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 9th Jan 2024, 17:36
  #561 (permalink)  
 
Join Date: Aug 2009
Location: GPS L INVALID
Posts: 580
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by Lake1952
I was also thinking that this feature, if indeed this is fact, is too much information!
Actually the 737 door has two decompression panels that should only open if the flight deck depressurizes, not the other way around - so either that door was not locked, or the differential pressure sufficient to somehow still open the door.
Originally Posted by AMM
Control Cabin Door Decompression Panels
The door has blowout panels that will open if there is a rapid decompression in the flight compartment. A rapid decompression will cause a sudden change in pressure between the flight compartment and the passenger cabin compartment. For each decompression panel, one edge is attached to the flight compartment door assembly with retractable bolts, while the other edge is secured to the door assembly with a mechanical pressure release latch. The mechanical latches are set to release under a pre-determined pressure, which will cause the decompression panels to open into the flight compartment.
In the case of a rapid decompression in the cabin compartment, the door is able to withstand the pressure difference due to the small area of the flight compartment.
STBYRUD is offline  
Old 9th Jan 2024, 17:44
  #562 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 15,848
Received 214 Likes on 100 Posts
Originally Posted by Stribeck
From the inside view, it can also clearly be seen that the bottom part of the aft hinge is intact and attached securely. The spring has been released as lateott pointed out in post 497, but I would argue that the locking pin is still in place, and the problem is that the bracket itself (which holds the locking pin) has come loose.
If by "locking pin" you mean one or more of the four bolts, the NTSB have specifically stated that none of the four have been found.
DaveReidUK is offline  
Old 9th Jan 2024, 17:51
  #563 (permalink)  
 
Join Date: Nov 2021
Location: Wisconsin
Posts: 2
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by EXDAC
I had considered a scenario in which improper installation of the upper locking bolts could cause fracture of the guides. I resisted posting until now.

Let's assume there is no spacer coaxial with the locking bolt. These locking bolts just need to be "snug" to perform intended function. What if the normal "book" torque was used on the locking bolts nuts when/if they were fitted? I suspect this would squeeze the guide channel subjecting it to loads it was not designed to withstand.
The bolt may have a shoulder that only allows compression to a certain distance.
schwarz633 is offline  
Old 9th Jan 2024, 18:12
  #564 (permalink)  
Psychophysiological entity
 
Join Date: Jun 2001
Location: Tweet Rob_Benham Famous author. Well, slightly famous.
Age: 84
Posts: 3,272
Received 37 Likes on 18 Posts
the cracked guides were a consequence, rather than a cause,
Dave, that makes sense.

-----------------------------

To me, the use of lock washers has always been an issue even with ordinary engineering. The ones that really bite are probably too destructive for aircraft. There seems to be no cutting edges on the bracket bolt washers.
Loose rivets is online now  
Old 9th Jan 2024, 18:38
  #565 (permalink)  
 
Join Date: May 2011
Location: U.S.
Posts: 84
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by Stribeck;
From the inside view, it can also clearly be seen that the bottom part of the aft hinge is intact and attached securely. The spring has been released as lateott pointed out in post 497, but I would argue that the locking pin is still in place, and the problem is that the bracket itself (which holds the locking pin) has come loose.
Originally Posted by DaveReidUK
If by "locking pin" you mean one or more of the four bolts, the NTSB have specifically stated that none of the four have been found.
I will add that I don't see how the spring can be extended without sliding the hinge collar (bracket) upwards along the spring shaft. If the retention bolt passes completely through both sides of the collar (bracket) and the shaft, there is no way the collar is moving along the shaft with an intact bolt in place. The bolt retains the collar, and the collar retains the spring.
lateott is offline  
Old 9th Jan 2024, 18:41
  #566 (permalink)  
 
Join Date: Oct 2002
Location: London UK
Posts: 7,678
Likes: 0
Received 43 Likes on 23 Posts
Originally Posted by DaveReidUK
It very much looks as if the distance the door plug needs to lift to clear the stops is less than the distance needed to disengage the rollers from the guides. That wouldn't be a problem in the hangar, but in the air (assuming no bolts fitted) the door would depart as soon as the stops were cleared and while the rollers were still engaged in the guides.

No prizes for guessing what would almost certainly happen to the guides in that scenario,
I'm way out of depth in the detailed mechanical discussion going on here, but it does appear that there's going to need to be a modification, which surely will mean design, testing, approval, manufacture, installation, etc before the type is allowed back in the air. Which is yet another disaster for the Max programme.

What are the chances, while all this is going on, of replacing short/medium term the "plugs" with a proper, already certified door at this position, like the high density users who are carrying on unrestricted, and doing without a few seats in the interim.
WHBM is online now  
Old 9th Jan 2024, 18:44
  #567 (permalink)  
 
Join Date: Mar 2007
Location: In my head
Posts: 694
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by Loose rivets
It's over exposed, but the photo with Bob and Jennifer Homendy shows the one of the guides, and it looks damaged. Not sure.
I have reduced the exposure inexpertly using Photoshop Express, and rotated and cropped the image to just the plug, but indeed the RHS roller pin tracking guide looks to me somewhat different to the shape of the undamaged tracking guide example we were shown earlier. The recovered plug seems to be missing any indication of the castellated nut on the outside of the guide, maybe part of the locking bolt is visible? But on the left side, is that the lock bolt and castellated nut sticking up - if so having lost the surrounding meat of the tracking guide on the left of the door? Hard to make firm judgements at these resolutions of either side.



Also can we perhaps just make out apparent dissimilarities in shape between Left and Right Hand Side tracking guides in the "plug in the bushes" pic (my yellow arrows)?


And what exactly are we looking at in Mudman's first three photos - are those bolts protruding out of the fuselage in his marked positions 1 & 2 under NTSB's plastic?? Can't be - nothing protudes below the outside of a closed plug, does it, or even below a part open one ... must be another trick of the light ...

And finally, I am with Mudman on his astounding last pic of the hinge on an inspected United aircraft - what design feature stops the hinge collar securing bolts from coming loose?

S&T

slip and turn is offline  
Old 9th Jan 2024, 18:46
  #568 (permalink)  
Moderator
 
Join Date: Aug 2006
Location: Ontario, Canada
Age: 63
Posts: 5,635
Received 64 Likes on 45 Posts
The metal casing really isn't very thick and the safety bolt hole takes away more of the substance to the guide. Getting thumped by the roller pin on the upstroke* might just start the casting cracking.
Though I am not familiar with this specific design feature of the B 737, in general, it is unlikely that any of the parts involved here are castings. Castings are penalized with a "casting factor" by regulation (FAR 25.621), which means that compared to "wrought alloy" [machined from solid] the part would be much thicker and heavier, and it is poor design practice to use a cast part where bending of the part in normal service is possible (clamp up by overtorqued bolt). The guide fitting shown in post #557 is most likely a machined from solid part, which is more likely to bend then crack at the first application of an excessive load.

Though Boeing may prescribe a more specific procedure, in general, AC43.13-1B, 7-40 describes how to torque castle nuts, which may include adding/changing washers if the specified torque cannot be reached and align a hole in the bolt for the cotter pin. Overtorquing (to align the hole in the bolt) is stated as not acceptable

Though less ideal, the cotter pin placement shown in the photo in post #557 does comply with the maintenance standards of AC43.13, it's just non ideal, as it is slightly more likely to snag the next mechanic's skin when he/she is working in that area - but it's otherwise safe and compliant (unless Boeing says otherwise). I like the fact that the presence of the nut and cotter pin is easily seen (with the sidewall panel removed), as opposed to being bolt head out, and the presence of the nut and cotter pin concealed by the guide fitting.

It appears that for the door/panel to move out of position, it would have to move downward in the guide fitting track first, which obviously, the installed bolts are there to prevent, when it is not intended that the door/panel be operable. So, I'm sure that the presence/absence of the bolts shown in post #557, and condition of the guide fittings will be major factors in the investigations!
Pilot DAR is offline  
Old 9th Jan 2024, 18:47
  #569 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 15,848
Received 214 Likes on 100 Posts
Originally Posted by lateott
I will add that I don't see how the spring can be extended without sliding the hinge collar (bracket) upwards along the spring shaft. If the retention bolt passes completely through both sides of the collar (bracket) and the shaft, there is no way the collar is moving along the shaft with an intact bolt in place. The bolt retains the collar, and the collar retains the spring.
An admirably succinct description of how the lower lock bolts work.

Assuming they are fitted, that is ...
DaveReidUK is offline  
Old 9th Jan 2024, 18:49
  #570 (permalink)  
 
Join Date: May 2009
Location: sfo
Age: 71
Posts: 309
Likes: 0
Received 0 Likes on 0 Posts
"What are the chances, while all this is going on, of replacing short/medium term the "plugs" with a proper, already certified door at this position, like the high density users who are carrying on unrestricted, and doing without a few seats in the interim."

Not sure how many certified, ready-to-go doors are laying around at this moment. My best guess, with all the just-in-time procedures in place these days, would be less than 10. Gonna need about 350.

Last edited by sb_sfo; 9th Jan 2024 at 18:52. Reason: to add from WHBM's post for clarity
sb_sfo is offline  
Old 9th Jan 2024, 18:55
  #571 (permalink)  
 
Join Date: Nov 2010
Location: Canada
Posts: 133
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by WHBM
I'm way out of depth in the detailed mechanical discussion going on here, but it does appear that there's going to need to be a modification, which surely will mean design, testing, approval, manufacture, installation, etc before the type is allowed back in the air. Which is yet another disaster for the Max programme.

What are the chances, while all this is going on, of replacing short/medium term the "plugs" with a proper, already certified door at this position, like the high density users who are carrying on unrestricted, and doing without a few seats in the interim.
I think the resolution will be simply making sure the plug is installed correctly with the correct number of bolts. There is no design failure that needs to be fixed. Especially if it is confirmed to be the same design on the -900 NG series.
MLHeliwrench is offline  
Old 9th Jan 2024, 19:13
  #572 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 15,848
Received 214 Likes on 100 Posts
Originally Posted by Pilot DAR
It appears that for the door/panel to move out of position, it would have to move downward in the guide fitting track first, which obviously, the installed bolts are there to prevent, when it is not intended that the door/panel be operable.
No. I fear you are misinterpreting the photos and diagram of the roller and guide.

The door can't "move downward in the guide fitting track" because the track is fixed to the door, and they can't move relative to each other.

The door moves relative to the roller (the latter being attached to the door surround). But in the closed position, the roller is nestling high up inside the closed end of the guide on the door, so there's no way the roller can go any higher (i.e. the door go lower).

While it may be more intuitive to expect the roller to be on the door, and the guide on the door surround, it's the other way round in practice:




Diagram thanks to Chris Brady

Last edited by DaveReidUK; 9th Jan 2024 at 19:55. Reason: added diagram
DaveReidUK is offline  
Old 9th Jan 2024, 19:18
  #573 (permalink)  
 
Join Date: May 2011
Location: U.S.
Posts: 84
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by slip and turn
And what exactly are we looking at in Mudman's first three photos - are those bolts protruding out of the fuselage in his marked positions 1 & 2 under NTSB's plastic?? Can't be - nothing protudes below the outside of a closed plug, does it, or even below a part open one ... must be another trick of the light ...

And finally, I am with Mudman on his astounding last pic of the hinge on an inspected United aircraft - what design feature stops the hinge collar securing bolts from coming loose?

S&T
In Mudman's photos from NTSB (thanks to him by the way for discovering they had such resolution!), you see the ends of the folded-outward hinge shafts along with their bolts and washers. This is as if you were looking from the top down at the hinge/bracket assembly in an installed door plug. Position 2 has the hinge guide fitting (collar/bracket) with the hexagonal nuts at the end, Position 1 only has the shaft with its washer and hexagonal nuts at the end.





Last edited by lateott; 9th Jan 2024 at 19:34. Reason: Typo
lateott is offline  
Old 9th Jan 2024, 19:26
  #574 (permalink)  
 
Join Date: May 2011
Location: U.S.
Posts: 84
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by WHBM
I'm way out of depth in the detailed mechanical discussion going on here, but it does appear that there's going to need to be a modification, which surely will mean design, testing, approval, manufacture, installation, etc before the type is allowed back in the air. Which is yet another disaster for the Max programme.

What are the chances, while all this is going on, of replacing short/medium term the "plugs" with a proper, already certified door at this position, like the high density users who are carrying on unrestricted, and doing without a few seats in the interim.
I would say almost zero chance. The modifications would be extensive, including electronics and hardware. Also the regulations may require an additional flight attendant perched at the new door(s).
lateott is offline  
Old 9th Jan 2024, 19:53
  #575 (permalink)  
 
Join Date: Apr 2019
Location: Sweden
Posts: 13
Likes: 0
Received 0 Likes on 0 Posts
I was wrong about the locking pin (Vertical Movement Arrestor Bolt) still being in place, after seeing better images I agree that the it appears gone and the Hinge Guide Fitting is stopped by the end plate of the Hinge Shaft, thanks to DaveReidUK and lateott for clarifying this (and also good picture with terminology).

However, my main point is the important fact that the Hinge Guide Fitting (HGF) is not attached to the door frame, and that it appears undamaged at the attachments. Furthermore, this exact problem was found on one of the inspected United aircraft.
See sketch below to illustrate this point. If the HGF is loose from the door frame, that will allow vertical movement of the door regardless of whether all the other bolts are in place or not.


Stribeck is offline  
Old 9th Jan 2024, 19:57
  #576 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 15,848
Received 214 Likes on 100 Posts
Originally Posted by lateott
I would say almost zero chance. The modifications would be extensive, including electronics and hardware. Also the regulations may require an additional flight attendant perched at the new door(s).
Not to mention the loss of at least two revenue seats as well.
DaveReidUK is offline  
Old 9th Jan 2024, 20:06
  #577 (permalink)  
 
Join Date: Mar 2007
Location: In my head
Posts: 694
Likes: 0
Received 0 Likes on 0 Posts
Originally Posted by lateott
Originally Posted by me
And what exactly are we looking at in Mudman's first three photos - are those bolts protruding out of the fuselage in his marked positions 1 & 2 under NTSB's plastic??
In Mudman's photos from NTSB (thanks to him by the way for discovering they had such resolution!), you see the ends of the folded-outward hinge shafts along with their bolts and washers. This is as if you were looking from the top down at the hinge/bracket assembly in an installed door plug. Position 2 has the hinge guide fitting (collar/bracket) with the hexagonal nuts at the end, Position 1 only has the shaft with its washer and hexagonal nuts at the end.
Thanks lateott for clearing that up for me! Had my eyes tested today to start to prepare to retain my drivers licence - never mind the 20/20 I still had 15 years ago for Class I !
slip and turn is offline  
Old 9th Jan 2024, 20:39
  #578 (permalink)  
 
Join Date: Jan 2014
Location: London
Posts: 3
Likes: 0
Received 0 Likes on 0 Posts
Whistleblower Interview

Interesting CNN interview with Boeing "whistleblower" Ed Pierson, now Executive Director of The Foundation for Aviation Safety.
Acme99 is offline  
Old 9th Jan 2024, 20:47
  #579 (permalink)  
 
Join Date: Dec 2014
Location: Somerset
Posts: 40
Likes: 0
Received 0 Likes on 0 Posts
Hinge Assembly

Originally Posted by lateott
In Mudman's photos from NTSB (thanks to him by the way for discovering they had such resolution!), you see the ends of the folded-outward hinge shafts along with their bolts and washers. This is as if you were looking from the top down at the hinge/bracket assembly in an installed door plug. Position 2 has the hinge guide fitting (collar/bracket) with the hexagonal nuts at the end, Position 1 only has the shaft with its washer and hexagonal nuts at the end.




Looking at Mudman’s photos it can be seen that the rear hinge guide is at top of its travel with the lift assist spring fully extended. The face of the hinge guide which is at the top photo is the face which we can see on the previous United loose bolts photo. For my money there is no sign of the vertical movement arrestor / stop bolt which should be visible given the shape and colour of the castellated nut which should be there. If the bolt was not installed then that hinge assembly would have been exerting an asymmetrical upward force on the door. If the equivalent bolt was missing from the forward hinge then both would have been exerting an upward force.
Alternative views from anyone with better eyesight or imagination welcome.

Last edited by Europa01; 9th Jan 2024 at 21:05.
Europa01 is offline  
Old 9th Jan 2024, 20:54
  #580 (permalink)  
 
Join Date: Jan 2017
Location: UK
Posts: 65
Received 2 Likes on 1 Post
Originally Posted by DaveReidUK
I can't recall ever torquing a castle nut - Sod's Law dictates that when you reach the specified torque, none of the slots on the nut will line up with the hole in the bolt for the split pin, so you would then have to tighten the nut past the recommended torque (not a good idea) or back it off (in which case, why bother with the torque wrench at all?).
One of my university tutors worked on the Comet 4 and Trident. As a young engineer he discovered how de Havilland were torquing Comet wing attachment bolts. These could not be reached with a torque wrench that could apply torque directly on the bolt axis. Instead they attached one end of an open ended spanner to the torque wrench with the other end engaging the head of the blind bolt.

It was fairly easy to show that depending on how you held the torque wrench/spanner combination you could get wildly different applied torques to the bolt. Even no torque at all. This discovery caused a certain amount of consternation in de Havilland production.

Another technique I have seen (from Deutz diesel cylinder head bolts if I remember) is to torque the bolts to a certain (small) torque then apply a certain number of turns. That probably makes it easier to line up locking fittings.

(SLF engineer)
paulross 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.