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Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

167 points by starkparker 1y ago

supportengineer 1y ago
The accident happened because a piece on the airplane wasn’t put back on the right way. The company that made the plane didn’t teach the workers well enough or check their work carefully. Also, the people in charge of making sure planes are safe didn’t do a good job checking on things.
- deleted 1y ago
  [deleted]
- heywoods 1y ago
  What Boeing plant was the aircraft assembled at where this failure occurred?
  - kayfox 1y ago
    As with all but the first few 737s, it was assembled at Renton. The door plug was installed in Wichita by Spirit Aerosystems and there were issues with rivets in the surrounding structure that Spirit removed the plug to correct in Renton. As a result of this Boeing is now refusing to sign off on fuselages with defects found at Spirit to be transported to Renton. And also Boeing will be buying back Spirit, which had been spun out of Boeing by the McDonall-Douglass management that took over Boeing when McDonall-Douglass bought Boeing with Boeings own money.
  - umeshunni 1y ago
    The fuselage is made by Spirit AeroSystems in Wichita, KS: https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-aerosystems-factory-boeing-737-max https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-a... The 737 assembly happens in Renton, WA
- bboygravity 1y ago
  And the whistleblower trying to warn people about this and other issues was potentially executed by the company.
  - Forgeties79 1y ago
    I see this conspiracy theory hasn’t died yet
    - CGMthrowaway 1y ago
      Are we still talking about John Barnett? This guy’s been talked about for years. You’re asking — we have Texas, we have this, we have all of the things. And are people still talking about this guy? That is unbelievable
      - MrZongle2 1y ago
        Well done. No notes.
      - kevin_thibedeau 1y ago
        Then let's talk about why the weapons shipments were suspended.
      - Forgeties79 1y ago
        Fantastic lol
    - user3939382 1y ago
      https://www.bbc.com/news/business-68534703.amp https://www.bbc.com/news/business-68534703.amp This is one of two. As theories go conspiracy is pretty plausible in this case. Unless you’re just naive about how the world works.
      - vel0city 1y ago
        There's supposedly video evidence of him parking his truck and nobody approaching it at all until people were there discovering the body. He had his personal firearm in his hand, ballistics suggest the bullet came from his gun, and it followed a path that made sense with him holding it and using it on himself. But hey I guess they did some kind of mind control on him.
- ryandrake 1y ago
  At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't, and people who are supposed to inspect their work who aren't inspecting, and people who are supposed to check the inspection process who aren't checking, and a legislative body who's supposed to regulate all the checking and double checking who aren't doing anything at all! It's like vast swaths of people are just fooling around, collecting a paycheck, but aren't doing what they're supposed to be doing, and we're all just miraculously surviving our day-to-day because a bunch of denominators are very large numbers!
  - pishpash 1y ago
    No, because some people still care and clean up enough after the slackers. The slackers also realize this and slack just enough for nothing major to happen often.
    - almosthere 1y ago
      This is not true, when that many people stop doing their job it spreads like a virus and the ones that still stand for good either a) leave companies or b) become infected also. They don't go against the grain. The people that do would have to have a constitution like no one you've met. Those people quit the moment covid-19 hit and they have since died or are just permanently retired.
    - metabagel 1y ago
      The issue at Boeing wasn't due to slackers. It was a process issue due to cutting corners (management issue).
  - HeyLaughingBoy 1y ago
    I have worked in the medical devices industry as a software engineer for about 20 years at this point. As you would expect, it's a very process-heavy field. I've generally worked with careful, competent people who want to do a good job and process goes a long way towards facilitating that. Every time I think about process though, I remember an editorial I read a long time ago about an engineer's experience in the aviation industry. He wasn't too thrilled about process. Instead, in his own words, "we were motivated by a very sincere desire to not kill anyone.
- deleted 1y ago
  [deleted]
pulse7 1y ago
"What We Found We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process."
- pulse7 1y ago
  Somehow Boeing is happening to the whole IT industry at the moment where AI is forced upon programmers instead of "properly developing software" ...
  - thewebguyd 1y ago
    It's a byproduct of unchecked capitalism. This behavior will continue as long as there are no real consequences for those in charge.
    - jiggawatts 1y ago
      There's always consequences for people in charge! It's just that all of the consequences are related to not-enough-profit, which explains everything you need to know.
  - nyarlathotep_ 1y ago
    My experience is somewhat limited professionally in software (just under a decade), but with very few exceptions I've seen little in terms of genuine professionalism as it pertains to anything that could be called "engineering." Most design/implementation decisions were basically (or literally) equivalent to "we use Kubernetes cause we've already got a lot of existing Terrraform for it", or "we have React developers." I know real professionalism and maybe even "engineering" practice exists somewhere (I mean it has to, for something rigorously proven, right?), but I've not personally experienced it; I've seen this everywhere, as a consultant and employee, both in the public and private sector. The number of times I've been on meetings or similar where there's tradeoffs backed by quantifiable data was a handful, at best, so the AI trend makes perfect sense to me. I really don't imagine with something like Boeing where there's a far higher burden of proof there's discussions around, like, some equivalent subjective thingy like "code smells" or "anti-patterns."
thomascountz 1y ago
> We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.
- pj_mukh 1y ago
  Looking forward to the length of the sentence the NTSB uses for Air India flight 171. Gonna be a doozy
  - JSteph22 1y ago
    Wouldn't it be the Indian authorities who issue a report?
    - twexler 1y ago
      Yes, but as the country of manufacture of the incident aircraft, NTSB is absolutely consulting on that report.
- nothingburger99 1y ago
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- CGMthrowaway 1y ago
  AKA Boeing did not train, guide or oversee its people well → Workers skipped the process meant to keep track of bolts and hardware → The bolts for the mid-exit door were never put back → At 14K feet, the door blew free.
  - gtech1 1y ago
    Physics question: why do I know (maybe wrongly) that in flight the doors are sealed shut by the difference in pressure ? And if so, why did it not work in this case ?
colechristensen 1y ago
The NTSB remains very good at its job and should serve as a model for government. A beacon of hope.
- CamperBob2 1y ago
  [flagged]
  - Alupis 1y ago
    [flagged]
    - cosmicgadget 1y ago
      Are you saying no one important is being DOGEs or that they can all be and the industry will self-police? It is tough to understand your snark.
      - CamperBob2 1y ago
        Not worth feeding the troll. Starve him out and he'll find his way back to Reddit.
        cosmicgadget 1y ago
        11yo account, ample points. Seems more like your standard snarky HN user who reports every political post and then comments on it.
        CamperBob2 1y ago
        He appears to command a brigade, going by the vote count. Amusing to watch, but a little sad as well.
        Alupis 1y ago
aredox 1y ago
Don't worry, as a consequence , Boeing is being awarded contract after contract by the current administration.
hughes 1y ago
Part of me wonders if the plug could be designed such that it's obvious when the bolts are missing. Would this have happened if it were impossible to assemble without them, or if it were easy to verify their presence? Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.
- burnt-resistor 1y ago
  The general principle would be making other parts with interference fit such that it or they visibly do not align without properly tightening/attaching parts below/about them. For example, the door plug should not sit in the correct position unless door plug bolts are all tightened and untightened door plug bolts shouldn't allow installing other parts like trim pieces to be flush. Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.
  - codedokode 1y ago
    I don't know if you were joking about the hammer or referring to a Russian assembly worker who used a hammer to install accelerometers in a rocket into a wrong position which caused it to attempt to fly downwards (no people were injured) [1]. [1] https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failures https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failur...
    - burnt-resistor 1y ago
      No, unfortunately, I'm not joking. The 737 NG and MAX fuselages were assembled inconsistently and badly for 20+ years. Bear straps and other critical parts were percussively persuaded into place.
  - tialaramex 1y ago
    Note that you can solve that last problem but you need to think outside the box. Hammering structural parts which don't want to go is hard work and if your workers have union protection you can bet they'll say "No". So what you need are strong union protections so that they feel able to say "No" when asked to do unreasonable things. Does that mean they're going to be a little harder to manage? Maybe, but mostly it means "Rule by fear" doesn't work and leadership might need to learn to inspire not threaten. Union protections help in one place you're already familiar with. If your pilot says "No, I don't like those clouds at all" and won't fly, the airline can't fire them for that. That's their judgement, if you fire pilots who you feel aren't risking passengers necks to make the line go up you're not going to have any pilots at all. Historically it helped for traffic control, but that's OK our old friend, Cowboy Actor and Friend of the Working Billionaire, Ronald Reagan smashed that, so now traffic control has the shocking poor working conditions Corporate America loves.
ratdoctor 1y ago
There are a couple of typos on the page > dDevelop guidance for Federal Aviation Administration managers and inspectors > <strike>P</strike>rovide Federal Aviation Administration managers
- packetslave 1y ago
  [flagged]
- deleted 1y ago
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- scoot 1y ago
  Fortunately neither of these is likely to cause an aviation incident or accident.
- mmwelt 1y ago
  Obviously, such mistakes have no bearing on the content of the report. However, there are usually certain expectations of a formal report from an official government bureau, including a standard of presentation.
tonymet 1y ago
i think proximate/ultimate breakdown would be more readable here. Proximate cause: poor installation. Ultimate cause: bad docs and quality control.
callamdelaney 1y ago
Having been on an air crash investigation kind of vibe since the Air India accident, I have conflicting opinions on boeing. On one hand, their quality control, engineering etc has been declining, not to mention the suspicious deaths of whistleblowers.. But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire. There are at least 3 accidents on airbus planes which can effectively be attributed to dual input. Loss of situational awareness, highly technical changes in the way the aircraft controls (why would this ever be a good idea), given certain circumstances. Imagine dying because of the different between ‘pull down’ and ‘push down’. On a boeing, when the captain pushes the nose down, you see immediately what he means. On an airbus, you’re dead by the time the captains input override is acknowledged. There are definitely pro’s to the airbus system but why cant we add input feedback?
- xenadu02 1y ago
  FWIW Airbus has tested a force-feedback side stick. Why they don't already offer it as an option I do not know. Maybe they are calmer now but for decades they took the attitude that "We built an un-crashable airplane because we are smarter than you" and took any criticism as a personal attack. If you're curious the 757, 767, 777, and 787 are all fly by wire but use both physical linkage under the deck and force-feedback servos to transmit control surface feel back to the pilots. But they also have torque tubes that can be overpowered and ... shocker... in a dual input situation they do the same as Airbus: average the inputs. But at least you have to really yank on the controls to make that happen.
- anonymars 1y ago
  I suspect this brief lecture (2 parts) on automation dependency will be right up your alley: https://www.youtube.com/watch?v=WITLR_qSPXk https://www.youtube.com/watch?v=WITLR_qSPXk
- juanani 1y ago
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- deleted 1y ago
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xenadu02 1y ago
Remember: McDonald-Douglass management (of the Jack Welch school) took over at Boeing post-merger. Widgets are widgets and people are just another kind of widget. Job #1 was to screw labor and engineering out of money so that money could go into management's pocket (in the name of shareholders but screwing shareholders is also part of the deal). They moved HQ away from Seattle specifically so engineers and production personnel couldn't stomp into management's offices and yell at them about safety or anything else. Then they started outsourcing whatever they could to remove as many people as possible from Boeing's union contracts, corporate benefits, etc and replace those highly paid professionals with the cheapest bodies they could find. After all - the Jack Welch school of thought is the Important People (managers) just need to break down the process (any process) into enough small simple steps that a monkey could do it. Then you could hire the cheapest possible unskilled labor and pay them peanuts but it wouldn't matter because a widget is a widget. People are just widgets. Swap an expensive widget for a cheap one. Duh. This first came home to roost on the 787 project. Boeing outsourced vast amounts of the project which came back to bite them in the form of delays. They were supposed to start flying in August 2007 and deliver to customers in 2008 but horrible subcontractor designs, rework, unfinished work, etc led to huge assemblies arriving in Everett in a shambles. Repeated delays meant the first aircraft wasn't delivered until September 2011 a full three years behind schedule. Boeing had to buy back in-house a number of their contractors to even make that happen. That was promptly followed by battery fires that grounded the entire 787 fleet for part of 2013. The first grounding of a transport category airliner since 1979. Did I mention the 787 had quality problems from 2019 until 2023 (some say ongoing problems even up to today), resulting in missing fasteners (!!!), improperly installed fuel lines, and other issues. For some time they not only had to halt deliveries they had to halt production. Does any of this sound familiar? It should because the exact same issues plagued the 737 MAX from the start! Rushed engineering without internal peer review or proper consideration (single data source). Rosy assumptions about how pilots would handle various emergencies. Outsourcing to screw labor. Terrible mis-management. Incompetent contractors. Complete lack of process control inside Boeing and complete lack of shits given by Boeing management at any level. Callus lack of regard for any human anywhere (passengers, pilots, airline employees, their own employees)... Boeing knew there was a problem with MCAS and their published guidance wasn't the final word but lied to Ethiopian airlines about it (whos pilots asked some excellent pointed questions). Those lies likely directly leading to the second hull loss event. Also the same expensive "solutions". Huge re-certification of their process and self-certification procedures. Buying back in-house contractors they originally spun out to cut benefits. And the 737 MAX itself being a terrible idea, cancelling the clean-sheet A32x competitor in favor of more duct tape and bailing wire on a design with way too many manual reversion modes. On the 787 alternate gear extension is a button press. Dual generator failure auto-starts the APU and deploys the RAT. Electric re-routes automatically. On the 737? LOL nope. All manual. Manual gear means copilot has to stand up, get behind their chair, open a floor panel, then pull three separate cables to about chest-height. Bird ingestion dual engine failure at 1500ft? Not a chance that's happening. But hey according to Boeing's new CEO that is all fine, we aren't doing "the new airplane". The amount of value destruction of Boeing as a company, Boeing's market share, Boeing's brand, and ultimately Boeing's share price as a result of management trying to screw over labor and taking a short-term view of everything is jaw-dropping. Nothing has changed at Boeing. They got caught with their hand in the cookie jar. They are doing the absolute bare minimum to make everyone shut up about it and get back to the status quo. How many more times are they going to lose self-certification status? How many more times will they be told to overhaul internal procedures and come up with yet another System to make sure they follow their own rules. All the while management keeps rewarding themselves for outsourcing, cutting pay/benefits, and business as usual. How long will this supposed new quality attitude last? Anyone gonna get promoted to SVP because we didn't have anymore accidents? Gotta weigh that against the exec who outsourced production of control surfaces so we could lay off 500 machinists at $150/hr fully loaded so a contractor can hire $25/hr smucks to do the work thus saving us millions. Gee wonder who's gonna get that promotion after all?
omgJustTest 1y ago
long story short: 1. boeing and spirit both work on planes 2. damaged rivets discovered and lots of back and forth to get them repaired. boeing does the doors and spirit does the rivets. 3. rework on rivets needed door plug to be removed, someone at boeing (who is not onsite) sees that the door plug needs to be removed, escalates this request but notes that work must wait for the next week because the only door person who is qualified to remove plugs is on leave. 4. door manager - on the day of the plug removal - de-escalates the door plug removal request. later that day the door manager, door master and three door crew enter area near the fuselage & door plug - correct documentation of removal not generated and none of them were trained to remove door plug. No one knows who removed the plug. 5. a boeing technician moves a stand that has what he believed to be a door plug bolt on top of it. he "strapped it and let it hang" to the fuselage. 6. Spirit indicates plug was removed and reworks rivets 7. No one checks the door plug was reinstalled correctly
- morninglight 1y ago
  Boeing also had a rivet problem on Japan Air Lines Flight 123 in 1985 and 520 people died. https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123 https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123
  - hbcondo714 1y ago
    > The crash is the deadliest single-aircraft accident in aviation history…caused by a faulty repair by Boeing technicians Extremely sad to learn this. It could have been prevented.
- tomcam 1y ago
  Damn son, thanks
  - omgJustTest 1y ago
    I really love reading NTSB and Coast Guard break-downs... a lot of very interesting engineering!
comrade1234 1y ago
So many Boeing shills posting here... who are you trying to convince on hacker news? No one here is influencing airlines or states on planes to buy. Boeing is dead.
- dtgriscom 1y ago
  That's a bit extreme.
golergka 1y ago
> dDevelop guidance Good to know it was written by a human and not an LLM.

167 points by starkparker 1y ago

The accident happened because a piece on the airplane wasn’t put back on the right way. The company that made the plane didn’t teach the workers well enough or check their work carefully. Also, the people in charge of making sure planes are safe didn’t do a good job checking on things.

deleted 1y ago
[deleted]
heywoods 1y ago
What Boeing plant was the aircraft assembled at where this failure occurred?
- kayfox 1y ago
  As with all but the first few 737s, it was assembled at Renton. The door plug was installed in Wichita by Spirit Aerosystems and there were issues with rivets in the surrounding structure that Spirit removed the plug to correct in Renton. As a result of this Boeing is now refusing to sign off on fuselages with defects found at Spirit to be transported to Renton. And also Boeing will be buying back Spirit, which had been spun out of Boeing by the McDonall-Douglass management that took over Boeing when McDonall-Douglass bought Boeing with Boeings own money.
- umeshunni 1y ago
  The fuselage is made by Spirit AeroSystems in Wichita, KS: https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-aerosystems-factory-boeing-737-max https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-a... The 737 assembly happens in Renton, WA
bboygravity 1y ago
And the whistleblower trying to warn people about this and other issues was potentially executed by the company.
- Forgeties79 1y ago
  I see this conspiracy theory hasn’t died yet
  - CGMthrowaway 1y ago
    Are we still talking about John Barnett? This guy’s been talked about for years. You’re asking — we have Texas, we have this, we have all of the things. And are people still talking about this guy? That is unbelievable
    - MrZongle2 1y ago
      Well done. No notes.
    - kevin_thibedeau 1y ago
      Then let's talk about why the weapons shipments were suspended.
    - Forgeties79 1y ago
      Fantastic lol
  - user3939382 1y ago
    https://www.bbc.com/news/business-68534703.amp https://www.bbc.com/news/business-68534703.amp This is one of two. As theories go conspiracy is pretty plausible in this case. Unless you’re just naive about how the world works.
    - vel0city 1y ago
      There's supposedly video evidence of him parking his truck and nobody approaching it at all until people were there discovering the body. He had his personal firearm in his hand, ballistics suggest the bullet came from his gun, and it followed a path that made sense with him holding it and using it on himself. But hey I guess they did some kind of mind control on him.
ryandrake 1y ago
At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't, and people who are supposed to inspect their work who aren't inspecting, and people who are supposed to check the inspection process who aren't checking, and a legislative body who's supposed to regulate all the checking and double checking who aren't doing anything at all! It's like vast swaths of people are just fooling around, collecting a paycheck, but aren't doing what they're supposed to be doing, and we're all just miraculously surviving our day-to-day because a bunch of denominators are very large numbers!
- pishpash 1y ago
  No, because some people still care and clean up enough after the slackers. The slackers also realize this and slack just enough for nothing major to happen often.
  - almosthere 1y ago
    This is not true, when that many people stop doing their job it spreads like a virus and the ones that still stand for good either a) leave companies or b) become infected also. They don't go against the grain. The people that do would have to have a constitution like no one you've met. Those people quit the moment covid-19 hit and they have since died or are just permanently retired.
  - metabagel 1y ago
    The issue at Boeing wasn't due to slackers. It was a process issue due to cutting corners (management issue).
- HeyLaughingBoy 1y ago
  I have worked in the medical devices industry as a software engineer for about 20 years at this point. As you would expect, it's a very process-heavy field. I've generally worked with careful, competent people who want to do a good job and process goes a long way towards facilitating that. Every time I think about process though, I remember an editorial I read a long time ago about an engineer's experience in the aviation industry. He wasn't too thrilled about process. Instead, in his own words, "we were motivated by a very sincere desire to not kill anyone.
deleted 1y ago
[deleted]

pulse7 1y ago

"What We Found We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process."

pulse7 1y ago
Somehow Boeing is happening to the whole IT industry at the moment where AI is forced upon programmers instead of "properly developing software" ...
- thewebguyd 1y ago
  It's a byproduct of unchecked capitalism. This behavior will continue as long as there are no real consequences for those in charge.
  - jiggawatts 1y ago
    There's always consequences for people in charge! It's just that all of the consequences are related to not-enough-profit, which explains everything you need to know.
- nyarlathotep_ 1y ago
  My experience is somewhat limited professionally in software (just under a decade), but with very few exceptions I've seen little in terms of genuine professionalism as it pertains to anything that could be called "engineering." Most design/implementation decisions were basically (or literally) equivalent to "we use Kubernetes cause we've already got a lot of existing Terrraform for it", or "we have React developers." I know real professionalism and maybe even "engineering" practice exists somewhere (I mean it has to, for something rigorously proven, right?), but I've not personally experienced it; I've seen this everywhere, as a consultant and employee, both in the public and private sector. The number of times I've been on meetings or similar where there's tradeoffs backed by quantifiable data was a handful, at best, so the AI trend makes perfect sense to me. I really don't imagine with something like Boeing where there's a far higher burden of proof there's discussions around, like, some equivalent subjective thingy like "code smells" or "anti-patterns."

thomascountz 1y ago

> We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.

pj_mukh 1y ago
Looking forward to the length of the sentence the NTSB uses for Air India flight 171. Gonna be a doozy
- JSteph22 1y ago
  Wouldn't it be the Indian authorities who issue a report?
  - twexler 1y ago
    Yes, but as the country of manufacture of the incident aircraft, NTSB is absolutely consulting on that report.
nothingburger99 1y ago
[dead]
CGMthrowaway 1y ago
AKA Boeing did not train, guide or oversee its people well → Workers skipped the process meant to keep track of bolts and hardware → The bolts for the mid-exit door were never put back → At 14K feet, the door blew free.
- gtech1 1y ago
  Physics question: why do I know (maybe wrongly) that in flight the doors are sealed shut by the difference in pressure ? And if so, why did it not work in this case ?

colechristensen 1y ago

The NTSB remains very good at its job and should serve as a model for government. A beacon of hope.

CamperBob2 1y ago
[flagged]
- Alupis 1y ago
  [flagged]
  - cosmicgadget 1y ago
    Are you saying no one important is being DOGEs or that they can all be and the industry will self-police? It is tough to understand your snark.
    - CamperBob2 1y ago
      Not worth feeding the troll. Starve him out and he'll find his way back to Reddit.
      - cosmicgadget 1y ago
        11yo account, ample points. Seems more like your standard snarky HN user who reports every political post and then comments on it.
        CamperBob2 1y ago
        He appears to command a brigade, going by the vote count. Amusing to watch, but a little sad as well.
        Alupis 1y ago

aredox 1y ago

Don't worry, as a consequence , Boeing is being awarded contract after contract by the current administration.

hughes 1y ago

Part of me wonders if the plug could be designed such that it's obvious when the bolts are missing. Would this have happened if it were impossible to assemble without them, or if it were easy to verify their presence? Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.

burnt-resistor 1y ago
The general principle would be making other parts with interference fit such that it or they visibly do not align without properly tightening/attaching parts below/about them. For example, the door plug should not sit in the correct position unless door plug bolts are all tightened and untightened door plug bolts shouldn't allow installing other parts like trim pieces to be flush. Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.
- codedokode 1y ago
  I don't know if you were joking about the hammer or referring to a Russian assembly worker who used a hammer to install accelerometers in a rocket into a wrong position which caused it to attempt to fly downwards (no people were injured) [1]. [1] https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failures https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failur...
  - burnt-resistor 1y ago
    No, unfortunately, I'm not joking. The 737 NG and MAX fuselages were assembled inconsistently and badly for 20+ years. Bear straps and other critical parts were percussively persuaded into place.
- tialaramex 1y ago
  Note that you can solve that last problem but you need to think outside the box. Hammering structural parts which don't want to go is hard work and if your workers have union protection you can bet they'll say "No". So what you need are strong union protections so that they feel able to say "No" when asked to do unreasonable things. Does that mean they're going to be a little harder to manage? Maybe, but mostly it means "Rule by fear" doesn't work and leadership might need to learn to inspire not threaten. Union protections help in one place you're already familiar with. If your pilot says "No, I don't like those clouds at all" and won't fly, the airline can't fire them for that. That's their judgement, if you fire pilots who you feel aren't risking passengers necks to make the line go up you're not going to have any pilots at all. Historically it helped for traffic control, but that's OK our old friend, Cowboy Actor and Friend of the Working Billionaire, Ronald Reagan smashed that, so now traffic control has the shocking poor working conditions Corporate America loves.

ratdoctor 1y ago

There are a couple of typos on the page > dDevelop guidance for Federal Aviation Administration managers and inspectors > <strike>P</strike>rovide Federal Aviation Administration managers

packetslave 1y ago
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scoot 1y ago
Fortunately neither of these is likely to cause an aviation incident or accident.
mmwelt 1y ago
Obviously, such mistakes have no bearing on the content of the report. However, there are usually certain expectations of a formal report from an official government bureau, including a standard of presentation.

tonymet 1y ago

i think proximate/ultimate breakdown would be more readable here. Proximate cause: poor installation. Ultimate cause: bad docs and quality control.

callamdelaney 1y ago

Having been on an air crash investigation kind of vibe since the Air India accident, I have conflicting opinions on boeing. On one hand, their quality control, engineering etc has been declining, not to mention the suspicious deaths of whistleblowers.. But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire. There are at least 3 accidents on airbus planes which can effectively be attributed to dual input. Loss of situational awareness, highly technical changes in the way the aircraft controls (why would this ever be a good idea), given certain circumstances. Imagine dying because of the different between ‘pull down’ and ‘push down’. On a boeing, when the captain pushes the nose down, you see immediately what he means. On an airbus, you’re dead by the time the captains input override is acknowledged. There are definitely pro’s to the airbus system but why cant we add input feedback?

xenadu02 1y ago
FWIW Airbus has tested a force-feedback side stick. Why they don't already offer it as an option I do not know. Maybe they are calmer now but for decades they took the attitude that "We built an un-crashable airplane because we are smarter than you" and took any criticism as a personal attack. If you're curious the 757, 767, 777, and 787 are all fly by wire but use both physical linkage under the deck and force-feedback servos to transmit control surface feel back to the pilots. But they also have torque tubes that can be overpowered and ... shocker... in a dual input situation they do the same as Airbus: average the inputs. But at least you have to really yank on the controls to make that happen.
anonymars 1y ago
I suspect this brief lecture (2 parts) on automation dependency will be right up your alley: https://www.youtube.com/watch?v=WITLR_qSPXk https://www.youtube.com/watch?v=WITLR_qSPXk
juanani 1y ago
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xenadu02 1y ago

Remember: McDonald-Douglass management (of the Jack Welch school) took over at Boeing post-merger. Widgets are widgets and people are just another kind of widget. Job #1 was to screw labor and engineering out of money so that money could go into management's pocket (in the name of shareholders but screwing shareholders is also part of the deal). They moved HQ away from Seattle specifically so engineers and production personnel couldn't stomp into management's offices and yell at them about safety or anything else. Then they started outsourcing whatever they could to remove as many people as possible from Boeing's union contracts, corporate benefits, etc and replace those highly paid professionals with the cheapest bodies they could find. After all - the Jack Welch school of thought is the Important People (managers) just need to break down the process (any process) into enough small simple steps that a monkey could do it. Then you could hire the cheapest possible unskilled labor and pay them peanuts but it wouldn't matter because a widget is a widget. People are just widgets. Swap an expensive widget for a cheap one. Duh. This first came home to roost on the 787 project. Boeing outsourced vast amounts of the project which came back to bite them in the form of delays. They were supposed to start flying in August 2007 and deliver to customers in 2008 but horrible subcontractor designs, rework, unfinished work, etc led to huge assemblies arriving in Everett in a shambles. Repeated delays meant the first aircraft wasn't delivered until September 2011 a full three years behind schedule. Boeing had to buy back in-house a number of their contractors to even make that happen. That was promptly followed by battery fires that grounded the entire 787 fleet for part of 2013. The first grounding of a transport category airliner since 1979. Did I mention the 787 had quality problems from 2019 until 2023 (some say ongoing problems even up to today), resulting in missing fasteners (!!!), improperly installed fuel lines, and other issues. For some time they not only had to halt deliveries they had to halt production. Does any of this sound familiar? It should because the exact same issues plagued the 737 MAX from the start! Rushed engineering without internal peer review or proper consideration (single data source). Rosy assumptions about how pilots would handle various emergencies. Outsourcing to screw labor. Terrible mis-management. Incompetent contractors. Complete lack of process control inside Boeing and complete lack of shits given by Boeing management at any level. Callus lack of regard for any human anywhere (passengers, pilots, airline employees, their own employees)... Boeing knew there was a problem with MCAS and their published guidance wasn't the final word but lied to Ethiopian airlines about it (whos pilots asked some excellent pointed questions). Those lies likely directly leading to the second hull loss event. Also the same expensive "solutions". Huge re-certification of their process and self-certification procedures. Buying back in-house contractors they originally spun out to cut benefits. And the 737 MAX itself being a terrible idea, cancelling the clean-sheet A32x competitor in favor of more duct tape and bailing wire on a design with way too many manual reversion modes. On the 787 alternate gear extension is a button press. Dual generator failure auto-starts the APU and deploys the RAT. Electric re-routes automatically. On the 737? LOL nope. All manual. Manual gear means copilot has to stand up, get behind their chair, open a floor panel, then pull three separate cables to about chest-height. Bird ingestion dual engine failure at 1500ft? Not a chance that's happening. But hey according to Boeing's new CEO that is all fine, we aren't doing "the new airplane". The amount of value destruction of Boeing as a company, Boeing's market share, Boeing's brand, and ultimately Boeing's share price as a result of management trying to screw over labor and taking a short-term view of everything is jaw-dropping. Nothing has changed at Boeing. They got caught with their hand in the cookie jar. They are doing the absolute bare minimum to make everyone shut up about it and get back to the status quo. How many more times are they going to lose self-certification status? How many more times will they be told to overhaul internal procedures and come up with yet another System to make sure they follow their own rules. All the while management keeps rewarding themselves for outsourcing, cutting pay/benefits, and business as usual. How long will this supposed new quality attitude last? Anyone gonna get promoted to SVP because we didn't have anymore accidents? Gotta weigh that against the exec who outsourced production of control surfaces so we could lay off 500 machinists at $150/hr fully loaded so a contractor can hire $25/hr smucks to do the work thus saving us millions. Gee wonder who's gonna get that promotion after all?

omgJustTest 1y ago

long story short: 1. boeing and spirit both work on planes 2. damaged rivets discovered and lots of back and forth to get them repaired. boeing does the doors and spirit does the rivets. 3. rework on rivets needed door plug to be removed, someone at boeing (who is not onsite) sees that the door plug needs to be removed, escalates this request but notes that work must wait for the next week because the only door person who is qualified to remove plugs is on leave. 4. door manager - on the day of the plug removal - de-escalates the door plug removal request. later that day the door manager, door master and three door crew enter area near the fuselage & door plug - correct documentation of removal not generated and none of them were trained to remove door plug. No one knows who removed the plug. 5. a boeing technician moves a stand that has what he believed to be a door plug bolt on top of it. he "strapped it and let it hang" to the fuselage. 6. Spirit indicates plug was removed and reworks rivets 7. No one checks the door plug was reinstalled correctly

morninglight 1y ago
Boeing also had a rivet problem on Japan Air Lines Flight 123 in 1985 and 520 people died. https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123 https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123
- hbcondo714 1y ago
  > The crash is the deadliest single-aircraft accident in aviation history…caused by a faulty repair by Boeing technicians Extremely sad to learn this. It could have been prevented.
tomcam 1y ago
Damn son, thanks
- omgJustTest 1y ago
  I really love reading NTSB and Coast Guard break-downs... a lot of very interesting engineering!

comrade1234 1y ago

So many Boeing shills posting here... who are you trying to convince on hacker news? No one here is influencing airlines or states on planes to buy. Boeing is dead.

dtgriscom 1y ago
That's a bit extreme.

golergka 1y ago

> dDevelop guidance Good to know it was written by a human and not an LLM.