Go Back  PPRuNe Forums > Flight Deck Forums > Accidents and Close Calls
Reload this Page >

Alaska Airlines 737-900 MAX loses a door in-flight out of PDX

Wikiposts
Search
Accidents and Close Calls Discussion on accidents, close calls, and other unplanned aviation events, so we can learn from them, and be better pilots ourselves.

Alaska Airlines 737-900 MAX loses a door in-flight out of PDX

Thread Tools
 
Search this Thread
 
Old 15th Jan 2024, 10:31
  #981 (permalink)  
 
Join Date: Feb 2010
Posts: 1,123
Received 85 Likes on 49 Posts
It is not made mostly of carbon fibre but aluminium.
Less Hair is online now  
Old 15th Jan 2024, 10:34
  #982 (permalink)  
DTA
 
Join Date: Jan 2024
Location: UK
Posts: 52
Received 0 Likes on 0 Posts
Originally Posted by Oro-o
I agree, I don’t think that makes any difference. For reference, here is the reported position in which it was it was found. It passed through some canopy above, I believe. This was in the Seattle Times article yesterday.

This is the image I was thinking of.


I think the one in your post is where it was moved to after being found.
DTA is online now  
Old 15th Jan 2024, 10:45
  #983 (permalink)  
aox
 
Join Date: Mar 2015
Location: UK
Posts: 228
Received 0 Likes on 0 Posts
Ok. Maybe only the later designs.
aox is offline  
Old 15th Jan 2024, 10:54
  #984 (permalink)  
 
Join Date: Sep 2009
Location: Seattle, USA
Age: 57
Posts: 30
Received 2 Likes on 2 Posts
Originally Posted by MarineEngineer
I note that the lift assist brackets are completely missing.
And if you look at the bottom of the plug, the aft hinge assembly apparently put up a little fight, and the forward one not as much. You can note the aft, lower inner frame is bent outwards from contact with the aft hinge pin assembly, and some of the outer paint is rubbed through to the zinc chromate layer underneath (inside blue circle). Or it at least looks like abrasion in the low-res photo, and not paint popping off from deformation.

Originally Posted by MechEngr
Perhaps the last gasp from the restraining cables after the guide brackets let go.
I don’t think that could cause an issue between the skin and the frame - the yellow arrow shows the restraining cable attachment, via that ring to the frame. Looks like the cable parted at the door end, which was connected to the frame.

So both aft connection points did not let go cleanly, but were forced - 1) the forced upper guide track and 2) the bent lower hinge area. I’m sure the NTSB people already know how this happened, with access to the whole unit and ability to examine the whole assembly, bolt holes, etc.



Oro-o is offline  
Old 15th Jan 2024, 11:44
  #985 (permalink)  
 
Join Date: Jun 2009
Location: Montreal
Age: 65
Posts: 41
Likes: 0
Received 0 Likes on 0 Posts
One thing the NTSB lab photo shows, I think, is that the lower hinge post guide fittings are attached to the door with one-lug nutplates. You can see them beside the NTSB lady's arm.

Something like MS21061. It's interesting because the places I've worked usually avoid one-lug nut plates when possible due to the risk of attachment rivet breakage. Non-trivial disassembly of structure is usually required to replace them.
incompleteness is offline  
Old 15th Jan 2024, 11:48
  #986 (permalink)  
 
Join Date: Dec 2014
Location: Schiphol
Posts: 487
Likes: 0
Received 2 Likes on 1 Post
Difficult to see but…

Fractured was word used by Mrs H early on for the top guides… photo not good quality, but looks a bit more like folded open… was not much flesh on the bracket there in the first place…

scenario option … 14,830ft 271kt 14.09psi.. top opens up …press 11.64 psi…plug caught be airflow opens wider, rips steel wire… 15,859ft 271kt 9.08psi … plug flips 90 deg down, then ripped off, … low hinges departure prevents plug from hitting the horizontal stabiliser …

forward (in DOF) hinge stripped, aft hinge ripped,
A0283 is offline  
Old 15th Jan 2024, 13:54
  #987 (permalink)  
 
Join Date: Mar 2019
Location: Bavaria
Posts: 20
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by incompleteness
Why does the door plug look overdesigned, with heavy machinged members? The main reason is because it works as a curved plate to carry the pressure, which means there is a lot of plate bending in the structure. Baseline fuselage structure works as a pessure vessel with primary loads in tension. Plate bending is structurally inefficient.

Why don't they bolt together the stop pads and stop fittings? That's because it would change the load paths. Doors are designed not to pick up general fuselage loads, they sort of "float". So if you created bolted connections to the fuselage at 12 points, the door would become primary structure and you would have to redesign local fuselage frames, intercostals, and skins, and add a nontrivial certification item to cover just the plug doors. For design, analysis, and testing, you are potentially looking at 7 figures.
This statement made me think of another possible chain of events:
The tension in the fuselage (along the circumference) will expand the doorframe, increasing the distance between roller pin and hinges.
Bending of the door will do the opposite to the upper guide track and hinge brackets.
If there is not enough play in the bolts and roller guide (remember the slotted holes on the hinge brackets which allow adjustment), the plug will take over fuselage tension due to pressure differential.
If this tension is strong enough to break/shear the lower bolts, stored energy may just be enough to snap the plug up off the lower pads and/or break the upper bolts or guide track.

Just another theory which would imply wrong adjustment (or design), not missing parts. But it somehow fits to the pictures so far.

This failure mode would be unique to the plugs, not applicable to the emergency doors. The 'real' emergency door design does not limit the 'floating' of the door on the pads as the plug does since the hinges are not blocked. Four bolts in all four corners on the plug counteract the intention of having the door/plug float on pads and decoupling it from the fuselage tension. Maybe they accidentially bolted the plug in the fuselage tension load path trying to have redundancy on the bolts.

Is there any difference in fuselage stiffness between NG/ER/MAX versions equipped with plugs? Could this be a contributing factor?

Are those loose nuts on the other planes really loose or did excessive tension stretch the screws, actually preventing further accidents?

I hope they will find the right answer.

TryingToLearn is offline  
Old 15th Jan 2024, 14:06
  #988 (permalink)  
 
Join Date: Dec 2002
Location: UK
Posts: 2,487
Likes: 0
Received 24 Likes on 12 Posts
Boeing was really, really bad at building airplanes

Without learning, history will repeat;
"Boeing was really, really bad at building airplanes"

https://valkstrat.com/the-myth-of-old-boeing/
safetypee is offline  
Old 15th Jan 2024, 14:16
  #989 (permalink)  
 
Join Date: Apr 2009
Location: Phoenix, AZ
Posts: 738
Received 41 Likes on 33 Posts
I wonder when "UP" and FWD" with corresponding arrows were marked on the door plug. Would those marking have been required for production assembly or only for someone unfamiliar with how the plug was fitted.
EXDAC is offline  
Old 15th Jan 2024, 14:19
  #990 (permalink)  
DTA
 
Join Date: Jan 2024
Location: UK
Posts: 52
Received 0 Likes on 0 Posts
Originally Posted by EXDAC
I wonder when "UP" and FWD" with corresponding arrows were marked on the door plug. Would those marking have been required for production assembly or only for someone unfamiliar with how the plug was fitted.
They were not visible on the earlier photos.
DTA is online now  
Old 15th Jan 2024, 14:22
  #991 (permalink)  
 
Join Date: Jan 2024
Location: Scotland
Posts: 52
Likes: 0
Received 0 Likes on 0 Posts
It's to differentiate it from any right-hand doors that fall off!
MarineEngineer is offline  
Old 15th Jan 2024, 14:34
  #992 (permalink)  
 
Join Date: May 2010
Location: SOF BG/EU
Age: 63
Posts: 91
Likes: 0
Received 1 Like on 1 Post
"Up" and "Fwd"

Originally Posted by EXDAC
I wonder when "UP" and FWD" with corresponding arrows were marked on the door plug. Would those marking have been required for production assembly or only for someone unfamiliar with how the plug was fitted.
Photos from Bob's garden are w/o those markings. So I presume it was the NTSB putting them after retrieval "out a an abundance of caution"
D Bru is offline  
Old 15th Jan 2024, 15:08
  #993 (permalink)  
 
Join Date: Jan 2024
Location: Sri Lanka
Posts: 4
Likes: 0
Received 0 Likes on 0 Posts
Pressure test after WIFI install

After installing WIFI antenna they must have done a pressure test of the cabin . After that the Warnings from the pressure systems started . What if the test moved or damaged something in the door plug . It has happened before on a Boeing in Oklahoma City that too much pressure during test caused big cracks in the fuselage . USAF KC-135. In 1999 .










Last edited by retiredCSE; 16th Jan 2024 at 06:11. Reason: spelling correction , wrong plane model
retiredCSE is offline  
Old 15th Jan 2024, 16:31
  #994 (permalink)  
 
Join Date: Jun 2000
Location: Chicago
Posts: 55
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by incompleteness
One thing the NTSB lab photo shows, I think, is that the lower hinge post guide fittings are attached to the door with one-lug nutplates. You can see them beside the NTSB lady's arm.

Something like MS21061. It's interesting because the places I've worked usually avoid one-lug nut plates when possible due to the risk of attachment rivet breakage. Non-trivial disassembly of structure is usually required to replace them.
Agree, I would not expect nutplates to be used for attaching the guide blocks here. They are much weaker compared to a tension nut. Its not a blind access location either. In this case however, it appears the bolts were never tightened/installed because the nutplates seem intact. If this had any to do with the nutplates, they would be pulled or deformed. Still seems odd to use them there. Its assumed those blocks are never required to retain the plug once its captured by the 12 stop lugs.
We still cant explain the missing fwd guide. The easiest explanation: it was never there.
BigJETS is offline  
Old 15th Jan 2024, 17:09
  #995 (permalink)  
 
Join Date: Oct 2019
Location: USA
Posts: 950
Received 307 Likes on 175 Posts
The fasteners would have been subject to shear loads rather than tension loads. This would have put the screws against the sides of the holes in the door. If they are replaceable element nut plates, the float of the nut plates would isolate the nutplate rivets from load. They may even have just turned with the rivet as the pivot to allow that contact.
MechEngr is offline  
Old 15th Jan 2024, 17:17
  #996 (permalink)  
 
Join Date: Jun 2000
Location: Chicago
Posts: 55
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by DTA

Whilst having the bottom of the door plug move out would explain the separation of the skin at the top it is hard to see how the bottom could have moved out first. The two shafts remain attached and the rear bracket mounting bolts appear to have been broken by considerable force suggesting the rear bracket at least was correctly in place (though probably not with a lock bolt).
I agree its difficult to explain anything related to the lower hinge assys and the connection to the plug via guide blocks. I am going on the assumption that mutiple hardware was missing or not installed, in addition to at least the top two lockbolts. If the guide blocks are not fully attached to the plug, then the hinges are not much of a factor.
The damages on the bottom rib are when the hinges were ripped out of the plug. It appears to me, they didnt pull straight out cleanly, but rather the plug was released bottom first, and pivoted on the top guides perhaps 10 degrees, which caused the bottom hinges to be removed violently against the rib structure. (It is this chain of events which dictated whether the plug went around, or straight into the H.Stab)
BigJETS is offline  
Old 15th Jan 2024, 18:03
  #997 (permalink)  
 
Join Date: Mar 2019
Location: Boston
Posts: 2
Likes: 0
Received 0 Likes on 0 Posts
Witness marks on the frame/fuselage skin?

If the bottom of the plug pivoted out, causing the top of the plug skin to hit against the opening at the top and causing the observed separation damage in the lab photo, would there not be witness marks on the the top of the plug door frame/fuselage skin? Are there any good pictures of the outside of the plane at the top of the opening?
Yogi62 is offline  
Old 15th Jan 2024, 18:20
  #998 (permalink)  
 
Join Date: Jan 2024
Location: Copenhagen
Posts: 16
Likes: 0
Received 0 Likes on 0 Posts
missing locking compound?

When comparing the picture from the NTSC lab to a Seattle Times entry "Boeing and U.S. aerospace set back by Alaska Airlines fuselage blowout" (I am not allowed to include URL, sorry) then I observe on the ST picture that all of the bolts are locked with a green locking compound, including the 12 studs. This I cannot find on the studs of the plug at the NTSC lab. I do as well miss the hole for the locking bolt in the guide track. Is it hidden due to warping of the of the guide track?


ScandinavianInterest is offline  
Old 15th Jan 2024, 19:30
  #999 (permalink)  
 
Join Date: Mar 2016
Location: San Diego
Posts: 4
Likes: 0
Received 0 Likes on 0 Posts
There are witness marks on the stop pads from the door resting on them. Could be damage from the departure but could also be rub marks over a longer period.
I think the door first went up a bit and the pins were no longer resting against the stop pads but the flange that holds the stop pins. During that period, there were probably leaks around the door which would explain the pressure system detecting fluctuations.
The question arises then if it would have been possible to see the plug sticking out a quarter inch during that time which might have been days / weeks. It would have been up half an inch as well.
ewumnrr is offline  
Old 15th Jan 2024, 19:49
  #1000 (permalink)  
 
Join Date: Jan 2023
Location: Puget Sound, WA
Posts: 193
Received 4 Likes on 2 Posts
Originally Posted by safetypee
Without learning, history will repeat;
"Boeing was really, really bad at building airplanes"

https://valkstrat.com/the-myth-of-old-boeing/
Requirements and production systems are different in aerospace, where extreme requirements are placed on both traceability AND safety AND even reliability. Defense programs can often make do with less safety. Transportation networks can make do with less traceability and reliability.

Any system that is working well to fulfill the above is doing its job better than one that is newer and more efficient but less good at fulfilling key needs.

Replacing old but tried and true processes in commercial aerospace is hard to do right. It might seem right from a financial and ability perspective, but those are not what keep large, deliberate aerospace enterprises running successfully.

Boeing would be better off with a corporate structure that has no shareholders.
remi is offline  


Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service

Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.