Lean Knowledge Management

APPENDIX B

The Concorde Accident: A Case Study

The Beginning of the End

In July 2000, at Houston’s George Bush Intercontinental Airport, airline mechanic John Taylor riveted a 17-in. wear strip he had fabricated to a DC-10’s General Electric CF6-50 engine. Taylor had difficulty positioning all the rivets and used aircraft mastic to help hold the wear strip in place.

A wear strip is a piece of sacrificial metal that acts both as a cushion and a tight seal for the engine’s thrust reverser cowling. Replacing a wear strip is routine aircraft maintenance and is not considered a safety issue affecting operation or flight. John Taylor did not follow the manufacturer’s recommendations when he fabricated it and decided to use a piece of titanium, presumably ...