Boeings Negligence Is Far Worse Than We Thought. Alaskas Blowout MAX Flew With NO BOLTS For 2 Months
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- Опубликовано: 6 фев 2024
- The NTSB Released its preliminary report and Boeing screwed up this whole situation more than anybody imagined.
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This is what happens when you replace a CEO with an engineering background with a man that oversaw a private equity firm
This happened at Rolls Royce as well and look what happened there
Boeing was an engineering company, now it is into marketing.
and then fire the QA inspectors and engineers who spoke out.
Boeing previously laid off a large amount of qualified inspectors to cut costs. The board and CEO are inept and should be removed
Agree completely. Boeing needs to be managed as an engineering company (and incidentally as a strategic, national treasure). We really can't afford to lose our aerospace engineering prowess due to daft management and short-term thinking.
Removed and JAILED for life. Let it serve as a lesson to greedy managers everywhere.
Yup! Hay you MBA's, this is Aviation, we check things twice just ... because. Now you know why, if you care to know.
This was many years ago I was working at a machine shop in Calif. and was just counter-sinking
some holes and then they returned some of them to me to fix because they did NOT pass
inspection, this part is what holds in the windows on the cockpit of a Boing 747, I think you
get my point on how important inspectors are.
Source?
If you want to enhance safety quit firing anyone who brings up safety issues.
They don't want to enhance safety. They want to enhance their bank accounts.
But you work at Dollar General. Please provide sources for your assertion.
@@RLTtizME He has never fired a whistle blower, and his planes have never crashed.
The ocean gate solution maybe someone should let these corporate executives know that the last person that try that died
@@robertsmith2956 So who is he Bob Smith if that is your real name. What whistle blower and what manufactured plane has never crashed?
If Boeing hasn't produced the documents to investigators after ONE MONTH, I say the FAA should ground all 737Max products until they do.
Have you heard of that thing americans call lobby and the rest of the world call corruption?
Seriously. They are hiding something. We already know what happened here, so why not release the docs? Could it be because there are other issues uncovered that will ground the fleet again?
The paperwork might show that there’s no continuity between Spirit’s rework in Renton and Boeing’s quality system.
Major Systemic finding. You are correct sir. This is what happens when you replace aerospace managers with automotive managers.
@@dond668I've worked in engineering for 2 German automotive companies and while one of the two has famously cut a major corner in emissions, I think they have been handling the occupant safety well and production consistency and quality control in safety related areas really well.
@@SianaGearz Modern aircraft are closer to space ships than cars. I’ve seen our aerospace suppliers QMS focus on cost reduction in that it takes engineers away from traditional aerospace quality work to focus on saving money. New requirements for Statistical Process Control (SPC) data is a good example of this. If the part meets requirements it’s good. Don’t add SPC requirements of PPAP especially when you only build 100 parts a year and have never had a failure.
When will management start being held accountable? It’s time upper management starts getting prison time. 😊
America prisons are filled with murderers.
The US is the land of corruption and corporate loopholes. Nothing will change at Boeing.
We have no knowledge of where the problem lies. It may be that inspection of the bolts before installing the insulation and interior was not called for in the procedure. To jump to the conclusion that it was criminal negligence on the part of management is premature. There is clearly error involved somewhere, but the details remain to be seen.
@@flagmichael No knowledge????
- this doo plug was open at Boeings assembly
- Boeing's instructions tell in the case of dismounting the door plug those bolts to be reinstalled after the closing of the door.
- Boeing's instructions don't tell in the case of a just opened door plug anything about those bolts after the closing of the door.
The workers are told to stick to the instructions .....
@@flagmichael ever since Boeing bought McDonnell Douglas the stock price and return on investment has been the focus over engineering excellence and safety. That’s a management issue. Then there’s the two Max crashes and the lost passenger lives.
Never, ever let the bean counters be in charge of anything where failure can kill people. Never!
Never let the bean counters be in charge of quality of anything with any safety impact at all.
Spot on!
Q: What is the mating call of the Harvard MBA?
A: "Cheap, cheap, cheap!"
Those birdz need to be caged !!!
Yeah. So cheap it doesn't work anymore.
This is not a question of cost. In fact, it is far cheaper to adhere to policies. You don't run red lights to reduce your driving costs, right? Same thing here: there was an error either in the procedure to reinstall the interior, or a quick and easy step was overlooked.
@@flagmichael The Procedure was not followed. The documentation for that procedure is missing.
The important question IMO is, is there any evidence that the procedure was ever followed or is it only there for certification purposes?
Given the reported incidences of bolts missing after this incident, I would posit that the procedure was habitually ignored in favor of shorter service times and that the documentation the procedure should have generated is mostly absent.
If that is true, then that points to a culture of ignoring procedure. On something as complex as a 737 MAX that guarantees that much more then a few bolts are missing.
I resigned my engineering position at boeing in 1989...I told the CEO at the time that if they did not clean up a few things.... that Airbus.. with 2% of the business would eat their lunch....
I am baffled even today how this range or issues could not have been seen as a cancerous level problem and corrected... this door plug situation is one of least of what has been reported over the last 30 years by numerous whistle blowers (all of it has been on you tube).
On another unrelated issue...Hanford Nuclear reservation in north east Washington state was aggressively forcing its engineers to lie...I ended up testifying before congress for 2 hours on how that degrades and ruins him, then his kids and the business and the culture...broad scale.
Historically there does not seem to any recovery from that.
In production however we build in a lot of redundancy... so that for example if there are 30,000 small rivets in a planes outer shell and if we stopped production to make it perfect...that would stop all production in its tracks....so we engineer a lot redundance....and people who insist on perfection are ridiculed because they do not see the protection that redundance brings.
its a fine line between the nit pickers and reality....There would be no degradation if the 0.00001% rivet was not perfect and the need to move on with production should be allowed regardless.... because the number of rivets was increased to insure reliability in the first place..
Similarly at the nuclear weapons plants....we cut all kinds of corners there then hid them rather just say openly we cut a lot of corners as we rushed to develop the bomb before German Reich did.
It appears that truth solves all problems.
However the agencies, government and private... and their policies tend to penalize it... so we do a lot of lying to save our skins.... and that ruins the entire culture.
This is what happens without engineers in charge.
Phil Scott
Engineers should be in charge.
When dishonesty is commonplace, the truth becomes an insult
Respect to you sir! With over forty years in aviation myself, I concur.
It's absolutely disgusting how fast things have slid down. The FAA, EASA, TC and every other paper pushing organization is more interested in how t's are crossed in paperwork than actual on the floor audits. There are more and more unqualified people on the floor that shouldn't be near a wrench, let alone lockwire who's shody work is being signed off by just one qualified AP or AME, instead of the whole floor being worked by qualified AP's or AME's.
Thank you 😊
From Boeing to BOING...😂😂😂
As my Pappy used to say, "The hurrier I go, the behinder I get".
Pappy was wiser than a tree full of owls.
I am retired aircraft mechanic. Fifty year ago, one of my coworkers had a bumper sticker on his tool cabinet: Why is it that there is never time to do it right the first time, but always time to do it over?
I’m more the type of guy who moves fast and breaks things. I’ve been promoted three times in the last three years, but I have some awesome quality inspectors whom I respect. They ensure that I don’t take too many shortcuts on the things that matter
@@pedromarques9267 Inspectors shouldn't have to be babysitters. They are looking for defects hoping to find none, but when they get to your production, defects are expected?
I worked with a guy like you, and when I said to the boss that he was not reliable, I was corrected. He could be counted on to screw it up, every time, that is reliability.
A number of the employees, including Mr. Mayhem at this window company were lay-offs from Boeing cut-backs in the 80s. We weren't in business long, no Federal subsidies.
Slow is smove and smove is fast.
Boeing's motto - "Profits before people! Profits before human lives!"
Sane with airbus really. Profits come first
@@nickolliver3021 come on, you can do more. Is that all? Say something about the European Union. The “Bad” Airbus and Europe are the only solace when you can't justify the sinking ship. And in fact, how does Airbus put its profits over human life? You still haven't answered me?😉
@@facethepersonal5836 Oretty much hidden inside all companies put profit over human life. Airbus have had many mistakes but seriously if people can't think of tbe airbus mistakes they are surely know airbus is perfect yet they never are
Your motto...snarky comments without the facts.
i used to work in pharma. business not charity. treatment not cure. etc etc.
at some stage all these "minor" items are going to result in a serious incident, and boeing will be finished. and its their own fault. greed over safety.
Nah, they'll ensure whatever happens is pilot error before that goes down.
Zero chance anything actually happens to Boeing.
Too critical for the country. Any major issues will be downplayed and at best a minor fine and some yelling in congress.
They are untouchable.
If they’ve already crashed two planes and killed a few hundred people and companies are still buying that same model plane, the company isn’t going anywhere.
Boeing will not be finished. Thr media is just too he'll bent on boeing
Too big to fail. And this is not the first time Boeing had an accident.
Adds gravitas when the cabin crew announces on a BOEING 737 flight, "while the captain has turned off the seat-belt sign, it is recommended you keep your seat-belt on at all times". Frankly, if I had no choice and ended up on a BOEING flight, Id keep a piss bottle with me.... like Amazon delivery drivers.
May want to increase life insurance
The only time I ever remove my seat belt, is if I stand up. No matter the aircraft make/model.
B.O.E.I.N.G. = Bankrupt Of Ethical Integrity Now Governs
This isn't about it being a Boeing plane. Some (rare) types of turbulence just can't be predicted. You'll be reasonably safe without the seat belt, just like in a car in a very low speed zone. But why risk it if not necessary?
Exactly. I wore my seatbelt unless I intended to get up back when I was a teenager many years ago. Why? Because it was what I did when I rode in a car.
Greed, Greed and more Greed to satisfy the stockholders.
That's the problem with trying to please shareholders -- they have no real skin in the game. Their "loyalty" is just a click of the [Trade] button away.
Greed is everywhere sadly. The world is declining
@@grayrabbit2211 More importantly, most shareholders care more about short term profit than the long term health of the company. At least those that are free to sell their shares at any moment. Off course, this often means that the people who pushed for short sighted business practices rarely pay the price when everything inevitably goes south. By then they've already made their fat stacks, and are well on their way to repeat the process with a different company.
The primary role of senior executives is creating healthy culture and ensuring that processes, priorities, and incentives are aligned with strategic objectives. That's what the extravagant compensation packages are supposedly delivering. In this case...not so much at either Boeing or Spirit. It is always about leadership (and leadership failures). Always. Time for the fancy people to leave Chicago and start managing by walking around the factory (if not getting canned for being idiots).
@@imkindofabigdeal4308 guess who can kick out and elect the leadership.
majority vote shareholders.
they are the actual leadership.
I used to work for a manufacturer. It was in the petroleum industry, to be fair. But all the same. Meetings about safety or quality are all just a way for management to say "We did something to address a problem." But in the end, nothing changed because the culture did not change.
Finally, a comment about the real world! Outside tightly regulated fields (I worked in aviation in my first career, and bulk electric power in my second career) there is a pervasive sense that regulators and government safety inspectors are just pains in the ash. There is just enough truth to that to keep the attitude going, but when it blows up in a company's face it is rather late.
I was the Chief Inspector for an avionics and instrument shop in general aviation for the last 8 years of my first career. Before I got to that stage I had seen the results of shortcuts, so I coined my words to live by: "Everything is a technicality until something goes wrong." That really paid off when I was the last person to touch a Comanche before the pilot loaded three passengers and flew off into a snowstorm. I had installed the repaired #1 nav instrument and ramp tested both, writing that on the work order. The next day our GADO inspector paid me a visit, asking what I knew about it and getting a copy of the work order. AFAIK the wreckage was not found, but at least I could certify the navigation was not a problem, and the NTSB was not interested in me. Whew!
The spokesperson for the FAA department in Booing stated: nothing to see folks. You see, it can fly at least 2 months without bolts. This is just a test flight.
It reminds me of Richard Feynman's investigations at NASA. He discovered a turbine blade that was cracked 50% of the way through. Management said "See, we still have a safety factor of 2!" No, that's not how safety factors work: a safety factor of 2 means you look at the shortest period turbine blades have run without cracking, then divide that in half, and that's the safe lifetime of a blade with a safety factor of 2. A blade with a crack in it has already failed.
It's a miracle nobody was injured. Had the aircraft been at cruising altitude there would have been fatalities.
They were very lucky that the plug didn't damage the horizontal stabilizer or the elevator because they are on the same height
Flight 811, happened before with a very similar setup, (though with a cargo door) that had fatalities.
@@asicdathens yeah.. it will be different story..
Max already had 2 fatal crashes. Every safety protocol and culture problem should have been reviewed and perfected. Boeing nor the FAA are serious in resolving underlaying issues. They just want the public to forget about it and move on.
It would have been a complete loss with a lost horizontal stabilizer, lose of control, and crash.
Boeing has given the phrase 'bolt for the door' a whole new meaning. Inversely.
"Bolts, we don't need no stinkin' bolts...."
The 5 instances of "rivet damage" that necessitated the plug removal are a major contributing problem and should be detailed as to how they occurred and were repaired.
Given the sheer number of rivets on an aircraft this size and the conservative excess of rivets installed so one or a few failures don't become critical, I'm less concerned with five damaged rivers than I am with the five being in one concentrated spot, as well as with the quality review missing that damage until the cabin interior was mostly fitted out. Some rework is inevitable, but having so much in this one spot and only realized so late is inexcusable - but not so much as a single (much less four) completely missing bolts on a significant component.
It looks like the rivets are of the solid type and were not activated properly and were mis-formed, so the question I would ask is why they were not removed immediately by the fitters who put them in and new rivets installed, instead of turning a relatively small job into a major break-down repair and almost causing a disaster? My guess is that the fitters didn't really care about the quality of their work and that someone further down the line would fix it, comes down to culture and attitude.
@@winstonsmith2885 5 in one place and that damage would have left spirit AeroSystems so they are just as guilty here if you guys assembled the frame correct the first time there would be no removal of the door for this too happen. But also the mechanics are also 100% at fault for not remembering or following a checklist for a crucial structure as a door/door plug. Safety and quality at both needs to change and maybe Executive members at both firms need to be fired and not given any bonuses in contract because peoples lives were at stake here and thats enough for me to say leave no cash for you.
Rivets repaired by the same subcontractor as well as prepare the location by removing the door and etc.....while other work being done by another contractor...
That incidence of five faulty rivets shows the quality system working. The failure of Boeing USA to quality inspect the reinstalled door plug shows the quality system failing. This is 100% on Boeing USA. Stop trying to find someone else (ie non USA) to blame.
To their credit, Boeing immediately cut back TikTok dance rehearsals to just 45 minutes per shift.
As a former DMIR at a supplier with both TC and PMA authorities, I am appalled that something like this happened, This is a complete failure of Boeing’s Quality System. I wrote my company’s compliance to their Quality System for each part supplied to Boeing.
The unfamiliar acronym use is pointless for 99% of readers here FYI.
This is just not a problem at Boeing but a problem with American business as a whole...
Try living in china or Russia.
@@northyland1157 Why omitting Europe?
That is a rather outrageous unsupported and stupid thing to say.
@@RLTtizME You must be broke and without a job,
Every time i buy something from American companies it's either poorly manufactured or designed to fail shortly after warranty. they tried in school to teach "planned obsolescence" to everyone when i was 12. i knew that was not the way to go. Greed and peoples stupidity are to blame for all these days.
Can't leave out the countless crooked politicians also robbing everyone and taking "kickbacks" for supporting manufactures agenda's.
@@hakanevin8545 Well first of all, Europe isn't a country, it's a continent. Secondly, the comment is about the mistakes of Boeing. So I'm not sure how Europe (or the EU) factors into that. Thirdly, it's, I think, talking about the maximization of profits vs. long term sustainability of the business. Which seems to be a trend that OP doesn't like for some reason.
Why doesn't the Boeing board realize all this has a chance of ending the company's 108 year history?
Because those responsible for this mess all have golden parachutes.
They would be bailed out by the gov too many government defense contracts and we are kind of in a soft ww3 with the Middle East they won’t let a defense contractor go down in the middle of conflicts.
What does this have to do with getting this quarter's numbers 0.1% higher?!
That's a VERY good question. Most are from the aviation business, but they've inexplicably let the problems just get worse and worse. Something is SERIOUSLY WRONG at Boeing.
Didn't you hear, they wanted a safety exception, if the pilot leaves the deiceing from the air intake of the engine on for more than 5 minutes the engine can fail. But it is the pilots mistake, not Boeing Noooo airbus just is using a switch off timer.....
The Leeham News whistle blower has detailed that there is quite a trail of communication on it's internal SAT communication system. I wonder if there is a senior manager telling staff "Just open the damn thing and get it fixed, then put it back. Don't worry about documenting it"
Smells like that, yes
I'd wager it is worse than that. I'd imagine that the Boeing safety managers didn't envision the door being opened at the Boeing plant and didn't have a procedure for it, so it was never documented. It was just done on an ad-hoc basis and there was no documentation before or after the rework and then once the interior trim was in place there was no procedure to go and check if the retaining bolts had been fitted if there was any doubt, because there was no procedure in the first place.
@@markphillips2076 Got a friend - retired BA engineer. There is a procedure. The whistleblower noted that IF the door is just opened and held on by it's two straps at an angle - no write up in CMES is required, which is the official place for logging such things. If it's taken off, then it is logged and must be inspected upon completion.
@@frankpinmtl, Yes, and many have commented on the absurdity of that CMES procedure. Once it became apparent that the 4 lock bolts have to be removed in either scenario, opening or removing, it’s obvious the bolts need to be reinstalled & inspected.
It sounds to me like the people writing procedures are maybe confused about the function of said door / plug / plug door / door plug. (Which is it? The techies have argued that point to exhaustion) The procedure writers are not A&P mechanics or engineers, they just write up what they think someone tells them. One does NOT inspect an airplane door after opening & closing it! If you REMOVE an airplane door it would certainly need to be inspected after being reinstalled.
In discussions on the 737 technical channel over a month ago it became apparent there are mistakes in the written procedure for opening the plug. Some said “up to open” and some said “down to open” like the (incorrect) procedure says. If workplace culture becomes one of “I just do my job according to procedure & cover my ass” all kinds of mistakes will happen.
Max, you must research Boeing’s process of “Rolling Shakes”, this is a system of carrying forwards defects so as to not impede construction schedules. That plug was removed to repair five rivet defects that were known earlier, and put off for later. . . That there were never any bolts installed should have been discovered on ‘open up’ of the plug to perform the repair, by a knowledgeable inspector, and documented.
The interior had to be removed to remove the door plug; the reassembly procedure should have had a hardware inspection before buttoning it back up. (No actual buttons were used, I'm sure!) The error was either an omission from the procedure, or failure to follow the procedure. The last I heard that was not yet determined or disclosed.
Begs the question - why did rivets need repairing on a brand new aircraft?
Shoddy workmanship and a failure to put it right immediately.
poor workmanship
Because Boeing decided to save money by farming out manufacturing of major components to suppliers. And by "saving money" I mean Boeing gets to pressure the supplier into doing things faster and for less money. So Spirit Aerosystems in Wichita kept delivering defective fuselages and had to send their repair guys to do rework in Seattle while the plane was being assembled. The right thing to do would have been to slow down deliveries of fuselages until the defect rate went down. Obviously, that's not what happened. The fact that Boeing doesn't have any paperwork for the Spirit repairs in Seattle is really ugly. The whole chain of command above that problem should be fired.
Because spirit has a huge number of problems. Boeing spun them off because they thought it would make them more profitable. Unfortunately them squeezing spirit for lower cost is creating quality problems.
We need to see the interview with the mechanic responsible for fitting the bolts and the quality examiner responsible for checking the work.
Exactly!
It is NOT for the mechanics and technicians to be responsible for fitting bolts or ANY work for that matter, only that they follow the previously approved written procedure for doing so. It is the responsibility of the engineer and a proper review board (that includes Quality Assurance Engineering) to create a written procedure detailing exactly what work is to be done and exactly what the inspection of the work should be performed. It is the responsibility of the on-site engineer and an independent QA inspector to confirm that the previously approved procedure was followed exactly as written and the work was done to an acceptable level of workmanship. This is why there are trained inspectors and engineers that oversee and are responsible to certify that things were done properly and review boards that look over and approve completed written procedures. If this isn't the way Boeing does things at this time, then they need to change their corporate culture right now, before another aircraft or space vehicle leaves a single one their plants.
Boeing has become the Oceangate of Airlines
Not quite - we need to get the Boeing CEO to be on every flight for that to happen. Arrogant and stupid as he was, at least Stockton Rush put his own life on the line too. Not Boeing - their C-levels probably fly Airbus only...
Well, the desing is good because no MBA can do it, it is an engineer thing. But the rest, from suppliers to assembly and quality ... this is where those MBAs can tight the nuts and cut corners. IDIOTS
If this condition of plug bolts missing is indicative of inadequate repair inspections, I would seriously consider that this is not the only problem that may exist throughout all boeing aircraft. There should be no acceptance of anything on these aircraft that isn't inspected, documented and verified by their quality control inspectors. The FAA has delegated too many of these inspections to factory personnel, It's like the proverbial fox in the henhouse at Boeing. When it comes to aircraft, quality escapes should not be tolerated when lives depend on a quality product. Boeing and the FAA needs to do a better job to verify that critical assemblies, repairs and reworks are identified, written inspection procedures and approvals be available in order for the assembly to continue.
I've said it before, and I'll say it again - Boeing has yet to put safety before speed. They remain competiveness with Airbus, not with new products but with older platforms that use technologies that are not thoroughly tested. They build fast but not well. It's past time to put engineers in charge of Boeing and put the bean counters out to pasture.
What amazes me is that major structural parts would be subcontracted. Things like seats, entertainment systems etc, but you’d have thought that the wings, fuselage and doors would be made in-house.
Exactly
Wait... if the paint was clean... then Spirit didn't install the bolts to begin with... and Boeing then opened the door, and didn't think anything of the missing bolts, and put it back in place without adding bolts... That sounds like both teams screwed up....
Seems to me that a design drawing was never consulted at any stage of this debacle.
My understanding is the fuselage leaves the spirit shops with the door attached but not bolted. Boeing does panel installation and work around the door and is responsible for final installation.
I believe the paint was applied at the Renton factory.
@@kw8757 This has nothing to do with design drawings. What happened was that Boeing had two different checklists for opening resp. removing a plug door, and the first did not include the checking of the bolts. This is a systemic issue, not merely personal negligence.
@@Daneelro You obviously don't work in aerospace, and if you do, you really shouldn't....unless you work for Boeing, in which case you'll fit in very nicely.
Drawing is bible. There will be a drawing
(or should be, but with the state of Boeing these days I wouldn't be surprised if there isn't one) showing the correct final fit of the plug door, showing all bolts in position, with tables listing the correct part numbers for all parts and fasteners with links to torque values and other details. Nobody bothered to look before the interior trim was put back in place. Criminal negligence.
Boeing doing a great impression of Alfed E Newman: "what? Me worry?"
Boeing's motto at the moment from management
"Given the choice, We want cash before quality"
That makes no sense at all. The shortcoming was either an omission of a hardware inspection step before reinstalling the interior or failure to perform that step. Neither one costs Boeing anything; failing to do that costs them a lot.
@@flagmichael So the people doing hardware inspections work for free and don't require payment?
The British have a saying for that,
Penny wise and pound foolish
The attempts to save pennies has cost Boeing millions of pounds.
I agree with everything you said, but no one seems to blame Alaska Airlines either because Alaska Airlines had a warning that there was a pressurization problem and Alaska Airlines still flew this airplane. Alaska Airlines decided to not to fly over water, but still fly. A blowout at any high altitude is disastrous regardless where it happens.
Very well said 👏
Bean counters exist everywhere..
An excellent point and no doubt why they will settle any lawsuits brought against them.
And the seat ... by mirable ... wasnt sold ... yeahhhhhh. ALASKA is crap.
I am an old man that remembers people saying " made in Japan out of a can " about Japanese poor quality products . The US military advisers in Japan realised that for Japanese industry to survive quality had to come first. They brought in guality programs that had been rejected by US auto manufacturers. Now Japanese products are known for their quality .
The CEO said they are responsible? Who else would be? Airbus?
Some people have blamed Airbus. The logic is that Boeing were panicking about Airbus selling more single aisle planes so rushed the 737Max in a desperate attempt to stay relevant, so it's all those sneaky Euro's fault.
I can't remember where I heard this but apparantly you can tilt the door open or remove it completely. The checklists for these two operations are different, the tilt requiring fewer checks/documentation on reinstallation. At the very least these two should be made equal in importance.
Yes, the language difference between remove and open. When they wrote the procedure for opening they left out this critical check of the bolts, they probably cut and pasted the opening procedure for regular doors or just made an error when they wrote that specific procedure.
Opening a door is something that happens daily. It can be done by cabin crew.
Removing a door, is a maintenance job. It triggers all kinds of bothersome paperwork.
They used the SOP for opening a door, to avoid paperwork. Paperwork that was intended to avoid 'forgetting' steps.
It doesn't matter if the door is removed completely or tilted open and held with the straps, all 4 bolts must be removed.
@@Aimless6 where's your source for that? I bet you don't have one.
I think it was in the Blancolirio channel.
Boeing - "when one door closes another one opens" yikes.
🤣
another goes flying
Boeing's new motto and corporate mission statement 😂
When you trust the paperwork and don't care about the people. When you want the workers to be just pegs in the machine, the machine bites your head off.
Companies tend to treat their customers the same way they treat their workers.
Yeaaa Boeing messed up big time, AGAIN!
And spirit
Unless airlines have their engineers there for the full duration of construction they are unlikely to change very much or find faults.
Considering how much a new airliner costs, and reputation costs to regain, an airline spending $500k to have their own inspectors on the line would be a wise investment. I'm not sure Boeing and Spirit Aero would go for it, BUT, if they want the business...
I had the privilege of being able to watch one of my cars be built at the factory. Quite impressive, and it was nice to meet the people who actually built the car. I have a plaque of their signatures on the inside of the glove box door, at my request.
Short Bros in Belfast built a lot of components fur Boeing-undercarriage doors for the.747 is one exanple. These were built to Boeing spec; quality controlled and inspected but they insisted Boeing double check as there was always the risk if transit damage that may not have been noticed..You need an operator fully trained to.do.the work correctly an inspector to check the work using a check list and random checks on the inspectors checks..
Once you start to base Boeing executive bonuses on safety performance rather than profit performance, then you’ll begin seeing far less of these critical issues popping up. I liked that old saying, “ The Quality goes in before the name goes on.”
Wasn't that Admiral?
@@FrewstonBooks
Might have been Quasar TV. Not sure. Do remember the saying though.
Umm, that photo of the hole, with paint completely untouched, possibly tells us that not only did Boeing workers forget to install the bolts, but that the aircraft was delivered without those bolts EVER having been installed? Or is it normal for Spirit to deliver the fuselage without those bolts installed? It might track since at the end of a job you always make sure you don't have any parts left over, and if the bolts were never there?
Exactly. As a mechanic when you remove something you bag the hardware for installation. There never were any bolts to bag. The mechanics put it back the way it was.
@@bhess1212 On an aircraft the used nuts and bolts should have been bagged and disposed of so they didn't become FOD, then new fasteners installed.
They paint the plane at that factory. At what stage the bolts/paint interact I don't know, but that could explain this conundrum.
@@mariannorton4161 The exterior of the aircraft will be painted in it's customer livery at the end of construction, but component parts like those shown in the photos are pre-painted in protective green paint or dove-grey paint which is usually not overpainted on places on the aircraft that won't generally be seen.
@@kw8757 That flat takes out any sort of chance that 'fk up' might have possibly been part of it just to sort of be kind. Just flat out negligence. The CEO has to go.
they are poor little lambs who have lost their way, baa baa boing
thanks Max you're the greatest!
Make that BAD, BAD Boeing.
Bad world bad life bad everything
Boeing has transitioned from being PROACTIVE about quality to being REACTIVE to defective parts and procedures.
There are many features of this report disturbing, but for me the no paperwork bit takes the biscuit. Are we to conclude that crucial repairs are undertaken without step by step work procedures and documentation ? If no paperwork is forthcoming the entire Board and executive team must resign, it would amount to scandalous carelessness in critical operations. If no paperwork here, Boeing is a house of cards ! No one will buy their planes because no one will fly their planes.
Seriously, you need paperwork to update a damn GPS database, but something involving removal, replacement and retorquing of bolts in a pressure vessel is fine?
In other Boeing news, the mechanics union is talking strike. Raises of 1% per year has not been enough to keep the new employee entrance from being a revolving door. Living expenses there are high, and wages haven't kept pace with those expenses.
Those raises amount to an annual pay cut of the annual rate of inflation minus 1%. Capitalism is broken.
But as long as there is cash available for stock-buybacks, the Board of Directors will be pleased.
Come on people, when you repair your Lawn mower, you always have parts left over. Every child knows that.
Funny... but lawnmowers generally don't fall out of the SKY!
The lack of wear on the paint around the screw holes tells the story that they were never there, hence no "leftover" parts.
@@kencarp57Some DIY people build Helicopters and other crazy things out of them ...
Like in the cartoons! The character shovels the remaining parts under the hood and the motor runs just fine.
@MBrieger according to the MSM, Vlad has been making show stopping mission critical drones out of washing machine chips
Without any disturbance of the bolt holes, that still suggests that Spirit never installed the bolts at all even when they delivered that fuselage. They also didn't properly secure the door plug when they repaired the rivets.
Boeing failed to properly inspect the repair before they put the insulation and wall panels back in. The bolts were never there, and no one thought to get 4 bolts to put in. This is a double quality lapse, and absolutely unacceptable.
Pretty sure "disturbance" would be referring to damage done by bolt heads tearing though the frame as the door plug separated.
@@ih302 It also means the bolts were never there, despite two separate chances to install the bolts. That kind of lapse is egregious.
It seems therefore that as there were no bolts when the plug was removed there was nothing to replace.
The replacement of the plug should follow an auditable formal procedure.
I’m not perfect but Boeing has been building aircraft for a looong time.
The bolts wouldn’t have been reinstalled - aviation bolts are REPLACED with new ones after every use.
@@ih302 There were no bolts! If a bolt tore through the door plug it would still be attached to the plug when they found it, right?
The passengers were lucky twice. The door plug could have hit the tail section too.
Before you fly, make sure that carrier does NOT use Boeing. Go Airbus.
The problem is *NOT* the bolt, but the procedures, including QA/QC.
This problem is just the tip of the iceberg. What are the real problems on these Max and other Boeing planes?
Could we trust Boeing anymore? Or the FAA btw?
My answer: HELL NO!!!
@@kencarp57 There's no point for me to board a Boeing plane until FAA get ride of its own corruption.
FAA is corrupt, rotten. Boeing planes are unsafe at any altitude (sic). Boeing management should be fired.
It might be a good idea to stop referring to opening and closing the door plug. The proper terms would be removal and reinstallation. The difference is you can open and close your front door everybody understands that but the door plug is more like removing all of the hinge pins and taking the door off and setting it aside then turning the knob and opening the door.
A Boeing manager told my partner that one of the most frustrating and scary challenges at Boeing's Renton plant is the language barrier. Too many workers on the Max line don't speak English at the level required for the complexity of their jobs and when given instructions they just nod like they understand, when in fact they absolutely do not
I want to know more about the pressurization problems that the airline knew about before the incident. Why couldn't the maintenance team figure out that the door plug was leaking?
It was behind a interior wall?
The are thousands of possible issues which can cause the issue.
Point is, as an aircrew you have to expect certain standards. Otherwise you can't fly any plane.
This is not the first plane with pressurization issues. It even could be the warning system itself that's causing the warnings. How would anyone know for sure. And Alaska Airlines at least did ban the plane from ocean flights. Not necessarily the best action, but at least some caution probably saved a lot of lifes.
Hindsight knowledge focuses on the very issue at hand. A luxury no one has before.
How do you test a system that is at present working perfectly oh omniscient one.
Do tell, and we can share the Nobel prize I will claim in our name.
Not connected , if door was leaking there would have been wistling noises even behind the wall liner
Because pressurisation is tested from the inside the cabin, and the door plug would have been covered up by the cabin wall linings and interior decor. And I suspect they did not apply Conan Doyle's axiom, which was that once you've excluded the likely causes, then only the unlikely ones remains. And possibly, the idea that a fuselage plug, normally secured with bolts to prevent it being expelled in fight, actually had none, fell into the "Dont be stupid. Nobody would do that" category. But Boeing did.
Hindsight is 20-20 vision though. It makes perfect sense that a pressurised cabin that couldn't maintain its pressurisation properly, probably had a physical leak somewhere in the fuselage, ONCE the pressurisation machinery and sensors had been found to be in working order. And they must have been to have been allowed to put the aircraft back into service over dry land... But this makes me feel even more uncomfortable that they found it to be airworthy even over land, without finding out the exact reason for the aircraft's inability to maintain pressurisation. That doesn't sit right with me. Whoever is responsible for that decision needs serious investigation and retraining in problem solving. It should have been grounded.
I have worked on passenger aircraft. Every job has specific instructions and an inspector checks the work before it is approved. That did not happen with Boeing.
Too many “mbas” and finance types in upper management. MBAs are taught that the ONLY thing that matters is stock holder dividends. Accountants typically put numbers if front of anything.
Including deaths... apparently
What is the last You hear in a crashing airplane?
BOEING!!
Airbus are known as crashing planes too
It Is about time that Boeing PR Department retired their nickoliver shill account as it never adds anything of value to any conversation.
@@nickolliver3021😂😂😂 you can do better. Say they are uglier than Boeing.
Airbusses have crashed into freezing water at 140 mph (Miracle on the Hudson), and into other airplanes while landing (JAL516). In both cases, everyone survived.
@@DolleHengst Fly Airbus, see the world
Fly Boeing, see the next one
Could these missing bolts have possibly caused the low cabin pressure problems experienced by this aircraft on previous flights?
No question.
Yes if the bolts were missing the door could have moved up slightly allowing the air pressure to leak past the door seal, even if it was an inflatable type seal, the door "cams" away from the fuselage as it moves up to unlock.
So any movement upwards will cause leakage.
My guess is yes, the plug was creeping out of its support and the seal weren't perfect anymore.
Pilots had reported the warning light illuminated on 3 other flights, Evidently Boeing didn't think is was a big problem.
Neither did Alaska Airlines !@@richardkrentz7553
I worked at RAF Airfield for 35 years. Shift Changes were always a dangerous period. All maintenance was recorded by each Technician and it relied on the critical information being written on the "Job Card". Supervision was done remotely by a person with Supervisory status. But, here is the "Big But", the Supervision was not always done by visiting the worksite. Basically, Supervision is not the answer. QA is also of dubious value. The Japanese car industry used "On the job" QA where the Technician doing the Job was also the QA expert. But it requires very special and conscientious workers, who are not "Overworked" and "Over Stressed". In this case I would advise Passengers to use "Airbus" as the Workers are European with generally a good work Ethic.
And what is the RAF now doing? not recruiting " useless, white male pilots" because of diversity policies, no wonder Putin laughs at us!
Anyone whose spent time in Seattle knows exactly how this happened. There is a societal atmosphere of rewarding and upholding dishonesty and incompetence, which permeates everything, in certain cities, including Seattle. Decisions have very real consequences, widespread prevalence of halfass/undisciplined work cant be contained to certain industries, but eventually infects everything. Where there is no culture of personal responsibility and excellence, employees can be expected to see how little they can get away with, and supervisors will sign off on hurried work, until another incidentoccurs. No amount of training or policy can replace self discipline.
Aviation is not part of any city's culture. In this case, there are only two things that could have led to the door plug taking flight on its own: the procedure for reinstalling the interior did not have a step for inspecting the hardware, or that step was missed.
Aviation is an international community, not some dinky city of under a million people.
@@flagmichael No, he is spot on when he talks about Seattle and the culture of absolute bullshi* that goes on here. Maybe you just have to see it to believe it.
Duct Tape should do
Think Boeing use Fuct tape.
If the door became misaligned prior the incident flight, its surprising and disconcerting that no ramp crews, or a member of flight crew caught a misaligned door during walk around if the door truly began to become slightly dislodged prior to the flight
If the door were engineered differently it wouldn’t have mattered if the bolts were there or not. The real question is why a door “plug” can open itself outwards in the first place, and why it wasn’t designed to plug itself with a cabin pressure seal as a fail safe.
This "door" is inoperable in most Max versions and is made operational when certain larger capacity seating arrangements are installed.
Because of certification requirements This "door" frame is built into the fuselage of of every Max model that has the option for the "cattlecar" seating.
@@Underestimated37 It was engineered to be swapped with a real door as needed by seating plan. Regular doors open out.
Yes and yes @@Underestimated37
@@steveurbach3093 no reason they couldn’t have had the plug be removed by pulling inward, the claim that they made it unsafe so they could change it for a door is bull, the other thing is the door itself has locks that hold it in that the plug does not have so there’s one layer of safety and a failsafe that the actual emergency exits have that the plugs do not have.
When I book tickets I always try to ensure I’m on an Airbus. Much better, quieter and more peace of mind.
lucky those doors didn't cause further damage ...knocking out any part of the tail = 100% fatality
There's a Highway to Hell, but if you are in a bigger hurry, Fly Boeing 737-MAX!
Or take a ride in your car. That is where you will meet your demise.
Never, ever leave a job 1/2 done. Leave it either completely assembled or completely disassembled.
Every complicated job should be listed in stages with each stage signed off. If you have to handover the inco I g tech should start at the last stage signed off even if it was started. That is how we worked for all my aviation career.
One rabbit hole leads to another. In this video, it's stated that there was some damaged rivets adjacent to the door plug. Insulation around the fuselage wall had to be removed along with opening the door plug to repair the damage. The fuselage was delivered from Spirit Aero. A team from Spirit Aero did the repairs. So my question is: apparently Boeing inspectors review the fuselage after receiving them and write up there findings . During the inspection process, did they notice whether the bolts were installed. The NTSB stated they did not notice any witness marks on the holes where the bolts are installed. You would think there would be a few marks as the fuselage traveled from Wichita, Ks to Renton, Wa. Plus, Boeing has not yet released any information about the missing bolts. They dodge a bullet that no one was injured.
From work in other industries with CFR-mandated QA/QC programs, this is a COMPANY OUT-OF-CONTROL and SACRIFICING SAFETY FOR $$$$.
I watched the self-destruction of PBAPS and it's shutdown by the NRC for basically a BAD ATTITUDE by almost ALL levels of the utility's workforce and management. Having been there on the ride down as a contractor, I would suspect Boeing has a swarm of similar quality issues just sitting in active fleets, waiting for all the holes in those swiss cheese risk-analysis barriers to line up.
Sadly, that's the case here. One safety hazard after another pops up.
It begs the question which safety hazards haven't been documented or found so far.
... and will be found by Boeing beta testers mid flight one day.
Remember, do not fly through icy weather for more than 5 minutes, as you have to switch off engine deicing. Otherwise the real chance that engines are literally going to destroy themselves is there.
I don't know what type of "safety standard" that is. That someone could even use the word safety for it.
🫣😐
With that many planes racking up that many flight hours, anything that can go wrong will eventually go very wrong.
That plug could have easilty damaged the horizonal and verical stabilizer. God was with those people for sure. Shame on Boeing
Where was god when the other two 737's crashed? On vacation that day? Stop believing in childish BS and grow the fuck up.
And it could have happened at cruise. The door would have ripped a chunk of the surrounding fuselage with it, damaged the structural integrity and sucked several seats and several very unfortunate people out. And possibly cause the pilots to lose control of the aircraft.
Where was your useless god when the two other 737's crashed killing all on board? You can keep deleting my comment but you can't answer my question you coward. Why do you believe in a god that doesn't exist, but if it did must surly be evil?
Dont worry! Boeing has a top notch DEI program.
That bolt hole at 5:59 looks so pristine it may never have had a bolt fitted.
Boeing dont need a quality review they need an aircraft maintenance day one basics review. I work as an aircraft supervisor and previously as an inspector, the golden rule when disturbing a system is you record the work you have done AND you create an open entry for the required recovery work. When the damaged rivets were discovered, the remedial work flow should have been determined and planned at that time, such that the area was prepared for the Spirit team and the recovery work was well documented and understood after the rework team had left. Whether this is a problem with their documentation system being too cumbersome for out of process work recording or just down to the lack of proper recording of work hopefully will become clear soon.
The "fitters" who activated those rivets would have known at that stage that they were not suitably formed and could easily have removed them and installed new rivets. Why it got all the way to the interior trim being fitted before being repaired suggests Boeing have an absolute shit-show of disorganised work flow.
Don't worry, Boeing will find another way to make mistakes. They have proven to be inventive the wrong way.
Better to let China build these airframes ....
I guarantee you there are a bunch of workers on the line who have been warning about this for years and are completely ignored
On the one had the fact that the part stayed in place for so long is a testament to the design and the negligence of the operator and the manufacturer. You can not ignore pressure seal warning lights and simply hope everything will be just fine.
When are people going to lose their jobs over this? I don’t see any accountability!
irresponsible staff and lack of quality controls will kill people and destroy Boeing
I worked for Boeing at the Renton factory during the 737 max crashes. I will never nor my family ever fly on a 737 max.
After the last 2 catastrophic crashes by Boeing, folks loudly stated that the next time the 737 flew it would be the "safest plane around"- in other words stating that Boeing was going to be extra careful from now on...but obviously nothing has changed at Boeing. I wonder what it will take to get management to take this seriously....or are they more than willing to let Boeing fail before they are willing to change their ways. I am putting my money on failure.
Re-work in any plane requires a plan be written by manufacturing engineering in a system called PDM. You have to create whats called an " exception module" that then prints out to then document the out of sequence work. The 737 aircraft are all built on a moving line which means the aircraft actually slowly move along to different stations non stop, ON PURPOSE, to create a " feeling of urgency" which were the companies own words- Well, gee- What could POSSIBLY go wrong there??? Also, it takes TEN MINUTES to print out the document that shows who did the work, and when.... But of course, NO ONE put those bolts back in-
I’m amazed that the door plug stayed in place for as long as it did without the bolts installed, especially with the assist springs pushing it upwards.
To be honest, I’m surprised that the blowout didn’t happen sooner, and while in cruise where the pressure differentials are at the greatest.
In a backroom somewhere there's a junior Boeing executive dying to use this fact as a testament to the build quality of their aircraft oblivious to the obvious 😅
@@restojon1 What? A 3 month warranty 😂
@@mikoto7693 Once at an altitude where pressurization takes some effect the door would tend to be held in place by the pressure on the door, and friction on the pads, so the vibration would mostly affect it in the early and late stages of the flight. I'm more surprised that the door was DESIGNED to fail open rather than shut, it is easy to design fail safe doors/plugs!!
Unbelievable! Imagine: After finishing the works at the fuselage, there were four screws LEFT OVER and nobody cares???
The bolts are still in a bin in a stockroom at Spirit . Never made it to the plane.
I always enjoy your insights about various topics in aviation. My day is brighter, thanks to you!
These quality fails are just the tip of the iceberg at Boeing. There are multiple quality fails that airlines encounter after delivery. And there are a constant series of complaints associated with FOD found in the aircraft and loose fittings. The thing is, its not just the 737, its all over the fleet, and the 787 has it's share of quality problems too.
Every single senior FAA manager need to be criminally investigated. The FAA is the last line of defence in terms of safety. And they continually fail the general public.
When the cat's away, the mice will play. The FAA has totally abrogated their responsibility over safety, even after crashes and multiple safety of flight incidences with Boeing. Regulatory Capture 101; it quite literally takes an Act of Congress to get them to pretend to do their job.
You'd think there would have been noticeable pressurization leaks before the accident flight. Did anyone report a problem?? A passenger maybe??
Here's the rub. They did. Alaska pulled the plane from overseas flights but allowed it to be used over land. They are screwed.
Boeing and Quality are two words that should never be used in the same sentence
My solution when working on my car is simple: I put parts like bolts and nuts in plastic bags and tape them to my windscreen left to right in the order they are taken out. Looks a bit stupid, but works fine for me. I wonder where the missing bolts are now?
Covering a spring loaded door with interior is a stupid design. Any door latch system should be visible for preflight inspection, even if the door is locked shut.
The swiss cheese event will happen!
Especially when you poke holes to save money.
I'm afraid it's gonna end up being a shredded cheese event.
Why is nobody talking about the design of the plug?
I'm a retired Aerospace Chief Engineer that's been involved with aircraft plugs in the past.
Every plug I've been involved with has been wedge shaped (internal face is larger than the external face). This means that, in the event of any attachment failure, the plug cannot be 'blown out' - aircraft pressurisation actually keeps it in place.
When I was doing aircraft maintenance in the Air Force I always did a final once over to see if I forgot anything. It wasn't required, but it's just good practice to step back and recheck your work before signing it off.
So this incident was due to rework?
That means the the lose bolts found by the airlines post incident were unrelated.
So more than just one quality system failure.
That makes me so confident to fly on any Boeing!
Then don't fly
Intelligent people knowing the Boeing standard of work fly airbus aircraft.
@@nickolliver3021
I can. There is always Airbus and Embraer who don't deliberately endanger people's lives.
I can just be selective about which airlines I use on which routes.
@@gregculverwell People will want the cheapest price not the expensive one. Again you don't choose airbus or embraer. Airbus has nearly endangered peoples lives but still boeing will be better next year
If Boeing sacked the PR wankers that make the nickoliver entity and got on with the job they are paid to do ie building decent and up to date aircraft we wouldn't be having these conversations.
The first sign that Boeing is planning on a recovery will be the discontinuation of the shill accounts.
By splashing this nickoliver entity all around Boeing are showing their contempt and their intention to never improve.
"Continuous Improvement" LOL, LOL, LOL.
I, for one, do believe in continuous improvement. It is hard work though.
Well, to be fair, this one didn't crash and kill everyone on board, so Boeing probably count this as a 'continuous improvement".
These is MBA snake oil at its finnest ..... Also QA people without technical background tend to speak this crap.
It’s a Management issue. Here’s an example:
A certain Airline in the UNITED States is closing its customer service desks in their major hub in the center of the UNITED States. In the past if your flight was late and you needed to be rebooked you could get help at the CUSTOMER SERVICE counter. Now, once you leave the jetway at the gate you MUST turn off Airplane mode on your phone. Call a customer service number and queue up with every other traveler in the UNITED States to get rebooked. If the delay was the airline’s fault and you need to wait until the next day, you will have to search for a hotel on your own and no voucher will be issued. You will have to file a claim with hotel receipts to the airline within about 30 days to get reimbursed. Reimbursement may take 3 months. You better be savvy on your passenger rights because the airline is counting on your ignorance. Correction, management bonuses are counting on your ignorance.
There's another subtle example of assembly floor management incompetence in the video. The damaged rivets. Note they didn't fix that until after the cabin was built out with seats and the wall skins installed. Now the empty metal frame fuselage arrived with damaged rivets and was documented. Why wait until the cabin finish work is done to address that problem? And it's hardly a cost cutting issue here, quite the contrary. It cost a lot more in labor to do this repair after the cabin was fitted out. This is just indifference and incompetence, plain and simple.
It looks like the same old story to me. Money. The big corporate people think that they can never make enough money. So they chop, cut, don't hire people, find ways around things, ignore stuff, etc. They do all this because it looks good on paper and they can say, look how much money I didn't spend! SSDD
A😢this is dangerous I lost an uncle in plane crash
Years ago a buddy and I started making some mechanical devices. Part time turned to full time turned into a real business with large corporate customers. We knew we needed a Quality Management System, but quickly learned that there were two types of QMS, the kind you say you have and the one you really use. We committed to the second type. Today as I sit in comfortable retirement I am so glad we did.
It is inconceivable to me that Boeing is unable to provide documentation for the work that was done. I never built aircraft parts but I know that in my humble non-aircraft business any work like that would have been documented and the root cause of the need for that work would have been investigated, resolved, and documented.
Thanks for your work, Maximus. I appreciate your timely and clear explanations.