4 ms·

The report on that incident says there was a hardware modification to make this impossible, to be incorporated before Jan 2023. (It also says this happened to

by stefan_ 4mo ago

The report on that incident says there was a hardware modification to make this impossible, to be incorporated before Jan 2023. (It also says this happened to Boeing in 2018 and they ignored it, of course)

cwizou 4mo ago
I missed that part, and since it's a newly delivered plane (this January), it's safe to assume the mitigation was in place. Preliminary report will be interesting here.
dheera 4mo ago
Wonder why they don't just grab a huge permanent Sharpie and write in huge letters "Do not insert pin here" on one hole and "Insert pin here" on the other hole. I'm actually serious, it seems to me they resist these kind of short-term helpers that would save lots of injuries.
- stefan_ 4mo ago
  I think the report says they just put a little cover on the hole where the pin shouldn't go (but can).
  - dheera 4mo ago
    Sure, but they probably took 3 years to have a design review, an executive review, some firings and layoffs, re-hire, orientation, a sprint planning meeting, a sprint retro, a post mortem, an OKR meeting, a KPI meeting, an all-hands, and then the cover probably got stuck in customs with tariffs, and then the tolerances probably weren't correct. Meanwhile the sharpie would take 1 minute.
    - phil21 4mo ago
      > Meanwhile the sharpie would take 1 minute. And eventually be missed/ignored by a rushed ground tech and fail again. Other than making it easier to blame someone, labeling is just a short term interim fix for such things. You design it to be physically impossible or as close to that as possible. Been there, done that in much less high stakes environments. Upping the training, documentation, and labeling simply makes the mistakes happen less often for a physical process obviously prone to a common mistake. Sure as an immediate airworthiness directive giant bright lettering is a great immediate “this month” fix. Certainly not a permanent one though. If you make a hole multiple things can be fit into, eventually someone will try.
- bombcar 4mo ago
  You’re likely a fan of this: https://i.sstatic.net/vaPH0.jpg https://i.sstatic.net/vaPH0.jpg

by stefan_ 4mo ago

cwizou 4mo ago

I missed that part, and since it's a newly delivered plane (this January), it's safe to assume the mitigation was in place. Preliminary report will be interesting here.

dheera 4mo ago

Wonder why they don't just grab a huge permanent Sharpie and write in huge letters "Do not insert pin here" on one hole and "Insert pin here" on the other hole. I'm actually serious, it seems to me they resist these kind of short-term helpers that would save lots of injuries.

stefan_ 4mo ago
I think the report says they just put a little cover on the hole where the pin shouldn't go (but can).
- dheera 4mo ago
  Sure, but they probably took 3 years to have a design review, an executive review, some firings and layoffs, re-hire, orientation, a sprint planning meeting, a sprint retro, a post mortem, an OKR meeting, a KPI meeting, an all-hands, and then the cover probably got stuck in customs with tariffs, and then the tolerances probably weren't correct. Meanwhile the sharpie would take 1 minute.
  - phil21 4mo ago
    > Meanwhile the sharpie would take 1 minute. And eventually be missed/ignored by a rushed ground tech and fail again. Other than making it easier to blame someone, labeling is just a short term interim fix for such things. You design it to be physically impossible or as close to that as possible. Been there, done that in much less high stakes environments. Upping the training, documentation, and labeling simply makes the mistakes happen less often for a physical process obviously prone to a common mistake. Sure as an immediate airworthiness directive giant bright lettering is a great immediate “this month” fix. Certainly not a permanent one though. If you make a hole multiple things can be fit into, eventually someone will try.
bombcar 4mo ago
You’re likely a fan of this: https://i.sstatic.net/vaPH0.jpg https://i.sstatic.net/vaPH0.jpg