Alaska Airlines 737-900 MAX loses a door in-flight out of PDX
This piece (and not only this one) could suggest that Gates is looking for a "guilty" individual, but it could also simply be that he's following a rational and appropriate line of questioning: If it wasn't the move crew's job to install the bolts, whose job was it? And how does it make sense that the door plug could be reinstalled and left without bolts, and then passed inspection all the way to delivery? It's much more likely that there's a process failure than simply a failure by "someone" to fill out a form.
I hope this isn't a manhunt. There is no worse way to address an issue like this one.
I hope this isn't a manhunt. There is no worse way to address an issue like this one.
Someone did someone a "favor" in removing the door for the riveters to do their work and didn't enter the event into the work management system of either company. It likely would have been clearly noticed except either someone with Spirit or the Boeing movers put that cable tie to secure the door, which also didn't get entered into the work management system of either company. No entry that the door had been altered, no QA/QC work order, no inspection - the records said the door was A-OK as delivered.
The problem is that without the door removal being entered into either the Spirit or Boeing work management system there would never be a call to re-inspect it. Boeing inspected the door on arrival from Spirit and found it was correctly installed. As far as Boeing QA/QC knew the door was never touched. Not only was it not the move crew's responsibility (they aren't assemblers and would likely violate union rules for them to touch a wrench, they had no work-order issued to put the bolts in and no bolts,nuts, washers(?), and cotter pins that were approved by QA/QC to install. It was up to Spirit to return the plane to acceptable condition and to inform Boeing of any alterations required by their work. Spirit has the procedures to install the door.
Someone did someone a "favor" in removing the door for the riveters to do their work and didn't enter the event into the work management system of either company. It likely would have been clearly noticed except either someone with Spirit or the Boeing movers put that cable tie to secure the door, which also didn't get entered into the work management system of either company. No entry that the door had been altered, no QA/QC work order, no inspection - the records said the door was A-OK as delivered.
Someone did someone a "favor" in removing the door for the riveters to do their work and didn't enter the event into the work management system of either company. It likely would have been clearly noticed except either someone with Spirit or the Boeing movers put that cable tie to secure the door, which also didn't get entered into the work management system of either company. No entry that the door had been altered, no QA/QC work order, no inspection - the records said the door was A-OK as delivered.
Whether Boeing fulfilled its obligations under the DPA is a separate question. It sure seems that, given that the door plug blowout incident occurred, it failed - but it is not evident that any crime was committed insofar as the door plug is concerned.
I'm having a hard time seeing this as other than a process failure.
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Want to go back to the NTSB letter and the action it takes, and the reasons for taking action. First, though, nothing here is in defense of Boeing. The reason for posting this is that at the moment, if there is one critical decision-maker in this entire situation, it is (in my view) the federal district court judge in whose court the criminal matter against Boeing is pending (and the DPA, and the crash (crime) victims' rights issue); certainly the Court is on any reasonable person's "short list" of the most heavily involved decision-makers at this time. (Maybe the law clerks read the forum? - it's worth a try.)
The NTSB action, in substantial measure, elevates form over substance. This is especially glaring in the instance of the Chief Engineer who, according to the Board letter, violated NTSB rules in his answer(s) to question presented to him by a United States Senator in Committee hearing. So, if the witness had adhered strictly to the details of the party agreement Boeing signed for the Board proceeding, he would have declined to answer under Board rules. And then - assuming the Senator did not press further for an answer - he would have received heaps of criticism from the press and other quarters for being evasive, hiding behind procedural technicalities, and more. Plus, how would the interests the Board rules exist to uphold, particularly public confidence in the safety of civil aviation (at least in this country), be served by not providing an answer to the question based on the information then uncovered by Boeing - this of course is about the "Dutch roll" incident. Again this is not in Boeing's defense, but that said, how could anyone with a working brain not understand that the Chief Engineer's answer was given with the unstated - but obvious - context that the information was based on what Boeing had uncovered or determined at that time. Not least, how does his answer interfere with or impede the Board inquiry into the incident? As a matter of form, it broke - or appeared to break - Board procedural rules about who gets to say what publicly and when. But regarding this specific answer he gave, that is just a matter of form. If there is more to this part of the Board action, about the answer given in the Senate hearing, please tell it.
With regard to the information divulged by the briefing on June 25, one issue that hasn't been addressed (or if it has been addressed, this SLF/att'y ain't seen it as yet) is, does the Board's expertise now extend to the factory floor? To process issues about how documentation systems work or if they even exist? Isn't this more FAA territory for the manufacturing certificate? This isn't to say that, if there was a meeting of people involved and a decision was made to divulge this information, that it was a "good call" - rules is rules, as the Board's primary rationale in the letter reminds us. But does this set of disclosures - improper as a matter of form, no doubt - actually impede or harm the Board's continuing investigation (even assuming that its remit does go onto the factory floor).
I suppose if the subject were the continuous slab caster in a Basic Oxygen Furnaces shop in a major steelmaking facility where I spent a summer of my youth, and a spill of molten steel - which did occur - had happened much more seriously, spilled much more quantity of raw steel, burned perhaps fatally the brickmasons who my coworker and I scrambled out of the way, then OSHA's inquiry could well have gotten into the seniority rules of the CBA by which my coworker and I happened to have the assigned jobs which included surviving in the face of raw steel spilling out where it ain't supposed ever to be. So federal safety investigation can, I guess, reach the shop floor. And all its nuances, "law of the shop" and so forth. But in that case, if Steel Company had been party to the agreement, and had briefed the press in advance of a major Metallurgy Convention in Farnborough, and mentioned a few things about how coworker and I happened to have been involved but in no way at fault, I'm just not seeing the big deal. Form over substance doesn't cut it, where raw steel is concerned. Maybe the happenings and failings of the door plug on that airframe implicate different types of administrative agency expertise factors.
If it can be shown how the Boeing press briefing did more than break the rules, tell it. Otherwise, it's more and more looking like the Board wants to crack down on Boeing for anything it can say with mostly a straight face. Ask yourself, does the information disclosed make it sound like Boeing isn't responsible for what happened, doesn't take it seriously, and will do anything or everything to hide the truth? Maybe it does, although the letter hasn't made that record.
The NTSB action, in substantial measure, elevates form over substance. This is especially glaring in the instance of the Chief Engineer who, according to the Board letter, violated NTSB rules in his answer(s) to question presented to him by a United States Senator in Committee hearing. So, if the witness had adhered strictly to the details of the party agreement Boeing signed for the Board proceeding, he would have declined to answer under Board rules. And then - assuming the Senator did not press further for an answer - he would have received heaps of criticism from the press and other quarters for being evasive, hiding behind procedural technicalities, and more. Plus, how would the interests the Board rules exist to uphold, particularly public confidence in the safety of civil aviation (at least in this country), be served by not providing an answer to the question based on the information then uncovered by Boeing - this of course is about the "Dutch roll" incident. Again this is not in Boeing's defense, but that said, how could anyone with a working brain not understand that the Chief Engineer's answer was given with the unstated - but obvious - context that the information was based on what Boeing had uncovered or determined at that time. Not least, how does his answer interfere with or impede the Board inquiry into the incident? As a matter of form, it broke - or appeared to break - Board procedural rules about who gets to say what publicly and when. But regarding this specific answer he gave, that is just a matter of form. If there is more to this part of the Board action, about the answer given in the Senate hearing, please tell it.
With regard to the information divulged by the briefing on June 25, one issue that hasn't been addressed (or if it has been addressed, this SLF/att'y ain't seen it as yet) is, does the Board's expertise now extend to the factory floor? To process issues about how documentation systems work or if they even exist? Isn't this more FAA territory for the manufacturing certificate? This isn't to say that, if there was a meeting of people involved and a decision was made to divulge this information, that it was a "good call" - rules is rules, as the Board's primary rationale in the letter reminds us. But does this set of disclosures - improper as a matter of form, no doubt - actually impede or harm the Board's continuing investigation (even assuming that its remit does go onto the factory floor).
I suppose if the subject were the continuous slab caster in a Basic Oxygen Furnaces shop in a major steelmaking facility where I spent a summer of my youth, and a spill of molten steel - which did occur - had happened much more seriously, spilled much more quantity of raw steel, burned perhaps fatally the brickmasons who my coworker and I scrambled out of the way, then OSHA's inquiry could well have gotten into the seniority rules of the CBA by which my coworker and I happened to have the assigned jobs which included surviving in the face of raw steel spilling out where it ain't supposed ever to be. So federal safety investigation can, I guess, reach the shop floor. And all its nuances, "law of the shop" and so forth. But in that case, if Steel Company had been party to the agreement, and had briefed the press in advance of a major Metallurgy Convention in Farnborough, and mentioned a few things about how coworker and I happened to have been involved but in no way at fault, I'm just not seeing the big deal. Form over substance doesn't cut it, where raw steel is concerned. Maybe the happenings and failings of the door plug on that airframe implicate different types of administrative agency expertise factors.
If it can be shown how the Boeing press briefing did more than break the rules, tell it. Otherwise, it's more and more looking like the Board wants to crack down on Boeing for anything it can say with mostly a straight face. Ask yourself, does the information disclosed make it sound like Boeing isn't responsible for what happened, doesn't take it seriously, and will do anything or everything to hide the truth? Maybe it does, although the letter hasn't made that record.
Last edited by WillowRun 6-3; 28th Jun 2024 at 17:38.
It would appear that Boeing’s work management system is a single point of failure; i.e., if the work is never entered into the system, the work is treated as having never occurred. There is no second check.
Right, but was the move crew also doing a favor when it reinstalled the plug? No work order for that either? And going back to the discovery of the defective rivets, doesn't the order for the repair automatically tell the system that undertaking and completing the repair requires additional steps that also require documentation? And wouldn't the system then be looking for that documentation? Either the answers to those two questions are "yes" and more than one "favor" was asked and granted — so probably no single individual or small team is responsible — or the answers are "no" and the system is blind to necessary associated procedures in at least this situation.
I'm having a hard time seeing this as other than a process failure.
I'm having a hard time seeing this as other than a process failure.
Everything traces back to removing that door plug without performing the associated paperwork.
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I suspect opening and closing doors and access panels does not call for paperwork - and that the move crew looked upon the plug as just another door.
I rather suspect they chose to go quick, cheap and convenient, which is no excuse for undisciplined noncompliance with approved, and therefore required, procedures.
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If it requires a tool and parts are removed it requires a paper trail, not a quick favor for a buddy.
OldnGrounded - for me a process failure is where there is a defined process and following those steps has an adverse result., otherwise every human activity would become part of a process. Since this door removal wasn't part of a process I'd rather not include it as a process failure. Training failure? Absolutely.
"doesn't the order for the repair automatically tell the system that undertaking and completing the repair requires additional steps that also require documentation?"
I doubt that there is any system that has, for every single rivet, a plan for every single step, so the order for the repair will be "remove identified rivets per XYZ and replace with rivet #ABC using procedure RTS. Contact QA/QC when complete." And this will be the same language, perhaps with different rivets, for tens of thousands of rivets anywhere in the aircraft. This would not be the case on an assembly line where the order of operations is established by a manufacturing engineering group, but this is the "we f'd up and need to fix it" line. Maybe a giant banner - "Before it is touched with a tool - Call QA."
OldnGrounded - for me a process failure is where there is a defined process and following those steps has an adverse result., otherwise every human activity would become part of a process. Since this door removal wasn't part of a process I'd rather not include it as a process failure. Training failure? Absolutely.
"doesn't the order for the repair automatically tell the system that undertaking and completing the repair requires additional steps that also require documentation?"
I doubt that there is any system that has, for every single rivet, a plan for every single step, so the order for the repair will be "remove identified rivets per XYZ and replace with rivet #ABC using procedure RTS. Contact QA/QC when complete." And this will be the same language, perhaps with different rivets, for tens of thousands of rivets anywhere in the aircraft. This would not be the case on an assembly line where the order of operations is established by a manufacturing engineering group, but this is the "we f'd up and need to fix it" line. Maybe a giant banner - "Before it is touched with a tool - Call QA."
Basic Oxygen Furnaces shop
Maybe tattoo the backs of hands during orientation. More than a few highly-undesirable consequences of both process failure and human error might be avoided.
Not to belabor this endlessly but what do you think the move crew expected would be happening to that door plug after they "secured" it with the zip tie?
Not to belabor this endlessly but what do you think the move crew expected would be happening to that door plug after they "secured" it with the zip tie?
It would be reasonable for the move crew that, since the door had been left open, there was an outstanding work order to close it for delivery or that someone would cut the cable tie to open it again to finish whatever it was opened for. Were I to suggest something about this corner of the debacle I would ban white cable ties from the factory and require fluorescent cable ties for any temporary work, preferably orange.
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- the parts they are working on, or
- the procedures for that, or
- intentionally did not comply with them or
- how to assure that everything put together safely
Training may be an issue, discipline to follow approved procedures, and/or workload.
But most certainly management which is responsible for all of it.
How can the FAA not pull the PMA?
My understanding is that the door plug was not removed but was “opened” to allow access for the line workers to perform the necessary repairs.
I could be wrong, but I remember reading that there were 2 operational issues which contributed to this incident.
The first was Boeing did not allow the Spirit workers to access Boeing’s proprietary manufacturing software/assembly line documentation system which is used to track progress and rework along the line. Boeing QA inspectors noted the problems with the door plug, however because the remediation didn’t require removal of the door plug, the proper code to inspect the door plug “after removal” wasn’t entered into Boeing’s tracking system. Thus, the Boeing QA inspectors never were alerted to inspect the door plug retaining bolts after the repair had been completed.
The second factor was the informal system Spirit had developed in tracking the assembly and rework needed along the line at the Boeing plant. This system was created out of necessity because Spirit had no access to the Boeing tracking software. I believe that Boeing QA inspectors didn’t have access to this (which if I recall correctly was little more than e-mails sent among the Spirit workers along the line).
Anyone involved in operation management in an assembly situation can see how the holes in the Swiss cheese lined up.
I could be wrong, but I remember reading that there were 2 operational issues which contributed to this incident.
The first was Boeing did not allow the Spirit workers to access Boeing’s proprietary manufacturing software/assembly line documentation system which is used to track progress and rework along the line. Boeing QA inspectors noted the problems with the door plug, however because the remediation didn’t require removal of the door plug, the proper code to inspect the door plug “after removal” wasn’t entered into Boeing’s tracking system. Thus, the Boeing QA inspectors never were alerted to inspect the door plug retaining bolts after the repair had been completed.
The second factor was the informal system Spirit had developed in tracking the assembly and rework needed along the line at the Boeing plant. This system was created out of necessity because Spirit had no access to the Boeing tracking software. I believe that Boeing QA inspectors didn’t have access to this (which if I recall correctly was little more than e-mails sent among the Spirit workers along the line).
Anyone involved in operation management in an assembly situation can see how the holes in the Swiss cheese lined up.
