The Story
The aircraft manufacturer had been under pressure for years. Delays had cost them billions. Competitors were gaining ground. Customers were demanding their planes. The message from leadership was clear: get these aircraft out the door.
So they did.
One January evening, a commercial flight was climbing to cruising altitude when a section of the fuselage — what’s called a door plug — blew out. The explosive decompression sucked a headrest and a child’s shirt into the night sky. Passengers gripped armrests as oxygen masks dropped. By some miracle, no one was killed.
The investigation found the cause: four bolts that were supposed to secure the door plug were simply missing. Not broken. Not failed. Missing. They had never been installed.
Further examination revealed a pattern. The manufacturer had been under such pressure to deliver that quality inspections were being rushed or skipped. Documentation was incomplete. Workers reported being told to sign off on tasks they hadn’t fully verified. The pressure to ship had overwhelmed the systems meant to ensure safety.
The aircraft was grounded nationwide. Congressional hearings followed. Whistleblowers came forward. The CEO announced his resignation. What had been a delivery delay became an existential crisis for the company’s reputation.
The Lesson
Temporal Ordering asks: Am I doing things in the right sequence?
The manufacturer prioritized delivery over verification. They shipped the aircraft before confirming the quality checks were complete. In their mental model, speed was the constraint and quality could catch up later.
But quality isn’t something you add at the end. It’s built into every step — or it isn’t there at all.
The sequence failure:
- Install the components — Done, but not verified.
- Document the installation — Incomplete.
- Independent quality check — Rushed or skipped.
- Certify aircraft as safe — Signed off anyway.
- Deliver to customer — Priority achieved.
- Customer discovers the problem — At 16,000 feet.
Each step was technically completed. But “completed” doesn’t mean “correct.” The manufacturer treated the sequence as a checklist to get through, not a chain where each link depends on the one before.
Applying It
When you’re under pressure to deliver, it’s tempting to treat quality as something you can fix later. But some sequences don’t allow for later. If the door blows out, there’s no patch for that.
Before you ship, ask: Have I actually completed the steps, or have I just checked the boxes?
The bolts weren’t broken. They were never installed. The manufacturer shipped before they were done — and “done” turned out to be the only thing that mattered.
This story is inspired by real events. Names, companies, and details have been fictionalized.