A culture existed within the engine manufacturer's Hucknall facility where it was considered acceptable to not declare what manufacturing personnel determined to be minor non-conformances in manufactured components.
During the ATSB’s investigation, Rolls-Royce advised that, in June 2007, an independent product process audit was conducted at the manufacturer’s facility at Hucknall. The audit found that items being produced at Hucknall contained high levels of non-conformance that were not being reported through the existing non-conformance management process.
The manufacturer reported the following safety actions had been taken in response to those audit findings:
All output from Hucknall (HCAS) was stopped.
Civil and Defence engineering teams were engaged to assess any non-conformance in order to identify anything that could affect fit, form or function.
The CAA were informed of a ‘compliance issue at Hucknall’.
All HCAS employees were briefed in July 2007, and again in October/November 2007. The key message to employees was to emphasise the concession process requirement that all non-conformances to the engineering drawings must be identified and assessed.
A major quality investigation (MQI) was raised on 15 August 2007 to investigate systems, processes and behaviours.
These actions were completed in June 2008.
The ATSB is satisfied that the action taken by Rolls-Royce adequately addresses this safety issue and therefore makes no recommendation.
