Process control means lining up the layers of swiss cheese such that the holes never line up.
Process control failure here, and serious one too.
Completely agreed. Complete process control failure...
One operator, in Opa Locka, got this wrong. The Swiss Cheese worked in thousands of other locations, but human stupidity has a way of penetrating every safety measure imaginable...
It could be as simple as not tasking the same guy with filling the DEF tank and filling the de-icing tank on the fuel trucks, ever. But you're correct, human beings have a natural talent for finding a way to cause a fail no matter how much fail-safe has been installed. I'm the "safety guy" here at our little company, when I see things being done that look sketchy to me I'm told we've never had an injury doing it that way...okay.
A14, Being in aviation will you ever know the root cause of the DEF fuel contamination?