Boeing 737 Max again, it would be nice if the windows stayed in!

[Gyro]

'My God, it's full of stars'

Alaska Airlines has grounded its fleet of 737 Max 9s after a cabin window and part of the fuselage blew out at a mere 16000ft! I shudder to think what it would have been like at 30000 ft, as it was, a kid lost the shirt he was wearing. Luckily there was nobody in the window seat, which had its cushion stripped off...

https://www.bbc.co.uk/news/world-us-canada-67899564


Not a S/W problem this time, unless maybe you include CAD, but a hell of a QA failure!


Edit: I missed the one on 29th December where a rudder control system bolt was found with no nut on it - Airlines were asked to inspect to see if their bolts were loose "Out of an abundance of caution..." Hmm.

[Andy Chee]

When they developed the original 737 airframe into the MAX airframe, I don't think windows were changed were they?

In other words, this problem potentially affects all 737s, not just the MAX.  That's assuming it's indeed a design flaw, as opposed to lax maintenance.

[Gyro]

Looking at it further, it appears that that window was part of a 'factory deactivated' emergency exit which has a row of seats in front of it on the Alaska Airlines stock. It looks as if it would have facilitated in-flight exit without touching the sides!

Altitude ceiling is specified at 41000ft, so it was really low when it happened. I though all plane exits were inward opening before swinging? 

[NiHaoMike]

In other words, this problem potentially affects all 737s, not just the MAX.  That's assuming it's indeed a design flaw, as opposed to lax maintenance.

Alaska Airlines was infamous for bad maintenance, the crash of Flight 261 inspired the movie Flight.

[themadhippy]

Not a S/W problem this time

even though it sounds like a bad windows installation

[Gyro]

Alaska Airlines was infamous for bad maintenance, the crash of Flight 261 inspired the movie Flight.

I wonder what maintenance / inspection is specified for something like that. Presumably it is made to look like a normal window behind what looks like widely overlapping wall trim (I know all interior trims and seats are removed for major inspections).

I always though plane doors are impossible to open when the cabin pressurized though. I always used to try an get an emergency exit seat for the legroom, before they started going down the queue offering them at extra cost. Maybe there's something to be said for having your kneecaps squashed tight against the seat in front.

[Andy Chee]

I always though plane doors are impossible to open when the cabin pressurized though.

[SiliconWizard]

That doesn't bode well.

[Gyro]

Hmm, that's what I thought. That probably rules out Boeng using the wrong nails when they nailed it shut. Presumably a tapered door can't shrink, so the tapered frame suddenly getting bigger?

I wonder if they saved on the door and frame and 'factory disabled deactivated' means 'bolted something else in instead'.


I see that US regulators have now ordered the grounding of 171 further Max 9s for inspection.

[Ranayna]

Alaska Airlines was infamous for bad maintenance, the crash of Flight 261 inspired the movie Flight.

I wonder what maintenance / inspection is specified for something like that. Presumably it is made to look like a normal window behind what looks like widely overlapping wall trim (I know all interior trims and seats are removed for major inspections).

I always though plane doors are impossible to open when the cabin pressurized though. I always used to try an get an emergency exit seat for the legroom, before they started going down the queue offering them at extra cost. Maybe there's something to be said for having your kneecaps squashed tight against the seat in front.

In this case i would not think that maintenance was the issue here.
The plane was just 10 weeks old.

I have no idea how much maintenance it would have required in this time, but i would think that maintenance on such a "factory deactivated emergency door" would be very rare, if ever required outside of a major overhaul.

Also not just this "door" ripped out, the whole panel containing the door was ripped, rendering all security features of the door itself totallty moot.

[tooki]

When they developed the original 737 airframe into the MAX airframe, I don't think windows were changed were they?

In other words, this problem potentially affects all 737s, not just the MAX.  That's assuming it's indeed a design flaw, as opposed to lax maintenance.

The aircraft in question is only two months old, so I think we can confidently rule out maintenance.

So my hunch is an assembly mistake, not a design flaw or bad maintenance.

[tooki]

I always though plane doors are impossible to open when the cabin pressurized though.

It was an emergency exit, not a regular door. Not sure if those use the same mechanisms.

But as Ranayna said, the door/window latching mechanism design is irrelevant if the whole wall tears off… 

[abeyer]

But as Ranayna said, the door/window latching mechanism design is irrelevant if the whole wall tears off… 

Except it wasn't a "whole wall" from what it looks like: the "panel" that came off was only the interior trim panel that covered the door, which was presumably blown out by the pressure when the door failed, but pictures clearly show the door frame/structure still seemingly intact on the plane and no other obvious structural parts missing.

[AndyBeez]

https://www.flightradar24.com/blog/alaska-airlines-737-9-max-exit-door-separates-in-flight/

[MarkS]

It's called a plug door. It's an opening designed as an optional emergency exit and was plugged in this case. The plug came out. The question is, why?

[SiliconWizard]

Well, maybe Boeing should have pulled the plug.

[tom66]

Flashback to this event, also on a 737 (though an earlier 737-700, delivered in 2000).
https://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1380

Uncontained engine failure caused cabin damage and led to a woman unfortunately being partially sucked out of the aircraft.  Whilst passengers managed to keep her inside the aircraft, she succumbed to her injuries (blunt force trauma according to the health department).

Obviously, there's quite a difference between an uncontained engine failure on an ~18 year old engine, and a door failing after just a few months in service.  NTSB will surely want to find that door.

[tooki]

But as Ranayna said, the door/window latching mechanism design is irrelevant if the whole wall tears off… 

Except it wasn't a "whole wall" from what it looks like: the "panel" that came off was only the interior trim panel that covered the door, which was presumably blown out by the pressure when the door failed, but pictures clearly show the door frame/structure still seemingly intact on the plane and no other obvious structural parts missing.

Well if it’s a plug-style door, then either:
- a section of wall would have had to go with it (=door stayed intact, wall failed)
- the wall is intact but the door itself failed
- it’s not a plug-style door at all, despite being called a “plug”

[schmitt trigger]

If I had been the quality inspector at the Boeing factory where this plane was assembled, I would be scared shitless right now.

[CatalinaWOW]

Maybe the problem is that the inspectors DON'T fear escapes. 

 But really this is just one more but of unfounded speculation. I could come up with a list of guesses longer than your arm.  Probably ought to wait for the investigation.

[floobydust]

Dennis Muilenburg, former President, chairman and CEO of Boeing did run the company literally into the ground.
Firing all the senior staff, whether engineers or production staff and then outsourcing - does have a consequence that MBA's and Wall Street can't fathom.
His $80M golden parachute, when he should be in jail.
Thank God his investment firm New Vista failed and he cannot do more damage to other companies as a SPAC (special purpose acquisition company, "blank cheque"). Canadian Flair Airlines he wanted to acquire and presumably also run into the ground.

I have seen, if you have constant a churn of staff, new hires then there are a lot of mistakes made. Almost impossible to repair a trashed corporate culture after a bad CEO leaves.

pic here it seems the entire door frame blew out    and there is wiring, cables at the bottom edge.

[bdunham7]

Dennis Muilenburg, former President, chairman and CEO of Boeing did run the company literally into the ground.

I'm not in the Dennis Muilenburg fan club, but it was Jack Welch protege James McNerny who really destroyed Boeing from the inside out.  These types of chickens take a long time to come home to roost, and a lot of damage was also done by Harry Stonecipher after the McDonnell Douglas takeover.  It took a sustained 20 year effort to get Boeing to where it is today.

And yes, all of them should have been working as WalMart greeters after they served their prison terms instead of walking away with a metric ton of cash.

[bdunham7]

Well if it’s a plug-style door, then either:
- a section of wall would have had to go with it (=door stayed intact, wall failed)
- the wall is intact but the door itself failed
- it’s not a plug-style door at all, despite being called a “plug”

These, like many airline doors, are not truly 'plugs' at all as you'd imagine them to be, given the folklore that they are impossible to open when pressurized.  What actually happens is that to open, instead of swinging inward only like you'd imagine a 'plug', they merely have to slide upwards a bit to get clear of multiple retaining stops and then they can swing out, down or fall off as the  case may be.  In theory, pressurization will force the door against the retaining stops and prevent that upward sliding from happening.  In reality, the plane isn't always pressurized.

In this case, part of the issue is that it wasn't a door at all, just a dummy 'plug' that they put in the doorframe.  At some point it came free and slid up and off its stops a bit, then later when pressurized.....POP!  A regular door being loose would have been noticed and set off alarms, but the dummy doesn't have sensors or alarms AFAIK.  There's a decent video going over these details.  Somebody screwed up, I'm guessing we'll know who soon.  It wasn't me!

https://youtu.be/nw4eQGAmXQ0

[floobydust]

Dennis Muilenburg, former President, chairman and CEO of Boeing did run the company literally into the ground.

I'm not in the Dennis Muilenburg fan club, but it was Jack Welch protege James McNerny who really destroyed Boeing from the inside out.  These types of chickens take a long time to come home to roost, and a lot of damage was also done by Harry Stonecipher after the McDonnell Douglas takeover.  It took a sustained 20 year effort to get Boeing to where it is today.

And yes, all of them should have been working as WalMart greeters after they served their prison terms instead of walking away with a metric ton of cash.

The pump'n'dump stock chart I thought mainly happened over Muilenburg's rule. Is it a good time to buy some Boeing stock lol. What's a door plug and a few bolts.
Although I can't imagine "forgetting to put those bolts in" happens without absent QA checks and the staff to do them.

I remember reading that corporate cultures never recover once crooks take over. It leaves people CYA and back-stabbing as the focus, no trust anymore. A CEO's aggression and putting shareholders first does too much damage.

[pickle9000]

Best description of the event.

[pickle9000]

Plane was new Oct 21 2033

[SiliconWizard]

Must have been pretty chilly.

[Ranayna]

Best description of the event.

Oh, so far i only have seen the inside picure also shown in the video thumbnail. The outside picture looks different from what i expected when i read people saying that a whole wall panel was ripped out. That - in my non expert opinion - really looks like just the door "dummy" (or whatever it should be called) was ripped out, taking the inside paneling with it.

[amyk]

Since they would have zero reason to actually open that non-door, it's odd that whoever was responsible for its design didn't make it physically impossible to remove like a normal door, e.g. by bolting it in place all around.

[nctnico]

'My God, it's full of stars'

Alaska Airlines has grounded its fleet of 737 Max 9s after a cabin window and part of the fuselage blew out at a mere 16000ft!

More precisely: an unused emergency exit got blown out. If a part of the fuselage blew out, the plane likely would have lost structural integrity. Maybe somebody tampered with it.

[PartialDischarge]

Most probably a couple of fitting bolts were forgotten during manufacture. Which is actually not that a simple problem to solve, except one expects Boeing to have the resources to do it right

[SeanB]

Given the issues at Boeing currently, mostly relating to a lot of strife between workers and management, and also with a lot of issues, regarding QC from subcontractors amongst others, having been found in recent times, not unlikely that the door was installed, and the person responsible for checking was meant to come next shift to verify, but never actually did, probably either because they were sitting with 500 tasks to sign off on, and 8 hours to do them, or was off the next day, and the next shift put the interior panels over the loose bolts. Either way there are multiple issues related to new aircraft on delivery on occasion. not good for Boeing, though the other major competitors also has reported issues with poor quality work on sub assemblies supplied from other sites, often needing to be scrapped entirely, and redone again. there are a lot of fake parts, or parts of dubious parentage, that also are in the spares lines as well, which has led to a few flights needing to divert due to in flight failures.

[tom66]

If bolts were missing, one would expect the numerous QC processes to notice it, right?

Some guy has to fit the door frame and door, someone has to inspect that, and someone has to fit the trim afterwards.  There are probably other in-between steps but this seems like a good minimum.

So presumably at least three sets of eyes missed this. 

Not good at all Boeing.

[Gyro]

Scary to think how many times that door would have been up to cruising altitude since the end of October and how many people have sat in that empty window seat (in fact a fair number of surrounding seats it it had blown out at full altitude)!

It's still puzzling that it let go at only 16000ft when it would have presumably been up to cruising altitude on the immediately preceding flight, that's not where you would expect missing bolts to show up, unless they suddenly vibrated out. A lot of passengers got really lucky!

[tom66]

The other odd thing is that the pilots reported some pressurisation warnings on a few prior flights, which suggested the door may have been 'loose' before it failed.  I don't know how well-sealed a plane has to be to guarantee pressurisation, but it suggests a possible progressive failure.  Perhaps if only bolts were fitted on one side the door could become somewhat ajar before it failed completely.  The repeated cycles from the last few flights could have exacerbated the fault.

Another extremely fortunate aspect was that the door didn't then hit the horizontal stabiliser as it flew off, which could have led to 177 fatalities if the plane became uncontrollable afterwards. 

[Gyro]

The other odd thing is that the pilots reported some pressurisation warnings on a few prior flights...

That ought to be a huge red flag - 'The cabin is losing integrity, find out why!'

[fourtytwo42]

I wonder if this extra-door was another of the "doesn't need testing/same aircraft" infamous modifications carried out to produce the MAX series from the basic 737 ?

[PartialDischarge]

This video explains how the panel is locked.

https://youtu.be/maLBGFYl9_o?

[johnk0gcj@gmail.com]

Maybe, 2023?

[pickle9000]

I wonder if this extra-door was another of the "doesn't need testing/same aircraft" infamous modifications carried out to produce the MAX series from the basic 737 ?

I'd vote for it being installed incorrectly. The fact that the area is not torn up is crazy.

[SeanB]

The other odd thing is that the pilots reported some pressurisation warnings on a few prior flights, which suggested the door may have been 'loose' before it failed.  I don't know how well-sealed a plane has to be to guarantee pressurisation, but it suggests a possible progressive failure.  Perhaps if only bolts were fitted on one side the door could become somewhat ajar before it failed completely.  The repeated cycles from the last few flights could have exacerbated the fault.

Another extremely fortunate aspect was that the door didn't then hit the horizontal stabiliser as it flew off, which could have led to 177 fatalities if the plane became uncontrollable afterwards. 

Pressurisation could have been attributed to either leaking or sticky outflow valves, which probably was noted as a thing for maintenance to look up when it was due for the first check. Or as an imbalance with a poorly adjusted AC pack that is not regulating inlet flow correctly.

[Gyro]

This video explains how the panel is locked.

https://youtu.be/maLBGFYl9_o?

At 9:50 there are two more locking bolts, at the bottom of the door, that are supposed to prevent the door from lifting and unlatching. How many bolts can you miss / not tighten / break?

Edit: That's four in total.

[floobydust]

It seems the doors are removed when the fuselage comes in from Spirit AeroSystems, to allow easier (interior) assembly at Boeing, and then they're put back in.
Might be where the ball got dropped, the locking bolts never were installed.

[Gyro]

... with a couple of strong springs on the hinge pins at the bottom to helpfully support the weight of the door when it's lifted!

[pickle9000]

I wanna see a video of a mechanic opening one.

[tom66]

This video explains how the panel is locked.

https://youtu.be/maLBGFYl9_o?

What's most interesting about that video is the hinge should have held the "plug" in place even if bolts failed - you would still have a depressurisation event but the door would not become detached and risk damaging the rest of the aircraft.

It's possible that failing under pressure broke the hinges too, but it seems like those would should been designed to carry significant forces.  There are two issues for Boeing here;

- Either someone forgot all four bolts and this wasn't caught in QC - easy fix, but embarrassing and further damages the reputation of newer Boeing aircraft.
- And/or the hinge mechanism is defective - potentially an expensive fix with aircraft grounded for some time until the hinge can be replaced with an improved design.

[Gyro]

Looking at the outside view in the video in Reply #27, those appear to be the two hinge pins sticking out horizontally. The front one is clean - minus the big guide retaining (travel limiting) washer and locknuts. The rear one appears to still have something still attached to it - the remains of the hinge guide ripped from the door?

[pickle9000]

This video explains how the panel is locked.

https://youtu.be/maLBGFYl9_o?

What's most interesting about that video is the hinge should have held the "plug" in place even if bolts failed - you would still have a depressurisation event but the door would not become detached and risk damaging the rest of the aircraft.

It's possible that failing under pressure broke the hinges too, but it seems like those would should been designed to carry significant forces.  There are two issues for Boeing here;

- Either someone forgot all four bolts and this wasn't caught in QC - easy fix, but embarrassing and further damages the reputation of newer Boeing aircraft.
- And/or the hinge mechanism is defective - potentially an expensive fix with aircraft grounded for some time until the hinge can be replaced with an improved design.

Correct me if I'm wrong. To open you remove 4 locking wires, 4 nuts and then the 4 retaining bolts. Next the door is tilted
out at the top and a large spring at near the hinge helps lift the door and de-latch it. So the top retaining points seem to
be the most vulnerable.

[pickle9000]

Looking at the outside view in the video in Reply #27, those appear to be the two hinge pins sticking out horizontally. The front one is clean - minus the big guide retaining (travel limiting) washer and locknuts. The rear one appears to still have something still attached to it - the remains of the hinge guide ripped from the door?

One of long bits at the bottom is probably the spring that carries the weight of the door so it can be delatched..

[AndyBeez]

@PartialDischarge thanks for posting the door plug photo. My theory, the bolts were overnight and the threads stripped. It is one thing to use a torque wrench or bolt driver, another to set it correctly. Outside of Boeing Field, the door may have been off for access when the cabin was fitted out?  Temperature and pressure cycling found the weakness. The bottom hinge threw the door downwards and away.

Where is the door? https://www.oregonlive.com/portland/2024/01/door-in-alaska-airlines-accident-believed-to-have-fallen-over-beaverton-publics-help-sought-in-finding-the-key-evidence.html

[pickle9000]

Found this apparently same type but looks to be other side. Not from the Alaska plane.

[Andy Chee]

Looks like the door plug has been recovered.

[tom66]

NTSB also confirming ETOPS certification was suspended due to pressurisation warnings. 

[AndyBeez]

Door found. Plus, proof that you CAN drop your phone out of a plane and it will survive the fall.
https://abc7.com/alaska-airlines-door-plug-blows-off-boeing-737-max-9-oregon-flight/14294292/

[Gyro]

Looking at the outside view in the video in Reply #27, those appear to be the two hinge pins sticking out horizontally. The front one is clean - minus the big guide retaining (travel limiting) washer and locknuts. The rear one appears to still have something still attached to it - the remains of the hinge guide ripped from the door?

One of long bits at the bottom is probably the spring that carries the weight of the door so it can be delatched..

Looking at the Boeing video, there was a spring on both hinge pins, I can't see anything to show that they are captive though.


When the door/plug opened it would have immediately been hit by a 400MPH sideways blast. The movement on the front pin would have been a bit more linear (pivoting on the rear one) so the hinge guide probably hit the end of the front pin with a lot of force. That might have been enough to knock off the washer and locknuts. With the front pin disengaged, the twisting motion on the rear pin would probably have been enough to rip the rear hinge guide off the door, leaving the apparent remnants still attached to it.

Now that they've found the door (in somebody's yard according to the BBC) there ought to be plenty of telltale evidence. I suppose it's always possible that, if the door had been removed for access, the hinge pin end washers and locknuts might have been left off as well as the locking bolts. A examination of the front hinge pin end with answer that one, it will either have snapped or stripped threads, or intact ones.

In terms of whether the door should have stayed with the plane, that's a tricky one. On the one hand, it coming off could easily have damaged the rear flight surfaces. On the other hand having a non aerodynamic door crashing up and down in the air blast might have had a tin-opener effect on the bottom of the airframe via the hinge pin mounts. It's not as if anyone was going to be able to close it again.  I'd be surprise if there isn't distortion around the hinge pin mounts on the airframe anyway.


P.S. Looking at the BBC report again, the decompression was enough to rip open the cockpit door and suck out the co-pilots clipboard and headset. If that happened at 16000ft, it doesn't sound good in terms of helping the pilots retain control during a sudden depressurization even. Surely the (anti-hijack?) door ought to be strong enough to let the cockpit depressurize in a slower and more controlled fashion.

https://www.bbc.co.uk/news/world-us-canada-67909417

(There's also further indication that the plane has shown decompression warnings on previous flights and had been withdrawn from routes over water! [Ed: as tom66 indicated])

[tom66]

Apparently, someone's iPhone survived the fall from 16,000 ft.  Quite impressive, though I guess if it just landed in a bush it may have absorbed the blow nicely.

https://twitter.com/SeanSafyre/status/1744138937239822685

(Also, please people, set your phones to lock after a short period of time.  A random stranger shouldn't be able to read your emails, even if you didn't expect your phone to be blown out of an aircraft.)

[Gyro]

Apparently, someone's iPhone survived the fall from 16,000 ft.  Quite impressive, though I guess if it just landed in a bush it may have absorbed the blow nicely.

Maybe Apple slowed it down.    https://www.bbc.co.uk/news/technology-67911517

[Jeroen3]

Boeing has a lost a door before...
https://en.wikipedia.org/wiki/United_Airlines_Flight_811

[SiliconWizard]

Boeing has lost more than a door I guess.

[pickle9000]

Looking at the outside view in the video in Reply #27, those appear to be the two hinge pins sticking out horizontally. The front one is clean - minus the big guide retaining (travel limiting) washer and locknuts. The rear one appears to still have something still attached to it - the remains of the hinge guide ripped from the door?

One of long bits at the bottom is probably the spring that carries the weight of the door so it can be delatched..

Looking at the Boeing video, there was a spring on both hinge pins, I can't see anything to show that they are captive though.


When the door/plug opened it would have immediately been hit by a 400MPH sideways blast. The movement on the front pin would have been a bit more linear (pivoting on the rear one) so the hinge guide probably hit the end of the front pin with a lot of force. That might have been enough to knock off the washer and locknuts. With the front pin disengaged, the twisting motion on the rear pin would probably have been enough to rip the rear hinge guide off the door, leaving the apparent remnants still attached to it.

Now that they've found the door (in somebody's yard according to the BBC) there ought to be plenty of telltale evidence. I suppose it's always possible that, if the door had been removed for access, the hinge pin end washers and locknuts might have been left off as well as the locking bolts. A examination of the front hinge pin end with answer that one, it will either have snapped or stripped threads, or intact ones.

In terms of whether the door should have stayed with the plane, that's a tricky one. On the one hand, it coming off could easily have damaged the rear flight surfaces. On the other hand having a non aerodynamic door crashing up and down in the air blast might have had a tin-opener effect on the bottom of the airframe via the hinge pin mounts. It's not as if anyone was going to be able to close it again.  I'd be surprise if there isn't distortion around the hinge pin mounts on the airframe anyway.


P.S. Looking at the BBC report again, the decompression was enough to rip open the cockpit door and suck out the co-pilots clipboard and headset. If that happened at 16000ft, it doesn't sound good in terms of helping the pilots retain control during a sudden depressurization even. Surely the (anti-hijack?) door ought to be strong enough to let the cockpit depressurize in a slower and more controlled fashion.

https://www.bbc.co.uk/news/world-us-canada-67909417

(There's also further indication that the plane has shown decompression warnings on previous flights and had been withdrawn from routes over water! [Ed: as tom66 indicated])

Wow super interesting.

[tom66]

United Airlines finds bolts needed "tightening" on "some" Boeing 737-9's.

https://www.bbc.co.uk/news/world-us-canada-67919436

I wonder how many other bolts on the aircraft need "tightening".  Boeing QC is epic.

[Gyro]

In its statement, United said: "Since we began preliminary inspections on Saturday, we have found instances that appear to relate to installation issues in the door plug - for example, bolts that needed additional tightening."

Hmm, the inclusion of "- for example" in the UA statement seems rather suspicious, especially as the bolts and (castellated) nuts that block the unlatching movement are clearly secured from coming apart by split pins (from the Boeing video [Edit: Reply #37]).

I suspect that some other 'examples' might include 'nothing there to tighten' and 'they forgot to fit the split pins'!

[floobydust]

The CEO David Calhoun needs to go out the door. Actually their board is a clown fest.
$1.4M pay and $22.5M compensation in 2022. He lost a $7M bonus because of 777X delays. His last one, $5.3M to stick around, retention grant.
His degree is in accounting FFS, he worked for investment firm Blackstone.

Imagine taking a few million less in pay and bonus, hiring more top notch qualified people to work on restoring the company?
Greed is good, greed is legal but I guess it doesn't matter if the ride comes to an end - you made millions like Muilenburg did. Party on.

If United Airlines is seeing faults, then it's systemic and Boeing can't spin it as a one-of. Stock down -8% so BUY BUY BUY 
edit: Spirit AeroSystems stock down -11% so BUY BUY BUY 

[bdunham7]

I suspect that some other 'examples' might include 'nothing there to tighten' and 'they forgot to fit the split pins'!

One of the things that can cause a bolt to "need tightening" is if the structure that it is clamping has collapsed or shifted in some way.  This can be as simple as shavings, grit or random crap caught in between surfaces or ti can be a more complex issue like fretting due to movement.  Either way, there should be a revised inspection schedule to examine these parts much more often until they actually know the cause.  Simply concluding that peope have been neglecting to torque the bolts would be simplistic and premature.

[floobydust]

There's an old adage "you can't inspect-in quality", from W. Edwards Deming I think. No amount of inspection ensures a quality product.

It appears everything hardware-wise is the same on these doors except the plug has the locking fasteners, they have cotter pins. I have used Loctite (red 271 permanent) on products on semi trucks with high vibration.

[tggzzz]

More information
https://theaircurrent.com/feed/dispatches/united-finds-loose-bolts-on-plug-doors-during-737-max-9-inspections/

Multiple aircraft, multiple locations, multiple sub-optimalities.

[BrianHG]

Lost door found:

[AndyBeez]

I guess something has to fall off in the shake down period.. but, I might expect this random assembly skilset from a DIYer who does the odd flat pack on weekends, but not from airframe fitters who do this as their day job. There is a serious QC fail in the supply chain. Always C check your brand new Boeing plane, even if it's under warranty.

[pickle9000]

Inspections finding loose bolts!


https://theaircurrent.com/feed/dispatches/united-finds-loose-bolts-on-plug-doors-during-737-max-9-inspections/

[pickle9000]

Lower hinge mount to door, upper bolts found loose as well but not on this aircraft.

[coromonadalix]

wow  they really play with our lives ...

[Andy Chee]

wow  they really play with our lives ...

Well airline carrier insurance companies do place a price on human life.

Evidently cutting costs in quality control is worth more to Boeing than the insurance payout.....

[pickle9000]

Keep in mind the design is old, that's crazy. Very lucky in terms of life.

[jonpaul]

Latest news: Prelim examination of other aircraft reveals improperly tightened door seal bolts

Jon

[pickle9000]

It sounds like the door shook loose mispositioned at ground level and was ready to go during the climb. Under pressure as long
as it's aligned it should stay put.

[floobydust]

"Across the five {it's now ten} aircraft, there is little consistency in the locations of the errant parts..."
Gulp- loose fasteners all over the place in the door, surely all the others are tight {engine falls off} 

[pickle9000]

"Across the five aircraft, there is little consistency in the locations of the errant parts..."
Gulp- loose fasteners all over the place in the door, surely all the others are tight {engine falls off} 

So I'm guessing but sounds like it was self inspected? For a computer monitor fine, airliner not so much.

[floobydust]

It's a gong show:
"Sauer said NTSB staff were both surprised and happy the door remained intact.
He was intrigued to see the door plug’s serial number and other manufacturing details apparently handwritten on the door in permanent marker.
“That’s an interesting way of doing inventory control,” he said. Writing on the door plug says it was manufactured in Malaysia." source
Yup, use a Sharpie 

"The process involves removing two rows of seats and the sidewall liner... United said each inspection will involve a team of five technicians working for several hours on each aircraft..."

[floobydust]

One product was melting DIN-rail terminal blocks which used a copper busbar to feed power to a group.
I was given a melted, burned section and at my desk, taking a screwdriver found some of the screws were loose.

Manufacturing manager insisted it was bad engineering, not rated for the load, redesign it etc. I think it was 20-30A.

I gave him a screwdriver and yelled "here, check for yourself!" because it was his underlings that obviously couldn't tighten screws properly. I think they get lazy and suffer fatigue because all they do all day is tighten screws. Some were tight, others loose so that inconsistency told me it was a manufacturing problem.
He would not take the screwdriver and check the torque, he just kept blaming engineering instead. It was quite a fiasco in front of all his staff, because I didn't back down.

[pickle9000]

One product was melting DIN-rail terminal blocks which used a copper busbar to feed power to a group.
I was given a melted, burned section and at my desk, taking a screwdriver found some of the screws were loose.

Manufacturing manager insisted it was bad engineering, not rated for the load, redesign it etc. I think it was 20-30A.

I gave him a screwdriver and yelled "here, check for yourself!" because it was his underlings that obviously couldn't tighten screws properly. I think they get lazy and suffer fatigue because all they do all day is tighten screws. Some were tight, others loose so that inconsistency told me it was a manufacturing problem.
He would not take the screwdriver and check the torque, he just kept blaming engineering instead. It was quite a fiasco in front of all his staff, because I didn't back down.

Yup, it's crazy. I was asked to troubleshoot brand new equipment for certain railways in Canada. The custom equipment
used to install and maintain rail. The engineering and software was excellent. Quality control was not as good as it
needed to be. On a few occasions I was asked by the railway to fix equipment with the OEM crew watching. Very interesting
situation. The railway had a massive amount of power. I remember the first call, I said "Your kidding" he said "I guarantee
you will get paid and the company will get to watch".  That was a good day for me. 

[floobydust]

On many occasions, I have taken new, completed electrical panels and did my own "tug'n'tighten" as they call it in the industry where you tug on a wire terminal to see if it will yank out, if OK still tighten the screw.
Sometimes a "bad" assembler will be sloppy or weak and you have loose terminals here and there 
I've even just gone through older panels and found loose terminals, which I tighten all because I'll get blamed for any problems just because I was the last person in the cabinet.


Boeing has unhappy employees, for years now, they post on Reddit. Why they can't tighten a bolt:

- Shift away from engineering focused leadership
- Little to no training for literally months and months.
    - People thrown into roles with no guidance whatsoever
-New hires training new hires
-New hires responsible for roles above their grade
-Massive amounts of turnover leading to major brain drain
-Bad RTO (Return to Office) policy
-Email chains 30 emails long of people asking questions and nobody having the answers or knowing who to even ask
-Compensation is below competitors
-Cutting benefits

It sounds like the culture there is a disaster 

[pickle9000]

So true, keeping your people happy and engaged is so important.

[PartialDischarge]

NTSB admitted that the guide tracks on the located door plug were broken and that bolts to retain this plug *may* have been missing.

A reporter during the meeting asked them a sharp question: if you can’t trust Boeing to place and tight these bolts can you trust them with the rest of the bolts in the plane?

[tggzzz]

"Across the five {it's now ten} aircraft, there is little consistency in the locations of the errant parts..."
Gulp- loose fasteners all over the place in the door, surely all the others are tight {engine falls off} 

In the late 60s/early 70s a 707 was discovered with only 75% of the required bolts securing an engine to the wing. After 9 months

IIRC there was a heavy landing in Tunisia, sufficiently heavy that the control tower radioed to ask if the captain needed assistance. (?Perhaps a local engineer refused to certify the plane was safe?). "Sub-optimality" was discovered during full maintenance 9 months later.

[pickle9000]

So I have no clue on this. Passengers will probably sue, i understand.

Will the airlines ask Boeing for compensation?

Who will management blame?

[jonpaul]

Alaska Air:


Terrible safety recorde. Recall the unlubed elevator jack screw causing the total loss , uncontrollable dive Alaska Air 261 MD-80 in 2000?
https://admiralcloudberg.medium.com/the-price-of-an-hour-the-crash-of-alaska-airlines-flight-261-c797a7c3d90d

Boeing: Usual history after the MBAs replace the Engineers.

Calchoun is the worst. Move t CHI, outsource (including hull and wng fab)
https://news.wttw.com/2022/05/05/boeing-will-move-its-headquarters-dc-area-chicago
https://www.boeing.com/company/bios/david-l-calhoun.page



If its a Boeing...I AINT GOING!

j

[tom66]

Lower hinge mount to door, upper bolts found loose as well but not on this aircraft.

A colleague pointed out to me that there are witness marks all over the bolts, which suggests the possibility of overtightening by someone, and then later loosening.

[SeanB]

Well fingers will be pointed at assembler, the integrator and the manufacturer, plus the suppliers of the sub assemblies.  But the blame from the FAA will land on the one who stuck the nameplate on the fuselage, because they are the ones who signed off on it. Loose bolts, missing ones, are not something you want to find on an airframe that is still under warranty, though there are still way too many instances of poor assembly, especially electrical wiring, where IIRC one instance was a mistake in the fire suppression wiring, where firing the bottles resulted in the working engine being snuffed, because the wiring was crossed to the bottles, and another where the fire indicators showed the wrong engine being on fire.

[Ian.M]

Its too early for anyone outside the investigation team to be certain, but it certainly smells like an assembly/maintenance f---up similar to the BA5390 windscreen failure back in 1990.  That was wrong size fasteners - #8-32 bolts in #10-32 holes!  See pages 36 to 41 of the PDF of the official report [here].

[Homer J Simpson]

[pickle9000]

Lower hinge mount to door, upper bolts found loose as well but not on this aircraft.

A colleague pointed out to me that there are witness marks all over the bolts, which suggests the possibility of overtightening by someone, and then later loosening.

I sure does seem like a human error.

[pickle9000]

Well fingers will be pointed at assembler, the integrator and the manufacturer, plus the suppliers of the sub assemblies.  But the blame from the FAA will land on the one who stuck the nameplate on the fuselage, because they are the ones who signed off on it. Loose bolts, missing ones, are not something you want to find on an airframe that is still under warranty, though there are still way too many instances of poor assembly, especially electrical wiring, where IIRC one instance was a mistake in the fire suppression wiring, where firing the bottles resulted in the working engine being snuffed, because the wiring was crossed to the bottles, and another where the fire indicators showed the wrong engine being on fire.

So the company gets fined, the guy that physically did the deed has to live with it, and the guy at top gets a 20 million dollar
severance package.

[floobydust]

Corporations are an ongoing, big problem - Priority #1 is "max" profit.
It's perfectly OK to make shoddy product - until people get hurt or killed enough to point a finger.
Even then, it's some fines, legal fees, throw Mr. Assembler under the bus, exec's get their bonus. Wall Street has it all priced in, great opportunity to buy.
I can't see this modus operandi changing.

The NTSB update today was very well done, professional despite journalists clearly not understanding how the door plug (or a bolt lol) works, and bombarding them with stupid questions, cockamamie theories as to why this happened.
The penny drops "these investigations take 12-18 months to complete".

I did see the one bottom bracket (left on the plane) was no longer bolted to the frame, matching the loose bolt on the United plane.
I think there should be a flat washer, the piece has a slot which of course does not work with a lockwasher because it gets crushed inside the slot.

https://www.flickr.com/photos/ntsb/53450362798/in/album-72177720313904488/

[mendip_discovery]

The NTSB update today was very well done, professional despite journalists clearly not understanding how the door plug (or a bolt lol) works, and bombarding them with stupid questions, cockamamie theories as to why this happened.
The penny drops "these investigations take 12-18 months to complete".

The CAA etc decided a few years back that regular updates of information they find reduces the amount of made up expert crap that gets flung about in these situations. A void of information is where the expert gets thier best opportunity to spread fear.

Going to the bolts thing. There should be a paper trail to figure out the issues. It could be related to bolt or nut production, or even torque wrench being outside if spec. From the experience I have there should be plenty of info about who did what and what tools where used and what else those tools have been used on. But first I guess they need time to see how many are effected and use that data to help find a common cause. Just not a good day for Boeing, then again I can imagine the crowing that would be happening if it was any manufacturer outside the USA. The MAX has has become infamous.

[schmitt trigger]

Could this accident become a “Comet” moment for Boeing, for which De Havilland never recovered?

I am NOT saying that the failures are similar or related. What I mean is that Boeing, which was already lagging behind Airbus, will see its commercial passenger business eroding further to the point of no return?

[tggzzz]

Could this accident become a “Comet” moment for Boeing, for which De Havilland never recovered?

I am NOT saying that the failures are similar or related. What I mean is that Boeing, which was already lagging behind Airbus, will see its commercial passenger business eroding further to the point of no return?

Sprint was spun out of Boeing partly so they could use their for competencies for other manufacturers Thus they also make structures for Airbus and Bombadier.

[tom66]

I think Boeing is "too big to fail".  The US government will ensure that much.  However, it's certainly possible it will harm their passenger aviation business.  I do wonder if they will leave the narrow-body jet market in the longer term and focus on Dreamliner, 767 and so on; this would be bad for competition but might leave room for e.g. Embraer to fill the gap.  Shame that Bombadier's CS jet just got absorbed into the A220 really as that would have broken the oligopoly between Boeing and Airbus.

[floobydust]

If any other 737 max model has issues on the emergency exit doors, call the Grim Reaper. I think it's still a powder keg.
Lion Air has three Max 9's and is inspecting, India found a missing washer on a rudder, doors OK.

This is a multi-billion dollar industry. Ryanair (Ireland) has $40B orders for 300 737 Max. 10 

Boeing is impotent, they can't make a new plane. The penalties for late delivery is all they care about.
Look at the delays and losses over the KC-46 stratotanker.
edit: added ryanair link

[SiliconWizard]

The passenger aviation business is already severely damaged, starting with the covid period and getting more and more dents due to the rising costs, and a clear political goal to limit commercial passenger flights in the future.

And keep in mind Boeing fired a large number of employees in the past few years. It may have helped them cut their losses but I doubt it's going to help them make better planes.

[pickle9000]

Juan is great.

[tom66]

The passenger aviation business is already severely damaged, starting with the covid period and getting more and more dents due to the rising costs, and a clear political goal to limit commercial passenger flights in the future.

And keep in mind Boeing fired a large number of employees in the past few years. It may have helped them cut their losses but I doubt it's going to help them make better planes.

Airline passenger numbers have recovered sharply.  The number of people travelling in 2023 was 12% lower than 2019, compared to 2020 and 2021 at around 50% down.  Most analysts expect 2024 to have more passengers than 2019. 

[pickle9000]

Personally I think the US government will inspect and say prove it, if they don't confidence in aviation will be
lowered. Boeing is to blame but there has been a real lack of oversight.

[floobydust]

The Wall Street driven aggressive, relentless pursuit of maximum profit, gotta get those quarterly numbers up, cater only to our shareholders - it's led to so much damage of companies, industries that have a lot of engineering and technology. I would say many of us have seen the decay. Sometime I wonder if it's not intentional, to destroy a manufacturer important to a nation's military.
When it reaches the conclusion of shoddy products that fail, lives lost - only then does some feeble correction effort get attempted. Corporate capitalism needs to change.

Boeing CEO Calhoun said he had been "shaken to the bone" by the accident.
"We're going to approach this, number one, acknowledging our mistake," Calhoun told employees, according to an excerpt released by Boeing. "We're going to approach it with 100% and complete transparency every step of the way."
Calhoun also told Boeing employees the company would "ensure every next airplane that moves into the sky is in fact safe."

Good luck Mr. Bean counter, this has all been heard before.

[CatalinaWOW]

The Wall Street driven aggressive, relentless pursuit of maximum profit, gotta get those quarterly numbers up, cater only to our shareholders - it's led to so much damage of companies, industries that have a lot of engineering and technology. I would say many of us have seen the decay. Sometime I wonder if it's not intentional, to destroy a manufacturer important to a nation's military.
When it reaches the conclusion of shoddy products that fail, lives lost - only then does some feeble correction effort get attempted. Corporate capitalism needs to change.

Boeing CEO Calhoun said he had been "shaken to the bone" by the accident.
"We're going to approach this, number one, acknowledging our mistake," Calhoun told employees, according to an excerpt released by Boeing. "We're going to approach it with 100% and complete transparency every step of the way."
Calhoun also told Boeing employees the company would "ensure every next airplane that moves into the sky is in fact safe."

Good luck Mr. Bean counter, this has all been heard before.

This is partly inherent in capitalism, but more in tax codes.  I can't speak to the rest of the world, but the US tax code enables the stock market lottery, which in turn drives corporate finance to short term results.  In principal we could fix this, but it would require politicians that reported to the electorate instead of their campaign financiers.

[pickle9000]

It's always how close you can push it to the line, stretching pennies. They say the words but I'd love to see
penalties at the top, and i mean money. A simple rule no bonuses for two years. Never happen of course.

How about no corporate lobbyists or campaign contributions? 

[coppercone2]

I wonder why the bolt is getting loose.

they have a bunch of technologies to prevent loosening... I wonder if there is a design problem with the bolt implementation or possibly the bolt

[pickle9000]

I wonder why the bolt is getting loose.

they have a bunch of technologies to prevent loosening... I wonder if there is a design problem with the bolt implementation or possibly the bolt

Everything critical like this relies on inspections. Unfortunately when done in house things are skipped. Look at a checkbox, yup done, inspect the left hand door plug yup perfect, I'm sure the rest will be fine.

Outside inspections tend to be better but even then redundant systems are needed.

[coppercone2]

its possible it got loose after inspection for some reason

its over confident to just blame the inspector there might be a real problem

thats another way to cover up because you can keep replacing cheap inspectors rather then having engineers do complicated analysis that costs more. I have seen installer/assembler been blamed for things that sounded good but scrutiny revealed it was simply not correctly implemented. its pretty sad usually when you find it lol

[Andy Chee]

its possible it got loose after inspection for some reason

A correctly installed castle nut and cotter pin cannot work itself loose.

Inattentional blindness could've caused the inspector to completely overlook missing cotter pins.

[Gyro]

It's unfortunate that the door plug catastrophe has overshadowed the 29th Dec rudder linkage bolt with missing nut that I briefly mentioned in my OP (briefly mentioned by floobydust and the Reply #99 video. It highlights that Boeing have simply forgotten how to build planes!

https://www.bbc.co.uk/news/business-67838424

I love the "Out of an abundance of caution, we are recommending operators inspect their 737 Max airplanes and inform us of any findings. We informed the FAA and our customers and will continue to keep them aware of the progress." quote.

When did Boeing last demonstrate an abundance of caution, or is this in their future plans.

[AndyBeez]

Thread lock anyone? Was the issue down to the fitters not having the correct tool, or the bolt heads are inaccessible with the correct tool? It could be a part that is specified to tighten as hard as you can, rather like wheel nuts.

Maybe the retaining bolts are just an 'option' anyway, as the door locking mechanism already keeps a functional and armed escape door permanently locked in place? I suspect the 'eject' mechanism could be the culprit; it was only the ill-fitted bolts that kept the door from falling out in the factory.

[Monkeh]

It could be a part that is specified to tighten as hard as you can, rather like wheel nuts.

Err.. which century is this?

Maybe the retaining bolts are just an 'option' anyway, as the door locking mechanism already keeps a functional and armed escape door permanently locked in place?

There is no door. There's nothing optional here.

[SeanB]

There is a torque setting for every single fastener with a thread in an aircraft. Either a general one for that thread pitch and diameter of fitting, or a more specific one for a lot of the higher stress and critical parts. Even screw terminals have a torque setting, it is not a Gutentight spec, but a specific setting for each one. That is why every aircraft maintenance bay has a row of calibrated torque testers on the floor, so that every fastener that is put in has the correct value applied. Looks like here though that there is a culture of do it fast, and self inspection, or in reality no inspection. As it is rather well known that there is lax QC, I would say that there is a bigger issue, in that nothing that has come out of this assembly line for the last decade is going to be good, just that the redundancies are keeping them together.

Seems the cost cutting of dumping those expensive people, the ones with knowledge, degrees and 20 years of work experience, and replacing them with people earning minimum wage, because the suits think that assembling an aircraft is no different than flipping a burger at the golden arches, and anybody with a pulse can do it. That the product from the arches does not resemble the pictures in the ad, is not thought by the suits to be important, but when you have no option to return and tell them to make it again, because you have now made a large hole in the ground, this is not really good.

[tom66]

Thread lock anyone? Was the issue down to the fitters not having the correct tool, or the bolt heads are inaccessible with the correct tool? It could be a part that is specified to tighten as hard as you can, rather like wheel nuts.

Pretty much everything in aviation that you tighten is torque spec'd.  Torque drivers are calibrated frequently. 

Also, I would hate to be your mechanic. Even wheel nuts are supposed to be torqued correctly.  Now whether that is actually done in the real world or not is another matter, but it's not safer to overtorque things.  In fact it can be less safe because the bolt might fracture.

[Stray Electron]

Well fingers will be pointed at assembler, the integrator and the manufacturer, plus the suppliers of the sub assemblies.  But the blame from the FAA will land on the one who stuck the nameplate on the fuselage, because they are the ones who signed off on it. Loose bolts, missing ones, are not something you want to find on an airframe that is still under warranty, though there are still way too many instances of poor assembly, especially electrical wiring, where IIRC one instance was a mistake in the fire suppression wiring, where firing the bottles resulted in the working engine being snuffed, because the wiring was crossed to the bottles, and another where the fire indicators showed the wrong engine being on fire.

So the company gets fined, the guy that physically did the deed has to live with it, and the guy at top who decided to use cheap untrained foreign labor and zero quality control to boost profits gets a 20 million dollar severance package, and gets hired by another major American manufacturing company. 

   Fixed it for you.

[YurkshireLad]

"We're going to approach this, number one, acknowledging our mistake," Calhoun told employees, according to an excerpt released by Boeing.

As in, "it's all OUR fault, not mine as CEO".

[pickle9000]

When it comes to things like doors, door plugs and windows in a pressurized fuselage not only
is it well understood but the designs are reused because they work. That includes attachment points.

Accidents and destructive testing have already dictated the design.

I suppose it's possible an engineer changed something but I'm sure that would be expensive.

[bdunham7]

Even wheel nuts are supposed to be torqued correctly.

The problem is that there is more to it than that and it is entirely possible to grossly misassemble things (even wheels) despite using a torque wrench and even applying the correct torque.  A loose bolt doesn't necessarily result from that bolt being improperly tightened or secured.  Stuff like this just doesn't happen if the final installer--the body actually doing the work--is skilled and experienced because they'll recognize when something is amiss, even if the procedures are being correctly followed to the letter.  For decades, Boeing has been doing everything in it's power--moving, selling off divisions, opening factories in other states, outsourcing--to shed those skilled workers that know how to do these things properly.  This is the result--airplanes falling apart because some workers failed elementary bolt science 101.

[pickle9000]

Even wheel nuts are supposed to be torqued correctly.

The problem is that there is more to it than that and it is entirely possible to grossly misassemble things (even wheels) despite using a torque wrench and even applying the correct torque.  A loose bolt doesn't necessarily result from that bolt being improperly tightened or secured.  Stuff like this just doesn't happen if the final installer--the body actually doing the work--is skilled and experienced because they'll recognize when something is amiss, even if the procedures are being correctly followed to the letter.  For decades, Boeing has been doing everything in it's power--moving, selling off divisions, opening factories in other states, outsourcing--to shed those skilled workers that know how to do these things properly.  This is the result--airplanes falling apart because some workers failed elementary bolt science 101.

That's a very valid point. From design, documenting procedures to hands on work.

[pickle9000]

I've been wondering about the loose bolts on the door side lower hinge. Assuming they where done correctly
at the factory then the door was pulled off completely. But why? Wouldn't it be easier to remove the 4 bolt/pins?

[CatalinaWOW]

"We're going to approach this, number one, acknowledging our mistake," Calhoun told employees, according to an excerpt released by Boeing.

As in, "it's all OUR fault, not mine as CEO".

I think it would be worse if he took all the responsibility himself.  While he owns a good share, anyone who didn't do the job right also has a piece of the blame.  My son is an A&P, and as part of the training they actually took an oath, the essence of which is to do what is right, not what the boss says.  I don't know if that is a universal part of the training, but if it is, it says clearly that the blame isn't all at the top.  Even if not formally trained or sworn this remains true.

Stating the blame as our responsibility (if done properly) could be a way to shorten the path back to making superb airplanes.  If he assumes all blame himself, he then has to start at the top and propagate the needed change down.  And it makes him the single point of failure, where if he gets it wrong it stays broken.    By formally making it a shared responsibility the process starts top to bottom in parallel, and can potentially succeed in spit of failures at any point in the chain. 

[TimFox]

When I was a Boy Scout long, long ago, we made a field trip to the local base of the Minnesota Air National Guard.
Even at a young age, I was impressed by a prominent poster in the hangar with an oath for mechanics that included a clause forbidding certifying an unworthy aircraft by order of a superior.

[coppercone2]

Yes the oversimplification and abstract approach to assessment of difficulty used to reduce salary is also a massive quality problems. The number one thing people do to take your money is make your job seem overly simplified.

[floobydust]

I needed to make some measurements at work, went to get a multimeter and found they are all gone. QC dept. has sent them out for calibration per ISO 9000, out of country "they'll be back in 10 days".
Fine, I'll just bring in my own test equipment in "uh no you can't do that, we don't have insurance coverage for that" 

So I can't move forward on the project but have to appease the deity known as the Project Schedule/Gantt chart. Imagine- you can't make voltage measurements for 10 days.
It's how abusive corporations can be- commanding things to be running at full speed, despite the flat tires we give you, and if you complain you go on the blacklist. We only want unicorns and rainbows on the team.

Tools required for these plug door bolts, maybe a socket that was gone, fell into the fuselage etc. or QC took the torque wrench away for cal etc. leaves an assembler in a pickle.
He's stuck and can't finish the step, and fuck it shift ended I'm going home. Management doesn't fix the process, they just chastise the employee for not getting the work done.

Boeing is behind on shipments, pressure cooker to make deliveries. I'll bet employees get treated quite badly around achieving production numbers and the endless command to "make more faster!" so the boss gets his bonus when the quota is met, but the lowly assembler only sees higher stress.

[vk6zgo]

Thread lock anyone? Was the issue down to the fitters not having the correct tool, or the bolt heads are inaccessible with the correct tool? It could be a part that is specified to tighten as hard as you can, rather like wheel nuts.

Pretty much everything in aviation that you tighten is torque spec'd.  Torque drivers are calibrated frequently. 

Also, I would hate to be your mechanic. Even wheel nuts are supposed to be torqued correctly.  Now whether that is actually done in the real world or not is another matter, but it's not safer to overtorque things.  In fact it can be less safe because the bolt might fracture.

Mechanics usually use a "rattle gun" which may or may not have a torque function.

They also tighten wheel nuts clockwise, which really "grinds my gears", having been brought up on the "adjust in a star pattern to equalise the stresses" mantra-----I even tighten covers on equipment that way!

That is, of course, actual mechanics-----the tyre changers are often only a few steps above the "burger flipper" level.

[MT]

[floobydust]

He's a bit out to lunch, the stop fittings are not only for the plug door. It had to traverse up and out, so it's obvious the locking bolts were not there. Never mind the lower hinge bracket bolts being loose on United...

People expect the NTSB to be on top of a shady manufacturer and they can't be, it's impossible - their job is finding incident root cause, not babysitting Boeing.
People expect the FAA to be on top of a shady manufacturer and they can't be, it's impossible - they would need to be as technically capable as Boeing.  That is very expensive for engineers and such, just for regulatory oversight, when that team could simply build planes with their knowledge and expertise.

At some point Boeing needs to be accountable and get their shit together, instead of people expecting agencies to find all mistakes. Like I said, you can't inspect-in quality.

The rudder fasteners were found loose, missing washers etc. some time ago. Clearly nothing was fixed up over at Boeing after that.
Having a bean counter for CEO - great idea 

[amyk]

It's even worse for Boeing if one considers that four fasteners had to be omitted for this to happen. This isn't even an inspection problem (which should ideally be finding very little errors, maybe one in a few dozen planes) --- I think it's either deliberate sabotage or a total lack of competence.

[floobydust]

That looks like a configuration error, where somebody put it together as "the usual" emergency exit door, not a plug door.
Or maybe getting those bolts out of inventory had an exception occur and they got forgotten. Many things can happen. It might be very difficult to work on the inside on your hands and knees with the two rows of seats over a bit too.
The planes are fucking sardine cans, I'm not fat or obese but do not fit in a seat at all- super cramped and uncomfortable. It really hurts after many hours. Hail hail MAX profit.
Imagine putting in those locking bolts, not a lot of room and the last two seat rows might even be in the way.

The bottom hinge bracket using split lockwashers over the slot is IMHO a design error. There should be a flat washer or more. I could see them working loose.

This door accident is showing so many gross errors by Boeing. Like it rolled out of Detroit circa 1976 or something.

[bdunham7]

The bottom hinge bracket using split lockwashers over the slot is IMHO a design error. There should be a flat washer or more. I could see them working loose.

I haven't actually seen a split, but if there is one I agree that is problematic IMO.  I can't imagine it being the design, and if it is we can conclude that it isn't working well since they appear to be coming loose on a regular basis.

[floobydust]

Pic shows two loose bolts (one at the far back) and I didn't like the lockwasher over a slot. I thought this is United Airlines? The castellated nut (locking bolt) gets a flat washer.
This piece is flopping outside the Alaska Airlines plane, so the bolts fell out or they broke.

I realized every car, some Canadian airplanes and Airbus - have a door ajar switch and indication light. It might have been useful here?
Hail hail MAX profit Boeing 

[pickle9000]

- The loose bolts all appear to be in line, not flopping around. So into a threaded hole or insert.
- Green lower pic behind the plastic appears to have at least one bolt and is still on the lift pin so at least one of the four retaining bolts are there.
- The green lift bracket attaches to the door so the door was hanging by that one point until it was sheared off.

I wonder if the other green bracket is still attached to the door?

[jfiresto]

Hail hail MAX profit Boeing 

It is just good old shareholder value and executive talent retention in action. The 737 [profit]MAX. I like that.

[tom66]

That looks like a configuration error, where somebody put it together as "the usual" emergency exit door, not a plug door.
Or maybe getting those bolts out of inventory had an exception occur and they got forgotten. Many things can happen. It might be very difficult to work on the inside on your hands and knees with the two rows of seats over a bit too.
The planes are fucking sardine cans, I'm not fat or obese but do not fit in a seat at all- super cramped and uncomfortable. It really hurts after many hours. Hail hail MAX profit.
Imagine putting in those locking bolts, not a lot of room and the last two seat rows might even be in the way.

The bottom hinge bracket using split lockwashers over the slot is IMHO a design error. There should be a flat washer or more. I could see them working loose.

This door accident is showing so many gross errors by Boeing. Like it rolled out of Detroit circa 1976 or something.

I think the seats are usually put in by the airlines, because they tend to be customised to the airline's requirements.  Either way they can be one of the last things to go in, after the interior trim is put on, so they shouldn't have blocked the assembly of the plug. 

[mendip_discovery]

I think the seats are usually put in by the airlines, because they tend to be customised to the airline's requirements.  Either way they can be one of the last things to go in, after the interior trim is put on, so they shouldn't have blocked the assembly of the plug.

Unless the plug is the one being used to get the units in.

[Gyro]

Ok, I think I have a mental picture of what has been going on here (from the fitting problems, loose bolts etc.perspective) but please bear with me, this is going to get wordy!

Fundamentals (which might not be immediately intuitive):

1. The bottom hinge pins and guides, and the top guide castings, are not responsible for keeping the door closed under cabin pressure differential. This function is performed by the Stop Pads and Stop Fittings. There are 12 of these, 6 on each side. The top and bottom edges are obviously rigid enough to resist cabin pressure without further local support.

2. As a 'plug' door, the stop pads and fitting interlock - The stop fittings on the door must pass inside the stop pads on the frame when the door moves downwards to the locked position. With them interlocked, there's no way the door can open under pressure differential (again, it is a plug design). The clearance between the pads and fittings must necessarily be close - you don't want the door moving out significantly as the cabin is pressurized.

3. Everything else - the hinge pins and guides and the upper roll pins and castings are only there to keep the 12 stop pads and fittings interlocked before the cabiin is pressurized. After this, they play no role in holding to door closed. Their only other function is to facilitate insertion and removal, which only happens on assembly, and probably, major inspection.

3. Fitting the hinge pin guides is part of the door manufacture. Their bolts will have been torqued up during assembly.


What I think is possibly happening at the factory (I've used 'door' for 'plug door' from now on), resulting from poor moral and time pressure:

1. The door must first be lowered onto the hinge pins at the bottom of the door frame. This isn't necessarily easy, the pins must be set parallel and introduced into the guide fittings on the door. First you have to slip on two uncompressed lifting springs onto the pins, then you have to get the ends of the pins into the guide fittings. The pins don't have alignment tapers, instead they have the threaded portion for travel stop washer and lock nuts, followed by a hard shoulder to the full diameter. The door itself weights 36kg. Damn, I can't get both pins in! First possible alignment issue - the spacing hings pins and guides might not match exactly: Possible bodge solution, loosen off the bolts on one of the hinge guides, there, that's better, both pins go in now.

2. Hinge the door in and try to push it down to the closed position. Firstly it needs to be pushed down against the spring pressure that holds it in the lifted position. Compressing the springs will increase the pressure to higher than the 36kgf needed to support it open - probably requires a boot pressure down on the bottom of the door.

3. Damn, the stop pads and fitting won't pass and interlock! Second possible alignment issue: The clearances are tight and something isn't sufficiently aligned - maybe the hinge pin guides, maybe the hinge mounts themselves to the airframe (I wonder if any of those bolts have been found loose!), maybe the roll pin guide fittings at the top of the door. Possible bodge solution, loosen the bolts on the upper guide fittings or hinge pin guide fittings to make the stop pads interlock.

4. Fitting the locking bolts (lower): The door needs to be pushed down against spring pressure, whilst bending right over and trying to push the bolts through from the rear (skin side) of the pin guide casting, whilst trying to align the holes in the casting with the one in the hinge pin (bugger this!). Hopefully it eventually goes in and the assembler isn't too pissed off to fit the castellated nut and pin. Now the other side, trying to do the same thing, only with the other (non favored) hand. Damn, I can't get the second bolt through! Third possible alignment issue: With the door is sitting in the frame, maybe it is impossible to get the other bolt to go through - the assembler is pushing against two springs and effectively trying to move the whole height of the door from side to side! Possible bodge solutions: 1) loosen the pin guide mounting bolts or 2) leave the bolt out - the other one and the top ones will hold it!

5. Top roll pin guide fitting casting locking bolts. This one I find most difficult to understand. At this stage, the door ought to be held down sufficiently by the hinge pin bolt(s). Maybe not if the pin guide mounting bolts have been loosened. Even if not, some downward foot pressure on the door ought to be enough to pull it down low enough for the roll pin to clear the bolt holes. I can't work this one out - worst case, the door is slightly tilted by the shenanigans at the bottom of the door I suppose. Maybe they were forgotten on that one plane and present on all the others under inspection. I'm sure the airlines would have flagged it damned quickly if the had found any of those missing, but up to now it mainly seems to be loose bolts.

6. Have every intention of tightening the awkward to access loose bolts whilst be pressured to get on with the next job.

All of the above might also have been complicated by the door being stuffed with fibreglass insulation. It's not shown in any of the pictures but the rest of the cabin is, so presumably the door too.
 
I don't think any of the four lock pins bolts need to be torqued up by the way, they are there to block side force and the castellated nut and split/cotter pin will prevent them from coming out, they would need to be backed off until the drilled cotter pin hole is accessible anyway. Worst case, overtigntening could crack the casting.


P.S. The movement stop washers and lock nuts on the ends of the hinge pins may or may not have been forgotten. Possibly one of them was on the lost door. One was certainly there because the ripped off pin guide (rear) was still with the plane. The front one was either not present of was ripped off, if so, there will be stripped threads on the pin and a hell of a witness mark on the plane door. Worst case, they aren't essential, although they could give some engineer a hell of a shock as the door jumps out on him when he opens it!

[Andy Chee]

All of the above might also have been complicated by the door being stuffed with fibreglass insulation. It's not shown in any of the pictures but the rest of the cabin is, so presumably the door too.

The fiberglass insulation should not be installed until the bolts have been inspected and signed off.

[Gyro]

At the first fitting, yes. But what about when the door is subsequently removed to aid internal fit-out at the Boeing factory? Do they pull it all out again in practice?

[Andy Chee]

At the first fitting, yes. But what about when the door is subsequently removed to aid internal fit-out at the Boeing factory? Do they pull it all out again in practice?

To gain access to the bolts for plug removal, yes, the fibreglass insulation would have to be pulled out.

[Gyro]

[deleted] too much added complication.

[MT]

[Gyro]

Lucky for Boeing that one was an Airbus.

[pickle9000]

I wonder if this whole thing could be an order of operations change?

Even if it had engineering approval without testing it's risky. Of course things like this instigated
by an efficiency expert.

[SiliconWizard]

I wonder if they will change CEOs again? Maybe that will help?

[coppercone2]

I wonder if they will change CEOs again? Maybe that will help?

I swear thats like a decoy flare at this point they need to make him fix it

the CEO makes a decision because someone tells him we are not making money doing this or that and you need to put your foot down. Who is saying it?
They probobly ask for financial analysis and no matter who asks the question they get the same result. There is some kind of problem some where. Clearly if they replace the man again then it will have the same results. Someone must have a very unrealistic view of the  process that keeps making these suggestions.

They need to look at the base information gathered used to make the recent bad decisions and determine why its either gathered incorrectly or processed incorrectly. Do analysis as if the CEO was the same person both times since the same thing keeps happening.

The company seems to be trapped in a time loop like time squared in startrek TNG.

[pickle9000]

I wonder if they will change CEOs again? Maybe that will help?

Yup, 80 million severance and gone in a cloud of smoke. Off to next job.

[schmitt trigger]

I wonder if they will change CEOs again? Maybe that will help?

What happened to “the buck stops here”?
IMHO, they should make the CEO stay and clean up the mess created under his/her watch. And reduce the salary to $1 a year.

Yeah, keep on dreaming.

[pickle9000]

The biggest problem I have with this incident is it's old tech and they know how to do it.

Reputation must have a dollar value.

[Stray Electron]

I wonder if they will change CEOs again? Maybe that will help?

What happened to “the buck stops here”?

    He left office in 1953.  https://en.wikipedia.org/wiki/Harry_S._Truman The current CEO of Boeing probably wasn't even alive then.

[floobydust]

Boeing's been missing or has loose fasteners on many occasions. Too many occasions.
Surely a multi-million dollar paycheque: "VP of Total Quality for Boeing Commercial Airplanes, chair of the Boeing Quality Operations Council and a member of the company’s Executive Council." Executive Carole Murray "... previously was senior director of Quality for the 787 Program".
We could promote her to CEO, add a few committees, that would fix everything 

Top heavy, big bucks executives are like parasites that drain all the cash and blood out of the lower workers.

It reminds me of the old "pop bottle in the door" stunt union workers in Detroit were pulling. My dad his '75 or '76 Ford F150 had that rattle and here I thought somebody just forgot their soda bottle there. Snopes says it's a myth (Cadillac door) but it really was happening back in the day.

If this is a pushback by disgruntled employees, and it's looking like that because a bolt is not terribly difficult to install, it's what you do all day... Boeing has pissed off the worker bees.
Soviet Union was like this too I thought, quality problems and nobody fixing it because those in charge make all the money, flog workers and do little else.

[CatalinaWOW]

Boeing's been missing or has loose fasteners on many occasions. Too many occasions.
Surely a multi-million dollar paycheque: "VP of Total Quality for Boeing Commercial Airplanes, chair of the Boeing Quality Operations Council and a member of the company’s Executive Council." Executive Carole Murray "... previously was senior director of Quality for the 787 Program".
We could promote her to CEO, add a few committees, that would fix everything 

Top heavy, big bucks executives are like parasites that drain all the cash and blood out of the lower workers.

It reminds me of the old "pop bottle in the door" stunt union workers in Detroit were pulling. My dad his '75 or '76 Ford F150 had that rattle and here I thought somebody just forgot their soda bottle there. Snopes says it's a myth (Cadillac door) but it really was happening back in the day.

If this is a pushback by disgruntled employees, and it's looking like that because a bolt is not terribly difficult to install, it's what you do all day... Boeing has pissed off the worker bees.
Soviet Union was like this too I thought, quality problems and nobody fixing it because those in charge make all the money, flog workers and do little else.

Blaming it on executive pay is as lazy as some of the management pronouncements. 

Now I agree that execs are paid way too much.  There is no way that I can believe that one of those million dollar earners is bringing that much more value to the company than someone who makes a mere 200k.  But there are 145,000 employees at Boeing.  Lets say that there are 100 of these million dollar babies.  Firing them all and spreading their salary over the workforce would result in an annual raise of less than $700.   Less than that if they were replaced by lower paid executives.   The figures on line say the lowest payed employee makes more than $50,000 a year.  If $700 for someone making $50k+ is the difference between doing a good job and doing schlock work there is at least as much wrong with the workforce as the management.

Executive pay may be an emotional issue, feeding feelings of unfairness, but saying those salaries are "draining the lifeblood" is an extravagant overstatement. 

[floobydust]

Yeah you're right you could only get maybe 250 employees if you redirected the exec bonuses.
CEO David Calhoun compensation is 154:1 of median employee so his $22.5M comp. is worth around 154 employees. He must have a very big head.
Compared to the number of layoffs, which are in the thousands before the pandemic and after.

Boeing slashed more than 12,000 jobs May 2020:
“This is a significant amount of knowledge and skill leaving the Boeing Company,” said Bill Dugovich, spokesman for the Society of Professional Engineering Employees in Aerospace (SPEEA)."
Boeing job cuts will fall heavily on engineers and machinists
Boeing to cut nearly 10,000 jobs in Washington, more than 12,000 overall

[HuronKing]

Executive pay may be an emotional issue, feeding feelings of unfairness, but saying those salaries are "draining the lifeblood" is an extravagant overstatement.

The Duke of Wellington said of Napoleon that he was worth 40,000 men on the battlefield.

I agree that a highly paid CEO can indeed be worth many more times the salary of an average median employee if that CEO brings strong leadership, corporate direction, and personality to the role.

Another good example is the way both Michael Eisner and later Bob Iger in turn developed Disney from a failing company into the largest entertainment company in the world.

There may be a case to be made that the problem isn't inherently highly paid execs at Boeing - but that they aren't fostering a culture of transparency, safety, and quality down the chain. In which case ANY CEO who is paid more than $1 is overpaid... because that CEO needs to be fired.

[tom66]

Yes - I think that's very true.  Fundamentally, CEOs serve one group and that's the shareholders/investors in a company.  They attract high salaries because there's a lot of competition for the best 'talent' in the executive world.  You could argue they are not worth the millions spent on them - as doubling their pay doesn't double their productivity - and that may well be correct, but in a competitive marketplace, not having a top CEO could lead a company to fall behind the competition and in the worst case could lead to the company failing.  Look at the failure of Intel with respect to AMD...  Dr. Lisa Su deserves every penny thrown at her, she clearly understands the marketplace, product and customer very very well and has led her team to great success.  On the other hand, Elon Musk... He's done well with Tesla (despite recent efforts) but clearly is not the right person to lead Twitter.

[HuronKing]

On the other hand, Elon Musk... He's done well with Tesla (despite recent efforts) but clearly is not the right person to lead Twitter.

This is very true. Not all CEOs are cut out to lead all kinds of companies.

Another important note about CEO compensation is that while some collect annual salaries in the millions, others actually collect very little in cash compensation.

Musk doesn't collect a salary. His net worth is entirely tied up in his stock options:
https://www.fastcompany.com/90960056/warren-buffett-elon-musks-salaries-net-worth-misleading#:~:text=His%20total%202022%20pay%20was,was%20a%20big%20fat%20zero.

[pickle9000]

A good engineer considers a multitude of factors, cost and risk are hopefully among them.

I'd hope a CEO does the same. They are beholding to shareholders and as such should be held  responsible for
destroying a company.

[Andy Chee]

Not all leaders like what they hear from their underlings.  In which case, the underlings are sacked, and replaced with "yes" men.

[TimFox]

One degree below the yes-men are the nodders, in the next row back, who wait for the yesses before nodding in agreement.

[pickle9000]

Whistle-blower said the government needs to inspect and verify like in the past.

[tooki]

I needed to make some measurements at work, went to get a multimeter and found they are all gone. QC dept. has sent them out for calibration per ISO 9000, out of country "they'll be back in 10 days".
Fine, I'll just bring in my own test equipment in "uh no you can't do that, we don't have insurance coverage for that" 

So I can't move forward on the project but have to appease the deity known as the Project Schedule/Gantt chart. Imagine- you can't make voltage measurements for 10 days.
It's how abusive corporations can be- commanding things to be running at full speed, despite the flat tires we give you, and if you complain you go on the blacklist. We only want unicorns and rainbows on the team.

At least you had a very clear scapegoat: the moron that sent all your meters out for calibration at the same time instead of breaking it up into two batches. Then you tell your boss that if they want any semblance of being on time, that it’ll be cheaper to overnight a new, factory-calibrated meter from the manufacturer than to put production on hold.

[CatalinaWOW]

Executive pay may be an emotional issue, feeding feelings of unfairness, but saying those salaries are "draining the lifeblood" is an extravagant overstatement.

The Duke of Wellington said of Napoleon that he was worth 40,000 men on the battlefield.

I agree that a highly paid CEO can indeed be worth many more times the salary of an average median employee if that CEO brings strong leadership, corporate direction, and personality to the role.

Another good example is the way both Michael Eisner and later Bob Iger in turn developed Disney from a failing company into the largest entertainment company in the world.

There may be a case to be made that the problem isn't inherently highly paid execs at Boeing - but that they aren't fostering a culture of transparency, safety, and quality down the chain. In which case ANY CEO who is paid more than $1 is overpaid... because that CEO needs to be fired.

Some CEOs areas impactful as Napoleon, and they deserve every cent of whatever salary they re paid.  But the executive compensation committees would have us believe that there are literally thousands or even tens of thousands of these unicorns in the western world.  I believe this is completely wrong.

But I also believe that the reason this situation has developed is that it isn't grievously harmful to the companies involved.  The selective forces countering this trend are weak.

[pickle9000]

Oversight is the only realistic solution. If it can't be a real inspector every time photos and signatures to
make investigations easier. The FAA is probably stripped of staff technically capable of doing all aspects
but that changes nothing. 

[Homer J Simpson]

Boeing 737 -9 Plug Doors and Spirit Aerospace Lawsuit

[pickle9000]

That's a pretty stunning video.

[MT]

Boing! part 2

[CatalinaWOW]

Boeing 737 -9 Plug Doors and Spirit Aerospace Lawsuit

By the standards of the opening quote, activities  like space flight, hang gliding, parachuting, deep sea diving and F1 racing are also not inherently dangerous.  In fact I am not sure I can think of anything that is inherently dangerous by that standard.  That doesn't correlate well with a more common notion is that activities which are unforgiving of mistakes are dangerous.

[NiHaoMike]

[coppercone2]

Executive pay may be an emotional issue, feeding feelings of unfairness, but saying those salaries are "draining the lifeblood" is an extravagant overstatement.

The Duke of Wellington said of Napoleon that he was worth 40,000 men on the battlefield.

I agree that a highly paid CEO can indeed be worth many more times the salary of an average median employee if that CEO brings strong leadership, corporate direction, and personality to the role.

Another good example is the way both Michael Eisner and later Bob Iger in turn developed Disney from a failing company into the largest entertainment company in the world.

There may be a case to be made that the problem isn't inherently highly paid execs at Boeing - but that they aren't fostering a culture of transparency, safety, and quality down the chain. In which case ANY CEO who is paid more than $1 is overpaid... because that CEO needs to be fired.

what does one royalty say to  the other? WE ARE IMPORTANT AND DESERVE MONEY


the duke talking about a king lol. its hard to take that seriously, it sounds kind of like 'please don't cut my salary'.

could there be a revolution to get rid of high paying CEO like getting rid of kings and queens that don't really do much good for society? If you look to history there is a clear trend.................... could corporate make it to the year 1765? it could end like the dark ages

[SiliconWizard]

Maybe. Right now, the revolution seems to be large companies and rich CEOs having more influence on politics than elected people, and being proud of it, so. The next revolution may take a while before it happens.

[tom66]

Ryanair to send engineers to oversee Boeing quality control 

https://www.bbc.co.uk/news/business-67994140

I wonder if they'll land at the right airport this time, or indeed, a passenger airport.   Funny story...

[tggzzz]

Ryanair to send engineers to oversee Boeing quality control 

https://www.bbc.co.uk/news/business-67994140

I wonder if they'll land at the right airport this time, or indeed, a passenger airport.   Funny story...

Landing at the wrong airport is more common than you might think, e.g. https://simpleflying.com/pan-am-707-raf-northolt/ https://simpleflying.com/flight-landing-wrong-airport-brief-history/

I've seen many aircraft almost land at Aston Down when they were aiming at Kemble. The most egregious examples merit an AAIB investigation with subsequent wide publicity in the GA community.

[tom66]

Landing at the wrong airport is more common than you might think, e.g. https://simpleflying.com/pan-am-707-raf-northolt/ https://simpleflying.com/flight-landing-wrong-airport-brief-history/

I've seen many aircraft almost land at Aston Down when they were aiming at Kemble. The most egregious examples merit an AAIB investigation with subsequent wide publicity in the GA community.

Yeah, I dig at Ryanair a bit, but they've never had a single fatality flight, and only a handful of incident flights in their time (none really due to plane or pilot error), so they must be doing something right given they fly probably hundreds of times a day.  I've heard they're a demanding airline to work for but pay their pilots reasonably well,  not big airline money but not pennies either.

Having only flown with them once I found it quite amusing to be offered duty free and lotto tickets mid flight.  I kinda feel bad for the cabin staff having to flog that stuff.  Seats were a bit tight but what do you expect for £50 return to Barcelona! 

[MT]

[SiliconWizard]

Nikki has been a bad girl.

[PartialDischarge]

I didn't quite understand how the door plug was held, I do now and it's a very clever design. Also now I understand why the door plug didn't fall in previous flight at a higher altitude: the higher the altitude the better the door plug self-locks into the frame.

The reason is that the stop pins on the door itself align with the stop pads on the frame, but in reverse, ie the stop pads (frame) are behind the stop pins (door) if one looks at the door plug from inside. See attached pics. So as pressure outside decreases the door force actually sits on the frame more and more, kind of self locking it in place.

[Gyro]

... Also now I understand why the door plug didn't fall in previous flight at a higher altitude: the higher the altitude the better the door plug self-locks into the frame.

As long as the stop pins are sufficiently aligned during pressurization, for the conical pins to lock in, yes. If it climbs with them misaligned, so that the stop tab castings are just sitting on the edges then it could still let go at any altitude. Of course a door warning sensor would have picked up this condition straight away, but unfortunately they couldn't be bothered to fit these on the plug doors, even though the annunciators for these are still on the flight deck.

Yes, it is a clever design, It took me a while to work out how they work. Initially they just looked like bump stops to make the door sit flush. Whether it can be regarded as a true plug door seems still open to debate as the stop fittings (ok, there are 12 of them )are bolted on and the door isn't tapered in the frame. It also creates a lot of potential alignment and tolerance requirements that might have resulted in a bit of unauthorized bolt loosening during fitting, as I suggested in reply #135. Pure speculation on my part of course.

[floobydust]

There were two failures- The NTSB is puzzled over the second. The locking bolts (likely) not installed, and the door moved laterally.
My understanding is the door has to first move DOWN to get the top lock pins out, compressing the springs, and then it's UP and out. But I could be wrong.
The bottom bracket screws found loose on the United planes, I think are the second mech failure here. Once those screws fall out...

The door could have been bumped off the stop pins on a previous landing.
You'd think somebody would notice a door ajar or the rattling sounds.

[Dundarave]

My understanding is the door has to first move DOWN to get the top lock pins out, compressing the springs, and then it's UP and out. But I could be wrong.
The bottom bracket screws found loose on the United planes, I think are the second mech failure here. Once those screws fall out...

Here’s the latest video from the 737 expert that provides a thorough description of the plug attachment system. https://youtu.be/5FcyvFfHsjQ?si=0rryavmB2_SfNs1R

The brackets are on the plug, and the pins are on the aircraft door frame.

The springs, incredibly, act to push the door up and into the released position.  The installers have to push the door down against the springs in order to get the locking bolts in.

I speculate that since there doesn’t seem to be a handle/leverage point on the inside of the plug, when it came time to put the 4 locking bolts in, there was no ladder outside for someone to help push down the plug against the springs so the bolts could be inserted.

The installer doddled off to report it, the interior guys replaced the wall coverings, and the bolts never got installed.

The design, while clever, was a bit too clever in the use of the springs to aid plug removal when necessary.

Further, if the pins and bracket arrangement had been reversed, with the pins on the plug and the brackets on the door, then indeed the springs would have worked to push the pins into the brackets.  Perhaps this was the original design thinking, but something happened to cause the pin/bracket swap during manufacturing changes.

Apparently,  other doors in the aircraft normally have pins on the door and brackets on the door frame.  So perhaps a change that caused unintended consequences.  Below is the relevant image from the video that shows the arrangement of the plug "guide track" (what I've been calling the "bracket"), and the door frame pins.

[Gyro]

...
You'd think somebody would notice a door ajar or the rattling sounds.

Well it is a Boeing 

If there had been an unlucky passenger in the window seat, he might have (briefly?) noticed the window not matching the hole in the interior trim.

[SeanB]

Probably was close to shift change, so the installer went off, and the next shift, seeing door in place, did not check, but simply put the interior and seats back, as they probably had a long list of stuff to finish, because the plane was due to depart before end of the shift.

[SiliconWizard]

Ouch, bad times for Boeing.
https://www.reuters.com/world/us/atlas-air-says-cargo-aircraft-landed-miami-after-engine-malfunction-2024-01-19/

[vad]

Ouch, bad times for Boeing.
https://www.reuters.com/world/us/atlas-air-says-cargo-aircraft-landed-miami-after-engine-malfunction-2024-01-19/

Quote: “ Investigators will be looking at questions like the age of the engine and its maintenance record.”

Boeing does not manufacture engines.

[CatalinaWOW]

Ouch, bad times for Boeing.
https://www.reuters.com/world/us/atlas-air-says-cargo-aircraft-landed-miami-after-engine-malfunction-2024-01-19/

Quote: “ Investigators will be looking at questions like the age of the engine and its maintenance record.”

Boeing does not manufacture engines.

No they don't.  But they won't be able to dodge this one either, since one of the prominent subjects of the failure investigation will be on the apparent failure of the containment system (fist sized hole in the top of the engine nacelle).  At least part of that is on Boeing's watch.  And probably done before the bean counter debacle cited by several on this thread.

[bdunham7]

No they don't.  But they won't be able to dodge this one either, since one of the prominent subjects of the failure investigation will be on the apparent failure of the containment system (fist sized hole in the top of the engine nacelle).  At least part of that is on Boeing's watch.  And probably done before the bean counter debacle cited by several on this thread.

The system is not required to contain all possible failures.  There are some disassembly modes that would be impossible to protect against without making the plane too heavy to fly.

[pickle9000]

 The "engine fire" (to be determined) is one of many failures that happen every day on all aircraft. Not saying it
wasn't serious it was but the plane landed safely. Lots of redundancy. That is very different from the inept
things going on at the FCC and Boeing.

[Andy Chee]

The "engine fire" (to be determined) is one of many failures that happen every day on all aircraft.

Apparently a chunk of the engine let go and punched a "softball-sized" hole through the top of the engine.

Punching a hole through anything does NOT happen every day on all aircraft!

[PartialDischarge]

Boeing cannot be blamed for this engine failure, but I still don't trust 100% the software solution to the MCAS fiasco which downed 2 new airplanes. Being software I just can't trust that airplane anymore.

[pickle9000]

The "engine fire" (to be determined) is one of many failures that happen every day on all aircraft.

Apparently a chunk of the engine let go and punched a "softball-sized" hole through the top of the engine.

Punching a hole through anything does NOT happen every day on all aircraft!

A hole is bad, no question but the engineering behind the engines is phenomenal. The cowling contains
Kevlar but its not perfect. Have a look at this:

[SeanB]

Last one is a 747 cargo, with GE engines. Basically an airframe made in the 1990's, and one that has literally millions of flight hours and landing cycles for the type. Nothing new about it, and the same for the GE engine. Yes it shed turbine blades, but they got contained and left out the back, not through the cabin, and the engine was safely shut down, with the other 3 still providing more than enough power.

[tom66]

Alaska Airlines CEO: We found 'many' loose bolts on our Max 9 planes following near-disaster

https://www.nbcnews.com/business/business-news/alaska-airlines-found-more-loose-bolts-boeing-737-max-9-ceo-says-rcna135316

Just reported.

[floobydust]

"... {Boeing} announced a one-day work pause at its Renton factory for employees to learn and focus on quality assurance."
"It is the first of many “Quality Stand Down” days Boeing will host over the next few weeks at its factories." 

I think most of us here have tightened important bolts- you know the kind with washers, maybe cotter pins, using a torque wrench. It's actually not that difficult after reading a manufacturer's instructions. Surely Spirit and Boeing have 3D exploded view drawings on-line as well to help assemblers, assuming that is the problem. Or is it?


"These troubles are heavily the result of the company’s Jack Welch acolytes and General Electric-style management, weak board of directors, union busting, and exchanging Boeing’s history of engineering excellence for McDonnell Douglas’ “bean counters.” Regular readers know I have written about this often."

"In 2001, a top Boeing aerospace engineer John Hart-Smith presented an internal paper before top executives warning of excessive reliance on outsourcing — a paper that was lauded by his peers within the company but ignored by management. Behind all this was one driving force: to keep the stock price up and reap high executive compensation."

"The Boeing Problem won’t be resolved until real consequences are visited personally on the top executives and the directors. A return to the culture of engineering excellence and reduction of subcontracting may be too much to ask from a company so invested in this business model. But it needs to happen, or more deadly incidents will occur.
“Given what has happened with the two fatal crashes and this incident, the financial targets have to take a back seat for Boeing and its supply chain”...
source: Seattle Times

Meanwhile the executives sit and circlejerk in the boardroom I guess.

[Andy Chee]

I think most of us here have tightened important bolts- you know the kind with washers, maybe cotter pins, using a torque wrench. It's actually not that difficult after reading a manufacturer's instructions. Surely Spirit and Boeing have 3D exploded view drawings on-line as well to help assemblers, assuming that is the problem. Or is it?

Having never worked on an aircraft assembly line, I presume all the tools (particularly torque wrenches) are provided to the workers?  They haven't gone down the private housing construction route, where builders bring their own tools to the worksite??

[pickle9000]

I think most of us here have tightened important bolts- you know the kind with washers, maybe cotter pins, using a torque wrench. It's actually not that difficult after reading a manufacturer's instructions. Surely Spirit and Boeing have 3D exploded view drawings on-line as well to help assemblers, assuming that is the problem. Or is it?

Having never worked on an aircraft assembly line, I presume all the tools (particularly torque wrenches) are provided to the workers?  They haven't gone down the private housing construction route, where builders bring their own tools to the worksite??

Order of operation, fastener, tools everything is normally on a checklist. Tools are supposed to be checked in
and out as well so things are not left inside an assembly.

[MT]

Seams Boing have all sorts of problems!

[tggzzz]

I remember when Boeing used to over-engineer their aircraft...

[MT]

Renton factory assembly culture; At the end of his online post, the whistleblower asks “So, where are the bolts?” then offers a guess:
“Probably sitting forgotten and unlabeled … on a work-in-progress bench. Unless someone already tossed them in the scrap bin to tidy up.”

https://www.seattletimes.com/business/boeing-aerospace/boeing-not-spirit-mis-installed-piece-that-blew-off-alaska-max-9-jet/

[Gyro]

“The reason the door blew off is stated in black and white in Boeing’s own records,” the whistleblower wrote. “It is also very, very stupid and speaks volumes about the quality culture at certain portions of the business.”

The self-described Boeing insider said company records show four bolts that prevent the door plug from sliding up off the door frame stop pads that take the pressurization loads in flight, “were not installed when Boeing delivered the airplane.” the whistleblower stated. “Our own records reflect this.”

I wonder if those records still exist!

[SeanB]

Probably got signed and stamped with the seal of some long dead QC person, who also stamped a few thousand documents as well.

[SiliconWizard]

Is this self-sabotage?

[MT]

[pickle9000]

Crazy that a plug door did not require an inspection unless removed. How could that happen it uses fasteners?

[floobydust]

A going theory is there were problems with missing rivets on the plug door. An 'unplanned removal' is a complex procedure and paperwork, QA inspection so they instead opted for just opening the door (removal of locking bolts) and since there is no QA after that, the missing bolts were not caught.

Whistle blower page 1 and page 2 tells us more how it is in the factory and pretty much terrible "... in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations".

Is this self-sabotage?

Destroying Boeing is entirely beneficial to the enemies of America. If you wanted to ruin a military supplier, how would you do it?
I have seen corporate espionage where an executive team is brought in with the hidden mandate to destroy the company. Usually a pump'n'dump on the stock, as well as "borrow borrow borrow" money go in max. debt, trim/layoff and outsource as much as possible, and then the climax -  short sell, scuttle the ship. Reap massive rewards.

I'm not believing it's a quality problem anymore.

[Stray Electron]

A going theory is there were problems with missing rivets on the plug door. An 'unplanned removal' is a complex procedure and paperwork, QA inspection so they instead opted for just opening the door (removal of locking bolts) and since there is no QA after that, the missing bolts were not caught.

Whistle blower page 1 and page 2 tells us more how it is in the factory and pretty much terrible "... in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations".

Is this self-sabotage?

Destroying Boeing is entirely beneficial to the enemies of America. If you wanted to ruin a military supplier, how would you do it?
I have seen corporate espionage where an executive team is brought in with the hidden mandate to destroy the company. Usually a pump'n'dump on the stock, as well as "borrow borrow borrow" money go in max. debt, trim/layoff and outsource as much as possible, and then the climax -  short sell, scuttle the ship. Reap massive rewards.

I'm not believing it's a quality problem anymore.

  So who are you trying to pin this on?    Bombardier?

[MT]

This will fill the Boing bucket even more "despite" it's most likely a maintenance issue.

[pickle9000]

Boeing is a military contractor, it sounds so sloppy. To be fair the FCC share blame needs to have staff in both facilities taking
pictures, inspections.

[CatalinaWOW]

A going theory is there were problems with missing rivets on the plug door. An 'unplanned removal' is a complex procedure and paperwork, QA inspection so they instead opted for just opening the door (removal of locking bolts) and since there is no QA after that, the missing bolts were not caught.

Whistle blower page 1 and page 2 tells us more how it is in the factory and pretty much terrible "... in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations".

Is this self-sabotage?

Destroying Boeing is entirely beneficial to the enemies of America. If you wanted to ruin a military supplier, how would you do it?
I have seen corporate espionage where an executive team is brought in with the hidden mandate to destroy the company. Usually a pump'n'dump on the stock, as well as "borrow borrow borrow" money go in max. debt, trim/layoff and outsource as much as possible, and then the climax -  short sell, scuttle the ship. Reap massive rewards.

I'm not believing it's a quality problem anymore.

  So who are you trying to pin this on?    Bombardier?

The list of potential suspects is long.  While I find it unlikely that it is a corporate source,  you can rattle off a long list of states with a strong enmity for the US, and quite a number on the list are potentially capable of pulling such an act off.  A fair number of those have a history of such actions.  I certainly have no data on whether it is true or not, only my general observation that when something happens that could be malice or incompetence, the smart bet is on incompetence.  Entropy is a powerful thing.

[floobydust]

  So who are you trying to pin this on?    Bombardier?

It's wildly systemic - loose/missing fasteners on plug doors, the rudder control tie rods, "many loose bolts"...  when they really aren't rocket science to install and tighten. The FAA looking at bolts at 50 locations is just unbelievable.
That's when I say something other than human error is at play here. Not trying to pin it on anyone. 100 things are wrong. Although, I think a CEO needs to be held responsible for the corporation they are in charge of, the consequences are entirely theirs to own. Imagine if a few people got sucked out of the plug door opening or the plane went down.

Find it funny that the greens push for it:
Harvard Environmental Law Review, Vol. 48, No. 1, 2024 Arkush, David and Braman, Donald.
"Climate Homicide: Prosecuting Big Oil For Climate Deaths (January 23, 2023)"
"... they argue that some big oil companies should be charged with homicide because of what the authors claim is reckless profiteering that has caused deaths from pollution and climate change."

MCAS killed 346 people, Boeing charged with 737 Max fraud measly $2.5B fine.
"Today's deferred prosecution agreement holds Boeing and its employees accountable for their lack of candor with the FAA regarding MCAS,” said Special Agent in Charge Emmerson Buie Jr. of the FBI’s Chicago Field Office. “The substantial penalties and compensation Boeing will pay, demonstrate the consequences of failing to be fully transparent with government regulators. The public should be confident that government regulators are effectively doing their job, and those they regulate are being truthful and transparent.” 
Former chairman and CEO Dennis Muilenburg, it happened under his rule: scott-free plus golden parachute.

[Gyro]

It looks as if the MAX9s are cleared to rattle back into the air as soon as tomorrow as long as they have completed their inspections!

https://www.bbc.co.uk/news/business-68090175


However (from the same article)...

"This won't be back to business as usual for Boeing," FAA Administrator Mike Whitaker said in a statement.

"We will not agree to any request from Boeing for an expansion in production or approve additional production lines for the 737 Max until we are satisfied that the quality control issues uncovered during this process are resolved," he added.

and...

United Airlines chief executive, Scott Kirby, also told CNBC that he is "disappointed".

"The Max 9 grounding is probably the straw that broke the camel's back for us," he said, adding that "we're going to build a plan that doesn't have the [Boeing] Max 10 in it".

[schmitt trigger]

There is a saying for an empire’s decay, that I believe would also apply to large corporations;

“Empires aren’t vanished from an enemy’s sword, they are obliterated from self-inflicted wounds.”
Or words to the effect. It has been a long time since I read it.

There were several US companies, IBM, GM, GE, Kodak and others, that so thoroughly dominated a particular business, that it was beyond inconceivable to even think about its downfall. Boeing was such a company in the commercial aircraft business. It is still a behemoth, don’t get me wrong. But is no longer the undisputed leader.

[NiHaoMike]

[coppercone2]

more like a torque wrench calibration problem

I heard culture problem before. but we knew what the problem was, it was pretty simple, a group of people decided to be really cheap.

I wonder if it has to do with those fancy electronic torque indicating wrenches they have now. I started seeing the high end models around online like 2-3 years ago. Maybe they suck.

[jfiresto]

I think I know what you are saying, but somehow, watching a group of executives return 120% of profits to themselves and the shareholders (effectively liquidating the company) does not strike me as being cheap.

[coppercone2]

I think I know what you are saying, but somehow, watching a group of executives return 120% of profits to themselves and the shareholders (effectively liquidating the company) does not strike me as being cheap.

yeah they have profits because they were cheap on inspections, tool QC, inspections of inspections, training,, retention etc

it could be something like
'we have those fancy LCD torque wrenches that show you to the mili newton now. we don't need that inspection anymore so long the employee can read green lights!'. Meanwhile there is a lost washer impinging on bolt #1 and a juicy fruit gum wrapper crumple under bolt #2 and bolt #3 had wire strands in the thread and so on. Because the 20$ an hour untrained new hire was just told "put this in there, wait till its green, go to next one'. an then it gets sent off to the air field.

when the door got blown off all the garbage that obstructed the bolts probobly got throw out over kansas

and culture is IMO something like "that bracket is all dented from shipping boss bolt looks like it wont go in right! no we can't replace that its too expensive just straiten it out with those blocks over there and give it a little bit more torqueeeeee!!! OK!!! DONT LEAVE ANY MARKS ON IT!!!!!" instead of "this bracket is all dented from shipping. We should send it back! hmm... its pricy but all right I will make a phone call. see if you can figure out a plan to fix it if we don't get approval for a new part so I can document this"

case #1 has two shady employees (yes man and a pusher) and case #2 has two reasonable employees (worried about problems and the other one is not scared to communicate or possibly get involved in a bit of a discussion).

[jpanhalt]

In the news again: https://www.foxbusiness.com/fox-news-travel/boeing-potential-delivery-delays-misdrilled-holes-some-737-max-fuselages

Boeing rivet for misaligned holes:


Years ago, a popular cartoon circulated in shops showing Boeing or Northrop  fasteners,  depending on your point of view.  I have searched and couldn't find it.  The image above is not from that cartoon, but should give an idea of what that cartoon showed.

[Gyro]

Emirates aren't very happy right now...

Boeing in ‘last chance saloon’, warns Emirates boss

The boss of Emirates airline has warned Boeing is in the "last chance saloon", saying he had seen a "progressive decline" in its performance.

https://www.bbc.co.uk/news/business-68201371

[Stray Electron]

In the news again: https://www.foxbusiness.com/fox-news-travel/boeing-potential-delivery-delays-misdrilled-holes-some-737-max-fuselages

   Based on the news this morning, they found a significant number of mis-located holes both in undelivered aircraft and in aircraft already delivered.  I have to wonder what kind of stresses and potential structural ruptures and "unplanned disassembles" those extra holes could lead to?

[MT]

Emirates aren't very happy right now...

Boeing in ‘last chance saloon’, warns Emirates boss
The boss of Emirates airline has warned Boeing is in the "last chance saloon", saying he had seen a "progressive decline" in its performance.

https://www.bbc.co.uk/news/business-68201371

This happened at Boings latest board meeting!

[Gyro]

In the news again: https://www.foxbusiness.com/fox-news-travel/boeing-potential-delivery-delays-misdrilled-holes-some-737-max-fuselages

   Based on the news this morning, they found a significant number of mis-located holes both in undelivered aircraft and in aircraft already delivered.  I have to wonder what kind of stresses and potential structural ruptures and "unplanned disassembles" those extra holes could lead to?

I remember a couple of crashes that were down to rear pressure bulkhead rupture, I think one was a 747. Needless to say something like that, in addition to the explosive decompression, plays catastrophic hell with the rear control surfaces.

[Monkeh]

In the news again: https://www.foxbusiness.com/fox-news-travel/boeing-potential-delivery-delays-misdrilled-holes-some-737-max-fuselages

   Based on the news this morning, they found a significant number of mis-located holes both in undelivered aircraft and in aircraft already delivered.  I have to wonder what kind of stresses and potential structural ruptures and "unplanned disassembles" those extra holes could lead to?

I remember a couple of crashes that were down to rear pressure bulkhead rupture, I think one was a 747.

Japan Air Lines Flight 123, gross misrepair of the bulkhead by Boeing technicians eventually ruptured resulting in a complete loss of hydraulics and the vertical stabiliser. Pilots retained control longer than anyone could ever equal in simulations.

Substantial number of unnecessary fatalities due to delayed rescue operations, partially thanks to political pressure.

[SiliconWizard]

Emirates aren't very happy right now...

Boeing in ‘last chance saloon’, warns Emirates boss

The boss of Emirates airline has warned Boeing is in the "last chance saloon", saying he had seen a "progressive decline" in its performance.

https://www.bbc.co.uk/news/business-68201371

That's ok, the CEO will get a new raise.

[Gyro]

Japan Air Lines Flight 123, gross misrepair of the bulkhead by Boeing technicians eventually ruptured resulting in a complete loss of hydraulics and the vertical stabiliser. Pilots retained control longer than anyone could ever equal in simulations.

Substantial number of unnecessary fatalities due to delayed rescue operations, partially thanks to political pressure.

Oh, that was it, the previous tail-strike repair. There was a hell of a lot of media coverage at the time.

[floobydust]

The feedback loop is too long, too slow - by the time Boeing CEO and Wall Street realize the dividends are obtained from massively destructive business practices- it's far too late. They don't care anyway, live for today's profit! What's weird is the industry is only two big players so you have no choice to say go Airbus.

I think it will end up like GM, Boeing commercial division go belly up and then massive bailouts.

[SiliconWizard]

What's weird is the industry is only two big players so you have no choice to say go Airbus.

That's what we think in the West.
Some countries outside of the Western world will probably have little problem going from Boeing to a chinese, or even russian manufacturer instead, if things go real sour.

[Stray Electron]

! What's weird is the industry is only two big players so you have no choice to say go Airbus.

   There is absolutely nothing weird about that if you've followed any of the large American companies. They make such large profits that they buy the competing companies out until there are one of two very large companies left to compete in that market. Ive seen it happen time and time again with banks, defense companies, electronics companies, large retail stores, cable TV companies, food production companies, computer companies, air lines and aircraft manufactures to name just a few.

  The U.S. Federal Trade Commission is supposed to block such large mergers where it would leave virtually no completion in the market but they RARELY do.

[RJSV]

   StrayElectron, I see your point about the monopoly/antitrust dynamic.  We seem to be in a huge situation right now,...as AD-ware gobbles up more and more viewer time, in apparent disregard for clients, or even the concepts around the relationships, ideally.
   No, the customer isn't even 'last in line's it feels like.
   It's only one media corporation/search engine/video producer/enterprise software that I'm talking about, here.

We got the BEST monopoly, ever.

[CatalinaWOW]

There is a bit of piling on here.  Mis-drilled holes are not terribly uncommon in the aircraft industry (particularly in the maintenance and repair area).  There are fairly well established procedures to determine whether they can be repaired (with established repair techniques) or if the part/assembly must be replaced.

So there is a mix of good news/bad news here.  Bad holes found - neither good nor bad.  It happens.  What matters is when you figure it out and what you do about it.   Boing (not other parties) found bad holes - good news, and maybe the first signs of a turn around in the quality culture.  Too soon to tell.  Boeing found bad holes in delivered airframes.  Bad news.  No one outside of Boeing and possibly the FAA knows how bad this news is.  In terms of safety impact it could be anywhere from nothing, to a dire risk.  From an economic perspective it could mean reduced airframe life, or expensive repairs.  It is bad news from the standpoint of Boeing QA at that point in time, but that isn't new news, there was already ample evidence of that.  Boeing went public with their findings.  Good news.  If it was totally voluntary pretty darn good news as more evidence of a renewed commitment to safety.  Not so good news from the perspective of stock prices and the effect on the general publics confidence in Boing products, but that's the bed they made.  Only time will tell how this plays out in the long run.

[nardev]

I hope this saga with Boeing will end but knowing the mentality of "managers which are only managers" and ego game, i'm afraid this would not be the last issue with this plane.

This is miserable.

Last year 4 times i was in 737 max and i was always near the doors and thinking if i should actually keep the belt or not.

[tom66]

"Bolts missing from door, says blowout report"

The US National Transportation Safety Board has released initial findings from its probe into the incident on an Alaska Airlines plane in January.

It says four key bolts that were meant to lock the unused door to the fuselage appeared to be missing.

https://www.bbc.co.uk/news/business-68220627

The NTSB website appears to be straining under load, but here is the preliminary report: https://www.ntsb.gov/investigations/Documents/DCA24MA063%20Preliminary%20report.pdf

Edit:  the description in the BBC report (haven't checked the NTSB one) is a near-exact match for the whistleblower comments - Spirit damaged the door, and process failure allowed it to be fitted without bolts being verified.  The only unconfirmed thing is, whether this happened because Spirit was unable to access the Boeing systems or not.

[Gyro]

...
Last year 4 times i was in 737 max and i was always near the doors and thinking if i should actually keep the belt or not.

Always, even if you loosen it off a bit! Clear air turbulence could have to face planting (or worse) on the overhead storage bin before you even know what's happening.

https://en.wikipedia.org/wiki/Clear-air_turbulence

[tom66]

PDF copy if anyone can't get the NTSB website to load.  (wget managed it eventually, Chrome gave up many times.)
https://drive.google.com/file/d/1oxhjRes07C1DE2xc9hleit5hKkiyaEEX/view?usp=sharing

[CatalinaWOW]

PDF copy if anyone can't get the NTSB website to load.  (wget managed it eventually, Chrome gave up many times.)
https://drive.google.com/file/d/1oxhjRes07C1DE2xc9hleit5hKkiyaEEX/view?usp=sharing

You just know that most of the people downloading this report are ambulance chasers checking the opportunities for a big payday.

[MT]

[mendip_discovery]

From the DCA24MA063 preliminary report,

The Manufacturing Records Group traveled to Boeing’s Renton, Washington, facility to review manufacturing records for the accident airplane specific to the left MED plug area. According to records, the accident fuselage arrived at Boeing’s Renton facility by rail on August 31, 2023. During the manufacturing process, if any defects or discrepancies were found, a Non-Conformance Record (NCR) or a disposition required NCR were generated.

On September 1, 2023, records show that NCR 1450292531 was created noting five damaged rivets on the edge frame forward of the left MED plug. See figure 14 for rivet locations.

Documents and photos show that to perform the replacement of the damaged rivets, access to the rivets required opening the left MED plug (see figure 15). To open the MED plug, the two vertical movement arrestor bolts and two upper guide track bolts had to be removed.

Records show the rivets were replaced per engineering requirements on Non-Conformance (NC) Order 145-8987-RSHK-1296-002NC completed on September 19, 2023, by Spirit AeroSystems personnel.  Photo documentation obtained from Boeing shows evidence of the left-hand MED plug closed with no retention hardware (bolts) in the three visible locations (the aft upper guide track is covered with insulation and cannot be seen in the photo). See figure 16. This image was attached to a text message between Boeing team members on September 19, 2023, around 1839 local. These Boeing personnel were discussing interior restoration after the rivet rework was completed during second shift operations that day.

The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework.

Interesting. My interpretation is that the plug was removed and then put back in but maybe without all the bolts being done up hence the failure. I wonder if it was a case of A assuming B would refit and do the bolts up but B assumed A had done it.

However that doesn't explain the reports of other plug doors having issues.

[tooki]

Boeing is a military contractor, it sounds so sloppy. To be fair the FCC share blame needs to have staff in both facilities taking
pictures, inspections.

The FCC definitely isn't in charge of aircraft manufacturing oversight.

[tooki]

Crazy that a plug door did not require an inspection unless removed. How could that happen it uses fasteners?

They were inspected when first manufactured. Why re-inspect something that passed its final inspection, if it hasn’t been touched since?

[jpanhalt]

They were inspected when first manufactured. Why re-inspect something that passed its final inspection, if it hasn’t been touched since?

That theory doesn't quite apply to civilian aircraft.  "Annual*" inspections  are required and detailed.  As just one example, wing attachment bolts that are factory installed and rarely, if ever removed get inspected.

*In the US, our military has its own standards.  An "annual" may be performed once a year or by an approved continuous maintenance/inspection program.  The former is most common for smaller, general aviation aircraft.  The latter generally applies to much larger or more complex aircraft.   Rules in other countries may vary.

[Gyro]

Crazy that a plug door did not require an inspection unless removed. How could that happen it uses fasteners?

They were inspected when first manufactured. Why re-inspect something that passed its final inspection, if it hasn’t been touched since?

Because it was 'touched since', see the latest video. Sprite fitted it to the fuselage before they shipped it to Boeing. There it was removed at Boeing to facilitate repair of some rivets in the frame (fuselage). It was then re-fitted and not finally inspected.

[mendip_discovery]

They were inspected when first manufactured. Why re-inspect something that passed its final inspection, if it hasn’t been touched since?

That theory doesn't quite apply to civilian aircraft.  "Annual*" inspections  are required and detailed.  As just one example, wing attachment bolts that are factory installed and rarely, if ever removed get inspected.

*In the US, our military has its own standards.  An "annual" may be performed once a year or by an approved continuous maintenance/inspection program.  The former is most common for smaller, general aviation aircraft.  The latter generally applies to much larger or more complex aircraft.   Rules in other countries may vary.

Yeah but this was a new aircraft (~3 months) with only 510 hours on it so not really into annual checks territory. All aircraft have annual checks and other checks based on the number of hours in service much like cars get annual checks and ones based on mileage.

[MT]

U.S. regulators are warning airlines to limit the use of an anti-icing system on Boeing 737 Max jets in dry air to avoid overheating engine-housing parts,
which could cause them to break away from the plane.

The Federal Aviation Administration says the risk to the flying public is serious enough that it will put the order into effect in just 15 days, and without allowing public comment first.
The FAA said if the engine inlet gets too hot, parts of the housing could come off and strike a window, causing decompression and a hazard to passengers in window seats.
The FAA is dictating that flight manuals tell pilots and airlines not to use engine anti-ice in dry air for more than five minutes. Otherwise, the FAA said, “during certain combinations
of altitude, total air temperature” and engine settings, the engine inlet inner barrel could be heated beyond its design limit.


https://nationalpost.com/news/faa-warns-of-safety-hazard-from-overheating-engine-housing-on-boeing-max-jets-during-anti-icing

[SiliconWizard]

That keeps getting better!

[watchmaker]

Boeing is a military contractor, it sounds so sloppy. To be fair the FCC share blame needs to have staff in both facilities taking
pictures, inspections.

The FCC definitely isn't in charge of aircraft manufacturing oversight.

Tooki,

My understanding of US inspection policy is that agencies may designate individuals who serve as contract inspectors on site.  There was a time when a federal inspector was on site, for everything from food processing to aircraft certification.  But as citizens demanded fewer govt employees, this approach evolved.  It is even reflected in education by our accreditation bodies approved by the Dept of Education to verify educational institutions meet standards, from elementary school to medical residencies.

But in all cases, the final responsibility rests with the designating agency.

So from my point of view, yes the FAA is involved, and yes they have responsibility for the fiasco.  What makes it worse is that this scenario has been a very slow moving train wreck since at least the 1990s.

https://www.faa.gov/other_visit/aviation_industry/designees_delegations/individual_designees/manufacturing

[jpanhalt]

U.S. regulators are warning airlines to limit the use of an anti-icing system on Boeing 737 Max jets in dry air to avoid overheating engine-housing parts,
which could cause them to break away from the plane.

OMG.   That's terrible.  The B29, which was instrumental in defeating Japan in WWII, had a problem with engine overheating.  Namely, the cowl flaps, which are usually closed during cruise, needed to be left open.  Of course, that was approved because of the exigencies of war.  Is the 737 a strategic bomber, and who did Boeing think we were fighting?

[BrianHG]

Will Boeing last?

[schmitt trigger]

Boeing is “too large to fail”, plus it has plenty of military and space contracts.

The US government, aka the taxpayers, will bail them out.

[floobydust]

But what gets fixed up in that fail+bailout process?
You can't mandate safety or manufacturing quality. You can't mandate against corporate greed and catering to Wall Street investors. The MBA's don't quite get it.
The Boeing Problem is from damage decades in the making and their culture is rotten.

Automaker bailouts were around $17B and "Management-Restrictions were placed on executive compensation and privileges, including pay, bonuses, golden parachutes, incentives, and benefits. Executives were also restricted from compensation agreements that would encourage them to take “unnecessary and excessive risks” or to manipulate earnings (Cooney et al., 2009, pp. 42–43)." source

Wow I guess that fixes everything 

[NiHaoMike]

[SiliconWizard]

Or maybe we're supposed to accept these unfortunate events as the new normal, aviation has been the safest mode of transportation until now, but it has been very costly. So maybe we, as passengers, need to lower our high expectations a bit so that shareholders can get more profit. We're just being selfish with those expectations.

[MT]

https://www.zerohedge.com/markets/congressman-sold-boeing-stock-hours-doj-probe-was-announced

QUOTE:
And as the pressure ratchets up on Boeing, it's becoming increasingly obvious that management is running the same type of interference it did during the infamous MCAS scandal and ensuing cover-up attempt which cost former CEO Muilenburg his job. Sure enough, on Wednesday we learned that Boeing - in a pure coincidence that Jeffrey Epstein would approve of - "overwrote", i.e. deleted, security camera footage showing work being done on a door that blew out on the Alaska Airlines MAX jet in January.

It's not just the footage however: NTSB Chair Jennifer Homendy said it is unclear "who performed the work to open, reinstall, and close the door plug on the accident aircraft," as Boeing is "unable to find the records documenting this work." In Homendy's letter, she writes that despite requests to Boeing and interviews at the Renton, Washington factory where the panel was removed, the identity of the crew member that worked on the panel remains unknown and has would be unable to "provide a statement or interview to NTSB due to medical issues."

[tggzzz]

https://www.zerohedge.com/markets/congressman-sold-boeing-stock-hours-doj-probe-was-announced

Zerohedge?

I have a bridge in New York, which I want to sell. Are you interested in buying it from me?

[floobydust]

Or maybe we're supposed to accept these unfortunate events as the new normal, aviation has been the safest mode of transportation until now, but it has been very costly. So maybe we, as passengers, need to lower our high expectations a bit so that shareholders can get more profit. We're just being selfish with those expectations.

Wall Street and the MBA's leave engineering setup to fail - starved of time, R&D, senior people and outsourcing bits and pieces, rush rush hurry hurry scorecard, get that plane out the door!
So what are the engineer's expectations? Just be happy to collect your paycheque I guess, even though the bean-counter CEO's is 158x more dollars.

Who would want to work for Boeing?

Fuckin' icing has killed 100's if not 1,000's of people in aviation and here we are today with Boeing pushing for a Wile E. Coyote nacelle heating scheme and FAA can you look the other way please. Such advanced greed-tech, way to go.

[MT]

https://www.zerohedge.com/markets/congressman-sold-boeing-stock-hours-doj-probe-was-announced

Zerohedge?
I have a bridge in New York, which I want to sell. Are you interested in buying it from me?

No not "liberal" Zerohedge but "NBC news and NTSB" if you had done your homework and clicked the links in the text.
Happy now when we found your pacifier? Btw already forgot you bought that bridge from your friend Trump 20 years ago?

[tggzzz]

https://www.zerohedge.com/markets/congressman-sold-boeing-stock-hours-doj-probe-was-announced

Zerohedge?
I have a bridge in New York, which I want to sell. Are you interested in buying it from me?

No not "liberal" Zerohedge but "NBC news and NTSB" if you had done your homework and clicked the links in the text.

If you wanted us to read other sources you should have linked to those sources.

Zerohedge is low a very low quality source.

Happy now when we found your pacifier? Btw already forgot you bought that bridge from your friend Trump 20 years ago?

Can you please explain what you mean by that, because I don't understand it.

[AVGresponding]

Happy now when we found your pacifier? Btw already forgot you bought that bridge from your friend Trump 20 years ago?

Can you please explain what you mean by that, because I don't understand it.

No-one does, it's gibberish.

[tggzzz]

Happy now when we found your pacifier? Btw already forgot you bought that bridge from your friend Trump 20 years ago?

Can you please explain what you mean by that, because I don't understand it.

No-one does, it's gibberish.

... and from that we can make inferences about other parts of his post(s).

But should we, and would they be accurate?

[Gyro]

...aaand another one bites the dust:

Boeing chief executive Dave Calhoun to leave as firm faces safety crisis

Boeing boss Dave Calhoun will leave at the end of this year amid a deepening crisis over the firm's safety record.

The head of its commercial airlines division is retiring immediately too. Golden handshakes all round again I suspect.

https://www.bbc.co.uk/news/business-68656925

[TopQuark]

https://www.nytimes.com/2024/03/25/business/boeing-ceo-steps-down.html

Stan Deal, the head of the division that makes planes for commercial customers, will retire immediately and will be replaced by Stephanie Pope, the company’s chief operating officer, the company said in a statement.

Ms. Pope has seen a relatively rapid ascent in recent years. In early 2022, she was promoted from her role as chief financial officer of the company’s commercial airplanes division to head of Boeing Global Services, which provides aftermarket support to customers. After a successful run there, she was promoted in December to chief operating officer of Boeing, a move that was seen as setting her up to take over for Mr. Calhoun in a few years.

So they replaced the head of the commercial airplane division, with the ex-CFO of said division. What could possibly go wrong.   

[SiliconWizard]

Lol, it keeps getting better!
Let's see how low they can sink.

[tom66]

Rats fleeing the sinking ship?

[vk6zgo]

https://www.nytimes.com/2024/03/25/business/boeing-ceo-steps-down.html

Stan Deal, the head of the division that makes planes for commercial customers, will retire immediately and will be replaced by Stephanie Pope, the company’s chief operating officer, the company said in a statement.

Ms. Pope has seen a relatively rapid ascent in recent years. In early 2022, she was promoted from her role as chief financial officer of the company’s commercial airplanes division to head of Boeing Global Services, which provides aftermarket support to customers. After a successful run there, she was promoted in December to chief operating officer of Boeing, a move that was seen as setting her up to take over for Mr. Calhoun in a few years.

So they replaced the head of the commercial airplane division, with the ex-CFO of said division. What could possibly go wrong.   

One would think it wouldn't be too much to ask for an engineering company to have an engineer or two in the upper echelons of management, but it seems it is!
Engineers are not always stellar managers, but they usually do have a better grasp on the realities of the physical world.

[SiliconWizard]

They should change the company's name, isn't that what happens when some company needs to freshen up its image?

I suggest "Boing".

[floobydust]

A revolving door door for execs and board members, and it will change nothing.
Imagine working there for a couple years, get the multi-million dollar golden parachute despite the failures. Boeing CEO paid 158x the average worker.
I suspect the DOJ/FBI criminal investigation has the rats worried a little. Better eliminate the whistle blower. Check.

The new CEO she's another B.Sc. bean-counter, like Calhoun. WTF does accounting have to do with safety-critical, top engineered products?

Anyone here remember the ladder manufacturing left inside the 787 tail? That was Spring 2019 and 5 years later SFA has changed. That's quality control lol.

[SiliconWizard]

Damn, the only time I had the opportunity to fly with a 787 (and I was really looking forward to it at the time) was a few years ago, unfortunately it didn't happen as there was a last time "technical problem" with the plane and they had to get us another flight. Oh well.

[Gyro]

Oh dear, another bit fallen off (737-800)...

Airline regulators in the US have begun an investigation after an engine cowling on a Boeing 737-800 fell off during take-off and struck a wing flap.

https://www.bbc.co.uk/news/business-68758088


It ought to be possible to design some sort of 'maintenance proof' latches or fasteners.


P.S. I missed this one from a couple of days ago,  Boeing's payout to Alaska Air for the door plug...

Boeing has paid $160m (£126m) to Alaska Air to make up for losses the airline has suffered following a dramatic mid-air blowout in January.

https://www.bbc.co.uk/news/business-68737292

[langwadt]

Oh dear, another bit fallen off (737-800)...

Airline regulators in the US have begun an investigation after an engine cowling on a Boeing 737-800 fell off during take-off and struck a wing flap.

https://www.bbc.co.uk/news/business-68758088


It ought to be possible to design some sort of 'maintenance proof' latches or fasteners.

the 737-800 has been flying for 30 years, almost 5000 produced, that wouldn't happen if it wasn't  a good plane

Airlines screwing up maintenance isn't necessarily on Boeing

[hans]

It's not like these things didn't happen way before. Or on other jets. It could be a human error, e.g. not closing the latches properly, pilots/techs not checking them during walkarounds, etc. Last-minute maintenance happens all the time.

That could be more on the airline instead of Boeing.

It's "just" that anything failing on a Boeing plane is now big news..

[BrianHG]

 

[floobydust]

"Boeing CEO Dave Calhoun, who announced last week he’ll step down later this year, received compensation last year currently worth $23.6 million..."
"... despite Boeing’s $2.2 billion loss in 2023...". No bonus I wonder why. source
Dennis Muilenburg, his predecessor, left with a $62 million payout. 346 dead and he's living' the life 

It's not like these things didn't happen way before. Or on other jets. It could be a human error, e.g. not closing the latches properly, pilots/techs not checking them during walkarounds, etc. Last-minute maintenance happens all the time.

That could be more on the airline instead of Boeing.

It's "just" that anything failing on a Boeing plane is now big news..

Boeing fully deserves all the media coverage. They have worked hard to earn it. It's the only thing that puts any pressure towards change. What a strange feedback loop.

[hans]

It's not like these things didn't happen way before. Or on other jets. It could be a human error, e.g. not closing the latches properly, pilots/techs not checking them during walkarounds, etc. Last-minute maintenance happens all the time.

That could be more on the airline instead of Boeing.

It's "just" that anything failing on a Boeing plane is now big news..

Boeing fully deserves all the media coverage. They have worked hard to earn it. It's the only thing that puts any pressure towards change. What a strange feedback loop.

Don't get me wrong -- I rather step into an Airbus than a Boeing. When you compare the 737 vs A320 incident list, I'm pretty confident that the number of airplanes built doesn't offset its length.
Although Airbus also screwed up with their first demo flight of the A320, despite it being more contributed to pilot error rather than design error. Airbus like to tell people that their FBW protections makes for a plane you cannot crash. However, during the years it has also been shown that the fly-by-wire concept has (had) fundamental flaws.
The 737Max crashes were much worse than that, though, and a door falling out because its not bolted down is also very bad..

But at some point reason has to kick in IMO. The press is now posting every incident with a Boeing as breaking news, while this kept happening for many years, and before many were fine with it. At some point its also impossible to fault a manufacturer for everything. E.g. its hard to fault a car manufacturer for a bonnet flying open if you didn't close it properly.
Of course this means I'm speculating what happened with this jet. But there are many more people touching those parts a plane than Boeing, in particular close to take-off, so it could be anyone's fault.

[soldar]

There is a saying for an empire’s decay, that I believe would also apply to large corporations;

“Empires aren’t vanished from an enemy’s sword, they are obliterated from self-inflicted wounds.”
Or words to the effect. It has been a long time since I read it.

There were several US companies, IBM, GM, GE, Kodak and others, that so thoroughly dominated a particular business, that it was beyond inconceivable to even think about its downfall. Boeing was such a company in the commercial aircraft business. It is still a behemoth, don’t get me wrong. But is no longer the undisputed leader.

"A great civilization is not conquered from without, until it has destroyed itself from within."

This is a quote from Anthony Mann's 1964 film, 'The Fall of the Roman Empire'.

I believe this and I have said it many times. Empires are destroyed and fall from within.

A rising empire, be it a country or a corporation, is willing and eager to take on the competition believing it can prevail.

An empire in decline tries to avoid the open competition and resorts to protectionism, dirty tricks, etc. When you see a country or corporation doing this you know they are in decline.

[soldar]

They should change the company's name, isn't that what happens when some company needs to freshen up its image?

I suggest "Boing".

Or, maybe, "Boeing Boeing"

[Gyro]

Another whistleblower, just to give you that warm fuzzy feeling if your flying in a 777 or 787. It knocked 2% off the share price yesterday, more than I would have expected - the market must be getting jumpy at the mention these days...

Boeing hit after new whistleblower raises safety concerns
Boeing is facing new pressure after a whistleblower reported safety concerns over the manufacturing of some of its planes to US regulators.
Engineer Sam Salehpour accused Boeing of taking shortcuts in the construction of its 787 and 777 jets.
He claimed he was "threatened with termination" after raising concerns with bosses
...

https://www.bbc.co.uk/news/business-68775413

[CatalinaWOW]

I would wait to see the whistleblowers data before reacting to strongly.  Anyone who has worked ina large organization has encountered the chicken littles who are sure the sky is falling. This guy may have a real issue, or it may be nothing.Just because Boing has lost its right to be presumed correct, the perfect credibility of everyone else cannot be presumed.

[themadhippy]

I would wait to see the whistleblowers data

Id wait to see if they  commit suicide just before they're due to give evidence.

[CatalinaWOW]

I would wait to see the whistleblowers data

Id wait to see if they  commit suicide just before they're due to give evidence.

That would be data.   But sounds like you already know the answer and don't need data

[SiliconWizard]

At this point, I don't know how Boeing is going to get out of this mess. Appointing a new CEO every couple years (while giving millions to the former one for all the "good" they did to Boeing) is soon going to show its limits to solve the issues.

[jfiresto]

Eventually, all but the most obtuse will recognize that addressing their problems through superior messaging will not fly.