Alaska Airlines 737-900 MAX loses a door in-flight out of PDX
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I can't remember coming across or hearing about a fastener fault that could be corrected with paint.
First thoughts when reading some of the posts …
just from my own aerospace experience, no more no less… one will have to translate these to the Boeing specific situation and terminology … sorry if this post is too long …
#1287 (permalink)eppy 24th Jan 2024 01:09
“…Throughout this thread there have been numerous terminology debates about Door vs Plug that many people just rolled their eyes to and ignored as being pedantic. Turns out it may be the one of the largest holes in the Swiss cheese…”
My experience - The earlier you are involved in the integral design and manufacturing process, and/or the more experienced you get, the more important terminology. To get a feel for it, increase your impression of importance by one order of magnitude.
Example: Investigating the issues sketched by posters about a plug originally destined for another line number, and the statements by throw*704AL, will encounter the definition of what it is, and a categorisation. Can you exchange one plug for the other plug type, or is it an exchange plus making the interface to fit type, or is it the previous one but requiring “tooling””, etcetera…
The one requiring “”tooling”” in this specific case might require that Spirit shall do the work (for multiple reasons)… the definition will also include whether the plug is a serial numbered item (which activates other processes) or ‘just a piece of structure’ …
If Spirit shall do the work, this means that you get them inside your final assembly line process … if the work is not okay, or backlog work (by fup or ramping up production). Properly organising this will take senior experienced manufacturing engineering and tool engineering and production engineering and others’ involvement to design a process that QA/QC can monitor and report on. Here you meet IT systems and read and/or write issues as indicated by throw*704AL.
This is why I stated the label “quality escape” in other places would be considered ‘non-sensical’, and pushing cause too far downstream.
The Swiss cheese model is a gross simplification.
#1312 (permalink)SLF3 24Jan2024 10:12
“The issue for Boeing, FAA and NTSB is that this system failure is so fundamental to Boeing (and its subs) QA/QC “
My experience - This is the consequence of the loss of safety culture. Wise to assume (as posted before) it takes 10 years to get back to basics, that is, from the moment (untainted) top management puts itself behind making the change.
#1320 (permalink)xetroV 24Jan2024 14:02
“… loose and excess parts found on an aircraft factory floor…”
My experience - Once any part hits the floor on an “OEM commercial aircraft newbuild final assembly line” you SHALL not use them anymore. Follow up (dispose, replace, paperwork (or not), etc) will depend on the definition of type and specifics.
#1330 (permalink)SRMman 24Jan2024 16:33
“From Flight Global: Boeing is to pause…Boeing Commercial Airplanes chief Stan Deal says the sessions will allow workers involved in the 737 production to “pause, evaluate what we’re doing, how we’re doing it and make recommendations for improvement”. Acc to internal employee communications, Boeing states: “During the stand downs, teammates will participate in hands-on learning, reflection and collaboration to identify where quality and compliance can be improved and create actionable plans that will be tracked to closure.” …”
My experience - people responsible as well as involved in such statements permanently disqualify themselves from leadership positions in “OEM commercial aircraft newbuild operations“ in the minds of experienced professionals who DO understand safety culture. This is one of the reasons why it takes ‘10 years’.
#1287 (permalink)eppy 24th Jan 2024 01:09
“…Throughout this thread there have been numerous terminology debates about Door vs Plug that many people just rolled their eyes to and ignored as being pedantic. Turns out it may be the one of the largest holes in the Swiss cheese…”
My experience - The earlier you are involved in the integral design and manufacturing process, and/or the more experienced you get, the more important terminology. To get a feel for it, increase your impression of importance by one order of magnitude.
Example: Investigating the issues sketched by posters about a plug originally destined for another line number, and the statements by throw*704AL, will encounter the definition of what it is, and a categorisation. Can you exchange one plug for the other plug type, or is it an exchange plus making the interface to fit type, or is it the previous one but requiring “tooling””, etcetera…
The one requiring “”tooling”” in this specific case might require that Spirit shall do the work (for multiple reasons)… the definition will also include whether the plug is a serial numbered item (which activates other processes) or ‘just a piece of structure’ …
If Spirit shall do the work, this means that you get them inside your final assembly line process … if the work is not okay, or backlog work (by fup or ramping up production). Properly organising this will take senior experienced manufacturing engineering and tool engineering and production engineering and others’ involvement to design a process that QA/QC can monitor and report on. Here you meet IT systems and read and/or write issues as indicated by throw*704AL.
This is why I stated the label “quality escape” in other places would be considered ‘non-sensical’, and pushing cause too far downstream.
The Swiss cheese model is a gross simplification.
#1312 (permalink)SLF3 24Jan2024 10:12
“The issue for Boeing, FAA and NTSB is that this system failure is so fundamental to Boeing (and its subs) QA/QC “
My experience - This is the consequence of the loss of safety culture. Wise to assume (as posted before) it takes 10 years to get back to basics, that is, from the moment (untainted) top management puts itself behind making the change.
#1320 (permalink)xetroV 24Jan2024 14:02
“… loose and excess parts found on an aircraft factory floor…”
My experience - Once any part hits the floor on an “OEM commercial aircraft newbuild final assembly line” you SHALL not use them anymore. Follow up (dispose, replace, paperwork (or not), etc) will depend on the definition of type and specifics.
#1330 (permalink)SRMman 24Jan2024 16:33
“From Flight Global: Boeing is to pause…Boeing Commercial Airplanes chief Stan Deal says the sessions will allow workers involved in the 737 production to “pause, evaluate what we’re doing, how we’re doing it and make recommendations for improvement”. Acc to internal employee communications, Boeing states: “During the stand downs, teammates will participate in hands-on learning, reflection and collaboration to identify where quality and compliance can be improved and create actionable plans that will be tracked to closure.” …”
My experience - people responsible as well as involved in such statements permanently disqualify themselves from leadership positions in “OEM commercial aircraft newbuild operations“ in the minds of experienced professionals who DO understand safety culture. This is one of the reasons why it takes ‘10 years’.
From Seattle Times.
…“Let me be clear: This won’t be back to business as usual for Boeing,” FAA Administrator Mike Whitaker said in a statement. “We will not agree to any request from Boeing for an expansion in production or approve additional production lines for the 737 MAX until we are satisfied that the quality control issues uncovered during this process are resolved.”…
https://www.seattletimes.com/busines...ction-regimen/
FAA restricts Boeing MAX rate ramp up and lays out extensive inspection regimen.
…“Let me be clear: This won’t be back to business as usual for Boeing,” FAA Administrator Mike Whitaker said in a statement. “We will not agree to any request from Boeing for an expansion in production or approve additional production lines for the 737 MAX until we are satisfied that the quality control issues uncovered during this process are resolved.”…
https://www.seattletimes.com/busines...ction-regimen/
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FAA halts Boeing 737 Max production expansion, but clears path to return Max 9 to ser
FAA halts Boeing 737 Max production expansion, but clears path to return Max 9 to service (msn.com)
"In the days ahead, our teams will continue to proceed in a way that is thorough and puts safety and compliance first," Enqvist said in the internal message.
FAA halts Boeing 737 Max production expansion, but clears path to return Max 9 to service
"In the days ahead, our teams will continue to proceed in a way that is thorough and puts safety and compliance first," Enqvist said in the internal message.
Boeing states: “During the stand downs, teammates will participate in ...
When "teammates" can vote to determine how Boeing assembles aircraft, let me know, and I'll prepare my pig for her first solo flight.
According to internal employee communications, the airframer states: “During the stand downs, teammates will participate in hands-on learning, reflection and collaboration to identify where quality and compliance can be improved and create actionable plans that will be tracked to closure.”
Plugs, Doors, Emergency Exits
Nomenclature has been a subject of vigorous debate.
[speculation]
People seeing the plug back in place assumed it had been secured.
Possibly we will eventually see a placard on the plug describing placement and torque of retaining bolts, and transparent windows in the interior trim allowing inspection. [/speculation]
[speculation]
- Doors are regularly opened in service and securely latched shut with a handle.
- Emergency exits are periodically opened for inspection and subsequently latched shut with a handle.
- Plugs require removal of retaining bolts to open for inspection or maintenance and the bolts must be put back in place
People seeing the plug back in place assumed it had been secured.
Possibly we will eventually see a placard on the plug describing placement and torque of retaining bolts, and transparent windows in the interior trim allowing inspection. [/speculation]
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In the meantime, Delta Airlines inspected all of the plugs on their 737-900s and found no faults before the FAA issued their recommendation to inspect them.
Proactive Maintenance Department.
Proactive Maintenance Department.
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I find it interesting that the "Throwaway" whistleblower (or whatever we want call him/her), assuming they are real and actually have insight on what happens on the factory floor, is referring to a "door plug" a few times at the beginning of their lengthy post, but then quickly revert to calling it a "door" for most of the rest of the post. And asserts that the SAT entry makes reference to a "door" which was opened.
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
Nomenclature has been a subject of vigorous debate.
[speculation]
People seeing the plug back in place assumed it had been secured.
Possibly we will eventually see a placard on the plug describing placement and torque of retaining bolts, and transparent windows in the interior trim allowing inspection. [/speculation]
[speculation]
- Doors are regularly opened in service and securely latched shut with a handle.
- Emergency exits are periodically opened for inspection and subsequently latched shut with a handle.
- Plugs require removal of retaining bolts to open for inspection or maintenance and the bolts must be put back in place
People seeing the plug back in place assumed it had been secured.
Possibly we will eventually see a placard on the plug describing placement and torque of retaining bolts, and transparent windows in the interior trim allowing inspection. [/speculation]
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I find it interesting that the "Throwaway" whistleblower (or whatever we want call him/her), assuming they are real and actually have insight on what happens on the factory floor, is referring to a "door plug" a few times at the beginning of their lengthy post, but then quickly revert to calling it a "door" for most of the rest of the post. And asserts that the SAT entry makes reference to a "door" which was opened.
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
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I'll extend that by saying, it is not good practice to have a non-functional removable item, that has to be removed for an inspection every 24 months, which would not be needed if that item wasn't there in the first place.
Don't have that hole in the fuselage in the first place or permanently close it forever.
Don't have that hole in the fuselage in the first place or permanently close it forever.
Last edited by C2H5OH; 25th Jan 2024 at 09:07.
I find it interesting that the "Throwaway" whistleblower (or whatever we want call him/her), assuming they are real and actually have insight on what happens on the factory floor, is referring to a "door plug" a few times at the beginning of their lengthy post, but then quickly revert to calling it a "door" for most of the rest of the post. And asserts that the SAT entry makes reference to a "door" which was opened.
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
If that actually reflects how workers on the factory floor are used to thinking about these door plugs, ie. as "doors" that can be opened rather than panels which can be removed, then the issue goes beyond nomenclature and into conceptualisation. Ie. the nomenclature is just a symptom of the idea which workers have in their heads of what the object is and how it should be dealt with. Worst case scenario would be workers having the approach of "they're all doors, some have bolts, some have not, need to check the paperwork", leaving the door open for an erroneous install of a door plug as a door, simply because "the paperwork didn't say to install the bolts".
Besides ordinary doors and emergency exits you have
- "plug doors" that are both doors (providing ingress & egress) and plugs (fitting tightly into a hole blocking it up) -- which are self-tightening when pressurised.
- "door plugs" which are neither doors nor plugs.
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[SLF] Isn't the terminology even worse than that?
Besides ordinary doors and emergency exits you have
- "plug doors" that are both doors (providing ingress & egress) and plugs (fitting tightly into a hole blocking it up) -- which are self-tightening when pressurised.
- "door plugs" which are neither doors nor plugs.
Besides ordinary doors and emergency exits you have
- "plug doors" that are both doors (providing ingress & egress) and plugs (fitting tightly into a hole blocking it up) -- which are self-tightening when pressurised.
- "door plugs" which are neither doors nor plugs.
So what constutes "closure"? Some measures for improvement of quality and compliance would clearly need to be continuous while ever Boeing are building aircraft, so there is no "closure" in those cases... or is this mainly about public appearance?
Les mots exacts
C2 
Les mots exacts; or ‘saying it like it really isʼ
WORDS MEAN SOMETHING
" When context is lost, words can be dangerous ".
Les mots exacts; or ‘saying it like it really isʼ
WORDS MEAN SOMETHING
" When context is lost, words can be dangerous ".
IMHO you have doors (functional for access) and plugs (non-functional) and you have "plug type" (surface mating, self-sealing & self locking under pressure) and "semi-plug type" (multi-point mating, self sealing but not self locking under pressure) and non-plug type (e.g. latched, pin locked). So in this case a semi-plug type plug.