis missile defense system — if you're trying to knock out a ship, they have a whole slew of rounds that would knock down some incoming missile. So it's pretty critical to the safety of the ship. Some Navy inspector was walking through the shop, and he noticed a guy using a handheld torch — actually an oxy-acetylene torch — because one of the aluminum bars was bent and he was heating it up to bend it back into shape so he could finish building the part. The Navy inspector said, where's your procedure on that? This is the early 80s, before things like ISO 9000 which require you to have procedures. But the Navy had procedures, because — remember I told you a lot of the total quality management came out of the SUBSAFE program — the Navy in the 1960s had instituted: you must have documented procedures for how you're going to manufacture something.

Illustration of ISO 9000's "everything must have a written procedure" requirement. Navy inspector found a worker putting a torch to heat-treated aluminum with no documented procedure; plant shut down for three days.

Exactly — you have to have these meetings, you have to have every procedure documented. I mentioned the other day, over at a Raytheon plant, the Navy was building something for the Aegis missile system, and the Navy inspector walked through, and a guy was putting a torch to a piece of heat treated aluminum. He says, where's your procedure on that? There was no written procedure. It shut down the plant for three days. Under ISO 9000 you must have a written procedure for everything in your manufacturing process.