A Billion Dollar Knowledge Transfer Mistake!

The United States Air Force lost a B2 Stealth Bomber valued at $US 1.4 billion because of a failure to transfer knowledge between pilots and maintenance technicians. The bomber crashed earlier this year at Andersen Air Force Base on the island of Guam. Apparently water distorted pre-flight readings in three of the plane's 24 sensors, making the aircraft's control computer force the B-2 to pitch up on takeoff, resulting in a stall and subsequent crash.

B2 Stealth Bomber

The official accident investigation found that the crash probably could have been avoided if knowledge of a technique to evaporate the moisture had been disseminated throughout the B-2 command. 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".

Well there's the human factor of knowledge management at play! Sharing knowledge matters; and failure to do so can be very costly indeed.  What more incentive do we need.

Regards, Graham



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Re: A Billion Dollar Knowledge Transfer Mistake!

Submitted by Nerida Hart on Mon, 09/06/2008 - 09:58.

Graham - this is a great story of knowledge transfer failure - I am always looking for good examples of this and you have provided a beauty - for more stories of failure/mistakes - have you looked at the Mistake Bank on Ning - see http://mistakebank.ning.com/

Nerida

Re: A Billion Dollar Knowledge Transfer Mistake!

Submitted by Graham Durant-Law on Mon, 09/06/2008 - 12:48.

Hi Nerida,

It's one of the better ones, complete with tangible dollars!  Just imagine what you could do with a billion dollar knowledge mangement system, apportioned equally to people methods, process development and enhancement, some technological innovations, and some decent content management.

Thanks for the link - I wasn't aware of it.

Best Regards, Graham