Alaska Airlines grounding fleet of Boeing 737 Max jets for inspection after emergency landing

[T_R_Oglodyte]

Errors by Boeing at Renton plant led to Alaska Airlines MAX 9 blowout, industry source says

The piece that blew off an Alaska Airlines jet this month was removed and re-installed improperly by Boeing mechanics in Renton, according to a person familiar with the details of the work.

www.seattletimes.com

 

[davidvel]

@davidvel

I would like your perspective on something I was thinking about. The results of the door plug inspections completed so far indicate that loose bolts on the door plug was not an isolated incident for that Flight 1282 airplane, but distressingly is a systemic issue with door plugs on the MAX-9. Moreover, right now there isn't any clear reason I can see to think the problem is limited to the MAX-9. How could a systemic error such as that occur, and how could it apparently not be detected????

I think we can rule out the possibility that this is rogue or negligent employees failing to do their job correctly, with those failures not being detected. Rather, to me this points to an open step in the manufacturing process.

In one of your earlier posts you had indicated that the door plug would be installed by Spirit in Wichita and would be removed by Boeing after fuselage delivery, so that Boeing could use that opening during final assembly. Subsequent information, however, indicates that may not have been the case; the door plugs were installed by Spirit in Wichita and never removed by Boeing.

Piecing together that information, I hypothesize that there was an unfilled and, until now, unrecognized gap between the Spirit and Boeing silo operations. Spirit was assembling fuselages with the understanding that Boeing would be using that opening in the fuselage during final assembly. So Spirit didn't perceive that installing and tightening bolts to final spec was part of their work requirement because Boeing would be removing the door plugs anyway.

Meanwhile, Boeing believed that that the fuselages it was receiving from Spirit included door plugs installed to final spec. Since Boeing never removed the door plug, Boeing never bothered to inspect the door plug installation. Which would also mean that Boeing's inspection of Wichita fuselage assemblies did not include the door plug.

This strikes me as the simplest and most direct explanation to explain a systemic gaffe of this magnitude.

It has now been established that the plug should be in its final assembly from Spirit, and Boeing wouldn't open it unless there are problems that need to be addressed. As noted in the most recent article by Dominic Gates of the Seattle Times, it is pretty well accepted now that the plug door had problems from Spirit that had to be repaired. This required opening (not removal) of the plug and the 4 vertical arrestor bolts. A maintenance item was not entered into the system to replace the bolts and reinspect them. Over the Labor Day weekend different crews worked on the plane with it eventually being buttoned up without the bolts being installed. Over time, the door worked its way up and away from the stop pads that keep it in place. It is simply incredulous that such a thing could happen, but it certainly did. That being said the Max 9 is flying again today, including a flight from Honolulu to Portland, so more likely than not it was not found to be a systemic issue by the FAA.

As to reports of other bolts being "loose" I have not seen any details as to what extent. There is an unverified photo of a UA plane with bolts that appear not to be properly seated on a lower spring bracket, however, even if the 4 bolts on that assembly came loose, the plug would stay in place. You would likely need 3 if not all four corner assemblies of the plug to come loose to allow it to move upward, and there probably would be some indication of something wrong prior to the 4th giving way. Also a loose bolt (or nut) could be one with 14 kn of torque instead of a required 14.5.

There is no doubt that there is a problem at both Spirit and Boeing, and the FAA announced that it is looking into these defects coming off both lines. Increased oversight activities include:

- Capping expanded production of new Boeing 737 MAX aircraft to ensure accountability and full compliance with required quality control procedures.
- Launching an investigation scrutinizing Boeing’s compliance with manufacturing requirements. The FAA will use the full extent of its enforcement authority to ensure the company is held accountable for any non-compliance.
- Aggressively expanding oversight of new aircraft with increased floor presence at all Boeing facilities.
- Closely monitoring data to identify risk
- Launching an analysis of potential safety-focused reforms around quality control and delegation.

 

[davidvel]

For many years, almost every pilot I knew personally told me to only fly Boeing, and stay away from Airbus (Scarebus). All those I knew who used to say this are now retired, I believe, and it was a different time. Yet for years I have preferred Airbus planes for comfort and didn’t really care much one way or the other which I was on. But now it seems Boeing has tarnished their name beyond a simple fix. Given the choice, I will book Airbus (and yeah, I’m on at least one Boeing MAX-8 next month which I don’t think I can change, though I may try).


Sent from my iPad using Tapatalk

If it makes you feel any better, the Max 8 doesn't have any plugs like the Max9 and 737-900.

 

[T_R_Oglodyte]

It has now been established that the plug should be in its final assembly from Spirit, and Boeing wouldn't open it unless there are problems that need to be addressed. As noted in the most recent article by Dominic Gates of the Seattle Times, it is pretty well accepted now that the plug door had problems from Spirit that had to be repaired. This required opening (not removal) of the plug and the 4 vertical arrestor bolts. A maintenance item was not entered into the system to replace the bolts and reinspect them. Over the Labor Day weekend different crews worked on the plane with it eventually being buttoned up without the bolts being installed. Over time, the door worked its way up and away from the stop pads that keep it in place. It is simply incredulous that such a thing could happen, but it certainly did.

Incredulous may be an understatement. But what is even more incredulous is that while it now appears that the door plug blowing off may have been a one-off for that airplane, the inspections triggered by that instance uncovered a separate, but systemic, issue. That is what is concerns me - there isn't any reason to presume that there aren't similar problems in other areas that haven't been identified simply because there hasn't been any kind of triggering incident.

The whole MAX fleet seems increasingly seems like a "peeling the onion" exercise - every time something happens and you dig in, you find something else or you see something that points to systemic safety failures.

It's simply stunning and mind-boggling to me, and points to huge breakdowns in safety and quality assurance programs. It strikes me as the types of things that happen when people are pushed so that getting it done is more important than getting it right.

 

[T_R_Oglodyte]

If it makes you feel any better, the Max 8 doesn't have any plugs like the Max9 and 737-900.

With fixes now approved on the MAX9 door plug, I'm no more worried about flying in a MAX9 than any other plane in the MAX fleet. My concerns are that I don't know how much deeper the whole fleet is affected. And the extent to which similar issues infect the non-MAX aircraft fleet.

 

[Ken555]

'I would absolutely not fly a Max airplane': Ex-Boeing manager raises alarm on jets returning to service

The airlines and Boeing say they're committed to safety. Some analysts and aviation experts, however, still have concerns about the Max 9.

www.latimes.com

Sent from my iPad using Tapatalk

 

[TolmiePeak]

Boeing needs to purge the McDonald Douglas bean counter mentality that is destroying one of America's great companies. Only then can they return to greatness. I still think the most dangerous part of any airline flight is the drive to the airport.

 

[T_R_Oglodyte]

I still think the most dangerous part of any airline flight is the drive to the airport.

Yep.

And driving to a timeshare for a vacation is more hazardous than flying to a timeshare for a vacation.

 

[T_R_Oglodyte]

After reading this article, I can only assume that Boeing management was on a rafting trip near the Pyramids when they put together this plan.

Boeing sets course to pull out of crisis

Boeing lost $2.2 billion last year, a smaller loss than expected. But Boeing leaders Wednesday dwelt little on the earnings, focusing instead on the crisis from the Alaska Airlines MAX 9 blowout.

www.seattletimes.com

 

[Tia]

clipped

********

Cycling back to the Boeing MAX, I'm part of a group that views the more significant issue, the problems with the MCAS system, to reflect a basic failure to apply fundamentals of safety engineering to the design of the aircraft, and that failure is likely attributable to the erosion in engineering standards in Boeing that ensued after the McDonnell-Douglas combination. A basic principle in safety engineering is that with mission critical systems, designs that eliminate a hazard should always be selected over designs that incorporate engineering controls to mitigate the hazard. Control of hazards should only be deployed when it is not feasible to eliminate the hazard.

Under the bean-counting culture brought in with the McD suits, when the problem with attack angle emerged (resulting from reusing prior engine mounts), Boeing eschewed the notion of redesigning the engine mounts (would have been more costly and delayed the project), and instead applied engineering controls.

As history subsequent showed, that engineering short-cut was a horribly flawed decision. And this is a classic example of how a "bug" played out in real time. To restate the obvious, if you design to eliminate hazard (in lieu of managing hazard), you eliminate the bugs.

Now sometimes you don't have any alternative but to use things like nuts and bolts to address a problem that can't be designed away. In which case, you do things such as set-up regular inspection schedules. And, as things proceed in real time, you learn from issues and refine and update procedures.

Anyone see this?

Boeing whistleblower John Barnett found dead in US

Prior to his death, John Barnett was testifying against Boeing over concerns about standards.

news.yahoo.com

comments are interesting after the article

 

[Snazzylass]

Anyone see this?

Boeing whistleblower John Barnett found dead in US

Prior to his death, John Barnett was testifying against Boeing over concerns about standards.

news.yahoo.com

comments are interesting after the article

Yes! Saw it last night. Troubling, for sure.

 

[emeryjre]

BA is in serious need of a change in Management
The Board of Directors have a responsibility to shareholders
In this case they have a responsibility to end users as well
It is obvious that something is wrong somewhere in the system
Well written statements from corporate headquarters about responsibility, we care, etc. etc are not going to do it
I have done well selling BA stock short over the last 5 years
I would gladly return my earnings in exchange for the BA of old

 

[Breezy52]

“end users”, yikes

 

[TolmiePeak]

Very sad that the whistleblower had enough and couldn't take it anymore. Boeing is one sick company. A top to bottom house cleaning is in order.

 

[easyrider]

It was in the news suggesting that it is a bad idea to use dish soap on door seals. I thought it funny because dish soap works well as a lubricant for many things.

Bill

MSN

The FAA found staff at Boeing's supplier using liquid Dawn soap as lubricant for a 737 Max door seal: NYT​

 

[1Kflyerguy]

It was in the news suggesting that it is a bad idea to use dish soap on door seals. I thought it funny because dish soap works well as a lubricant for many things.

Bill

MSN

The FAA found staff at Boeing's supplier using liquid Dawn soap as lubricant for a 737 Max door seal: NYT​

I thought the same thing when I heard this. Dawn dish soap works really well for a lot of things, and is easy to clean up when done. A few news articles also commented on working using hotel card keys as tool to help install things. When I worked as a mechanic, we often made our own tools, and nice flexible card key can do a lot of things... such as not cutting into a gasket like a metal scraper might...

 

[clifffaith]

I thought the same thing when I heard this. Dawn dish soap works really well for a lot of things, and is easy to clean up when done. A few news articles also commented on working using hotel card keys as tool to help install things. When I worked as a mechanic, we often made our own tools, and nice flexible card key can do a lot of things... such as not cutting into a gasket like a metal scraper might...

Cliff used his Contractor’s License card as the perfect tool for quickly and efficiently removing vertical blind slats. In 1992 he had to fly to Sacramento to take the contractors test to be in compliance with laws that changed regarding businesses that installed window coverings. He flew home that April night and saw the city burning after the Rodney King verdicts.

 

[T_R_Oglodyte]

I'm pretty sure that the findings do not mean that using dish soap and the hotel card key is dangerous.

The finding is procedural citation; namely, that the use of dish soap or the plastic card is not included in the standard procedure.

In doing process safety audits, this type of situation is very common. The people doing the work come up with a way to make the task easier, so they start doing it. What they are supposed to do is then initiate the process of revising the standard procedure to incorporate the hack. In other words, to take time out from their primary activities to create paperwork.

Because most people prefer to avoid paperwork, they let that change slide, and it goes unnoticed until an auditor (i.e., paperwork checker) reviews the process. That generates an audit finding, but when risk ranking is done it would be low hazard.

 

[WaikikiFirst]

finding is procedural citation

Agree with all this; however ...
saying that dish soap is a good short-term lubricant is not the same as saying that dish soap is an inert / neutral (pick a descriptor) liquid that will not degrade materials over time. I've never read all the ingredients. It is prob not far off shampoo, but note that both of those are meant to be RINSED OFF the surfaces quickly after cleaning, not to be left on. Since most of the packaged products you can buy in a grocery are chemistry experiments, I wouldn't count on dish soap being inert.