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> 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,
by 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 agoLooking forward to the length of the sentence the NTSB uses for Air India flight 171. Gonna be a doozy
- nothingburger99 1y ago[dead]
- CGMthrowaway 1y agoAKA 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 agoPhysics 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 ?
- BobaFloutist 1y agoI don't know the answer for this specific case, but the pressure is high on the inside and low on the outside. If you have a hinted door that opens inward, then pressure will keep it shut. If you install the door wrong and forget to attach the hinge properly, it could be blown outward.
- gtech1 1y agodon't all doors open outwards on airplanes ?
- CGMthrowaway 1y agoThis is why the door assemblies are referred to as "plugs" : The door is designed with special hinges & joints, such that opening the door involves first pulling the door inwards, rotating it partially, and then finally swinging it outwards. If the door is not pulled inwards first, the shape of the door (as a "plug") prevents it from swinging out
- 0rzech 1y agoAt school (Polish class in Poland) we were always taught to prefer complex and compound sentences over simple ones, because it's more elegant and speaks well the speaker/writer.
- tuukkah 1y agoSame happening in Hispanic school systems could explain the sentences in some of the Spanish Wikipedia articles.
- ecb_penguin 1y agoIt doesn't, though. It's pretentious and educated people will see through it. If the goal is to inform, then you should do the opposite.
- GuinansEyebrows 1y agoi imagine the language may change that though. With Polish having nominally 300k-400k words compared to English's >1m, i'd guess that it's a lot easier to misdirect and fluff up your writing in English.
- codedokode 1y agoEnglish has over 1 million words? No way. Except for pronunciation, it is relatively simple language.
- 0rzech 1y agoIt can if you count all the different forms of each word and proper nouns. But this way Polish may have even more words than english, given multitude of different forms. I've never checked that, though. There's also the tendency in English to make new words out of existing ones to create new meanings, while in Polish we often use multiple separate existing words to create new meanings. All in all, I believe English has more base forms than Polish.
- 1y ago
- ryandrake 1y agoReading aviation-related NTSB final reports is kind of a hobby of mine, and I must say, the NTSB is generally a treasure! Sure, you can find issues with some of their investigations, roads they might not have probed down as far as they could, but their culture of root causing and transparently reporting should be emulated across the government. I really hope they don't fall victim to the casual, random destruction our current administration is inflicting on broad swaths of the government.
- frumplestlatz 1y agoThe current aims of the executive branch are neither casual nor random, and I doubt the NTSB is in their crosshairs. The goals are both obvious and specific; it’s a culture war being fought at the funding level.
- cosmicgadget 1y agoThere is the culture war but don't ignore the dealmaking and profiteering. This can create the appearance of randomness because any entity can appeal to the executive for favor. Sounds like in this case either Boeing didn't donate enough or, more likely, nobody wants to f with airliner safety.
- lukan 1y ago"or, more likely, nobody wants to f with airliner safety" If that would be more likely, Boeing wouldn't be, where it is. To me it seems more likely Boeing has now too much attention on them, making fraud here even more dangerous/expensive.
- postpawl 1y agoA culture war on poor people who need Medicaid? That doesn’t seem like class war to you?
- xp84 1y agoCan you point out what aspects of the bill relating to Medicaid are most concerning? I don't just mean the DNC talking points, but rather specific provisions. When I read through the actual provisions[1] they are far less scary than what I hear being used as DNC fundraising fodder. For instance, I can't just show up in the UK without any legal status and automatically have all free healthcare from the NHS[2]. But the provisions removing federal tax money support to provide free healthcare to the undocumented is one of the things being pointed to by opponents of the bill as being especially evil. If you feel that way, why is the US the only country that ought to do that? [1] https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/ https://www.kff.org/tracking-the-medicaid-provisions-in-the-... [2] https://www.nhs.uk/nhs-services/visiting-or-moving-to-england/how-to-access-nhs-services-in-england-if-you-are-visiting-from-abroad/ https://www.nhs.uk/nhs-services/visiting-or-moving-to-englan...
- JoshTriplett 1y agoAlso, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".
- wat10000 1y agoThey know their business. The goal is safety, not punishment. Blaming workers is great if you're after revenge or a scapegoat, but generally doesn't improve safety.
- mrandish 1y agoAgreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training. In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.
- lobochrome 1y agoIn the end - action matters. Somebody didn’t put the bolts back in. Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.
- specialist 1y agoHave you read Donald Norman's Design of Everyday Things?
- bobsomers 1y agoModern safety analysis acknowledges that humans are fallible, and they are generally acting in a good faith way to try and do their jobs correctly within a given system they are operating in. That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.
- dlcarrier 1y agoMy favorite NTSB-ism is "controlled flight into terrain", which means "crashed". This is as opposed to "uncontrolled flight into terrain", which means "fell from the sky".
- hectormalot 1y agoI think CFIT is appropriate. There’s loads of cases where pilots flew into a mountain due to lack of environmental awareness. Here’s a bizarre example: https://admiralcloudberg.medium.com/lost-and-confused-the-crash-of-varig-flight-254-3f9a6c0e97c8 https://admiralcloudberg.medium.com/lost-and-confused-the-cr...
- scoot 1y agoBoth result in a crash – the first due to pilot error, the second due to mechanical failure.
- SaberTail 1y agoCFIT is not necessarily pilot error. For example, if ATC vectored a plane without ground proximity warnings into the side of a mountain, that would also be CFIT.
- FL410 1y agoIt’s a bit more nuanced than that. CFIT is intended to classify accidents where the aircraft itself was not causal. In any other case, it is assumed that there were mechanical or other aircraft-related factors that were contributory or causal.
- ghushn3 1y agoIt seems pretty clearly describing a state + an outcome. "(pilot control state) flight into (outcome of flight)" One of those pieces of jargon that feels silly until you go, "Oh, actually, this makes a lot of sense when you deconstruct it."
- gcau 1y agoIt's a legitimate distinction, "they were in control" and "they weren't in control". If the pilots are on a collision course with a mountain, but are happily sitting there thinking they're going the other way, there's nothing wrong with the plane, and the pilots are in control of the plane. In contrast to a horizontal stabilizer failure, where the pilots aren't in control, and instead say their goodbyes for the cockpit voice recording.
- leecoursey 1y ago[flagged]
- scoot 1y ago> We determined that the probable cause of this accident was the in-flight separation of the left MED plug I find this very strangely worded. It was an "incident", not an "accident"; and "the in-flight separation of the left MED plug" was the incident, not the cause of a non-existent accident. The actual cause of the incident (as determined by the NTSB) is what follows all that unnecessary verbage.
- deleted 1y ago[deleted]
- tuukkah 1y agoHow about like this? "We determined the accident's probable cause: The in-flight separation of the left MED plug happened because Boeing had failed to provide adequate training, guidance, and oversight. These would have been necessary to ensure that manufacturing personnel could consistently and correctly comply with Boeing's parts removal process. The securing bolts and hardware had been removed during manufacturing to facilitate rework, and the process intended to document and ensure proper reinstallation."