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.

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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Comments
Re: A Billion Dollar Knowledge Transfer Mistake!
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!
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