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Alaska Airlines 737-900 MAX loses a door in-flight out of PDX

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Alaska Airlines 737-900 MAX loses a door in-flight out of PDX

Old 22nd Feb 2024, 15:40
  #1841 (permalink)  
 
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"Boeing ousts 737 MAX chief in shake-up as blowout fallout mounts"

Boeing sacks MAX VP/general manager of Renton, replacing an engineer with a business degrees holding head of Boeing aircraft deliveries....

In addition, appoints "quality" executive at SVP level (up from VP).

https://www.seattletimes.com/busines...adership-team/

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Old 22nd Feb 2024, 17:00
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AMM

Originally Posted by DaveReidUK
I'm reminded that Chris Brady paraphrased the AMM description of the opening sequence in one of his videos. He subsequently acknowledged that it was incorrect:



I don't think his influence extends to getting Boeing to correct the AMM.
Given that this section of the AMM has been in circulation for a significant length of time you have to wonder why its errors have not been identified and corrected as the errors would have been immediately apparent to anyone attempting to use it. Possibly thereís no route to from anyoneís maintenance to Boeing to flag AMM errors identified in the field. Possibly there is a route but Boeing donít play. Possibly none of the maintenance carried out to date used the AMM.
The probabilistic safety assessment will make claims on competent maintenance but competent maintenance requires accurate and controlled maintenance information so none of the above possibilities are attractive.
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Old 26th Feb 2024, 07:51
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From Leeham news. Freewall article.

Ultimately, Congress is responsible for mess at FAA, Boeing, Spirit, et al

https://leehamnews.com/2024/02/26/ul...-spirit-et-al/
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Old 27th Feb 2024, 04:36
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Would I be out of line to suggest this might be the result of modern neo-liberal economic theory, leading to less involvement by govt & industries regulating themselves. Hmmm, I wonder.
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Old 27th Feb 2024, 06:08
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FAA has issued its expert panel report into Boing's management

https://www.faa.gov/newsroom/Sec103_...port_Final.pdf
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Old 27th Feb 2024, 07:48
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That report - if they don't name management employees who are specifically responsible to make the changes, this is not an effective report. This is the sort of report that creates endless bulleted PowerPoint presentations to tell employees they are all now empowered to do the right thing, while all the same conditions continue to exist that got the facilities to the place they are now.

Was it oversight that Spirit was not a participant? This was apparently started long before the door left, but much of the chaos on the floor at Boeing originates in Spirit facilities. American Airlines was there, but not Southwest. Odd.

Anyone else recall being exposed to Value Management as the panacea? Not Earned Value Management, the earlier one. How about 6-Sigma and the neighboring effort that led to people using tape to mark the carpet for exactly where their trashcan was supposed to be and their desk drawer where their stapler was supposed to be? 5S. And my favorite - CMMI.

See https://en.wikipedia.org/wiki/Management_fad#Examples

If I were to make a recommendation I would suggest eliminating PowerPoint from every company computer and insist on written reports that are to be read by participants prior to meetings. Anyone not having read the report(s) would be subject to a negative impression on their performance review and anyone writing garbage reports would see the same. Print them out on actual paper that the meeting members have to turn by hand and use hands to make notes on the papers. Those notes can be collected and stored electronically by scanning if anyone cares enough. But make the participants actually participate instead of the snooze-fest that PowerPoint almost universally generates with data flowing over people like water off a duck.

Best meeting ever - it was for a radar system and the concept was still damp on the page. EMI engineer had nothing particular to work with, so he went to a grocery store and bought items that were about the size as laid out in the concept. I still recall him raising up a salami to represent a linear actuator we planned to use. I recall no other PowerPoint meetings as clearly as that one, but I recall how the EMI woven shielding was to be attached to form a Faraday cage for all the components - even the canned corn standing in for the main rotary actuator - after 30 years.

Also - put the guy who heads the aircraft program in an office in the middle of the factory floor so that all the functions he needs to get the job done right have to walk through the plant to get to him and see what effect their job has on the product. Give them helmets and safety glasses and involve them.
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Old 27th Feb 2024, 08:01
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Originally Posted by MechEngr
That report - if they don't name management employees who are specifically responsible to make the changes, this is not an effective report. This is the sort of report that creates endless bulleted PowerPoint presentations to tell employees they are all now empowered to do the right thing, while all the same conditions continue to exist that got the facilities to the place they are now.

Was it oversight that Spirit was not a participant? This was apparently started long before the door left, but much of the chaos on the floor at Boeing originates in Spirit facilities. American Airlines was there, but not Southwest. Odd.

Anyone else recall being exposed to Value Management as the panacea? Not Earned Value Management, the earlier one. How about 6-Sigma and the neighboring effort that led to people using tape to mark the carpet for exactly where their trashcan was supposed to be and their desk drawer where their stapler was supposed to be? 5S. And my favorite - CMMI.

See https://en.wikipedia.org/wiki/Management_fad#Examples

If I were to make a recommendation I would suggest eliminating PowerPoint from every company computer and insist on written reports that are to be read by participants prior to meetings. Anyone not having read the report(s) would be subject to a negative impression on their performance review and anyone writing garbage reports would see the same. Print them out on actual paper that the meeting members have to turn by hand and use hands to make notes on the papers. Those notes can be collected and stored electronically by scanning if anyone cares enough. But make the participants actually participate instead of the snooze-fest that PowerPoint almost universally generates with data flowing over people like water off a duck.

Best meeting ever - it was for a radar system and the concept was still damp on the page. EMI engineer had nothing particular to work with, so he went to a grocery store and bought items that were about the size as laid out in the concept. I still recall him raising up a salami to represent a linear actuator we planned to use. I recall no other PowerPoint meetings as clearly as that one, but I recall how the EMI woven shielding was to be attached to form a Faraday cage for all the components - even the canned corn standing in for the main rotary actuator - after 30 years.

Also - put the guy who heads the aircraft program in an office in the middle of the factory floor so that all the functions he needs to get the job done right have to walk through the plant to get to him and see what effect their job has on the product. Give them helmets and safety glasses and involve them.
Agree 100%, especially on PowerPoint. I had not seen that Wikipedia page (it's brilliant) before. It should be stuck on the back of the toilet door in every board room.
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Old 27th Feb 2024, 09:04
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With reference to MechEngr's Wiki link, ISO 9000 is no fad. In fact, if the FAA and Boeing had adopted the ISO 9000 series, I doubt if we would be in this mess now.
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Old 27th Feb 2024, 10:47
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Hah! They forgot the Management System used by my last company before i retired - BBB - BulSh-t Baffles Brains.
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Old 27th Feb 2024, 11:49
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Smoking Guns

Originally Posted by shinz0
Would I be out of line to suggest this might be the result of modern neo-liberal economic theory, leading to less involvement by govt & industries regulating themselves. Hmmm, I wonder.
It might be more related to the fact that Cannabis is legal in that state...!
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Old 27th Feb 2024, 13:46
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Originally Posted by MarineEngineer
With reference to MechEngr's Wiki link, ISO 9000 is no fad. In fact, if the FAA and Boeing had adopted the ISO 9000 series, I doubt if we would be in this mess now.
At my company the response to getting ISO certification (say what you do, do what you say) saw our QA head destroy 90% of the QA documentation that governed the factory. Can't be found to be not following what no longer exists. It had been great. Put on the drawing to follow procedure XYZ and there is a procedure XYZ to follow. Not anymore. They literally had a bonfire/barbecue to celebrate not having to maintain that series of documents.ISO 9000 can be good, but as long as the company is being judged by the rules they themselves create, the opportunity to certify anything meant, in our case, certifying thin air.
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Old 27th Feb 2024, 13:57
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Originally Posted by MechEngr
At my company the response to getting ISO certification (say what you do, do what you say) saw our QA head destroy 90% of the QA documentation that governed the factory. Can't be found to be not following what no longer exists. It had been great. Put on the drawing to follow procedure XYZ and there is a procedure XYZ to follow. Not anymore. They literally had a bonfire/barbecue to celebrate not having to maintain that series of documents.ISO 9000 can be good, but as long as the company is being judged by the rules they themselves create, the opportunity to certify anything meant, in our case, certifying thin air.
Doesn't ISO 9000 require a company to have a quality management system that meets certain requirements and then a system to continuously review and improve them? I was a senior manager but I did not have to write any policies, just follow them. We had internal audits and external audits and these were to check that policies were followed and deviations explained and corrected. The heaviest audits were for head office as they should be ie, to make sure that head office was ensuring that all the other sections of the company were following written procedures. This is something Boeing was evidently not doing. Nor was the FAA.
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Old 27th Feb 2024, 16:43
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Originally Posted by MarineEngineer
Doesn't ISO 9000 require a company to have a quality management system that meets certain requirements and then a system to continuously review and improve them? I was a senior manager but I did not have to write any policies, just follow them. We had internal audits and external audits and these were to check that policies were followed and deviations explained and corrected. The heaviest audits were for head office as they should be ie, to make sure that head office was ensuring that all the other sections of the company were following written procedures. This is something Boeing was evidently not doing. Nor was the FAA.
ISO 9000 - in search of 9000 ways to certify/document a good process without actually having a good process.
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Old 27th Feb 2024, 16:52
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Originally Posted by GlobalNav
ISO 9000 - in search of 9000 ways to certify/document a good process without actually having a good process.
ISO 9000 is a series of Quality Management tools, five, not 9000. And it does require good processes. Is your post just American jingoism?

ISO is international, so please don't accuse me of British jingoism.
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Old 27th Feb 2024, 18:05
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Originally Posted by MarineEngineer
With reference to MechEngr's Wiki link, ISO 9000 is no fad. In fact, if the FAA and Boeing had adopted the ISO 9000 series, I doubt if we would be in this mess now.
Well, Boeing did so ...https://www.boeing.com/sustainability/quality#anchor3
Note: AS9100 is ISO 9001 "adapted" to aerospace.
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Old 27th Feb 2024, 18:59
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ISO 9000 did not require a good process. It required the company to follow the processes it has, good or not. Perhaps there has been an upgrade, but we still had workers with angle grinders on the final assembly line getting parts to fit that, were they compliant with the drawing, would have always fit and we had that ISO 9000 sticker. I forget the external company type that is supposed to "facilitate" ISO 9000 certification, but I don't recall any coworkers mentioning ever talking to them, just talking with the QA people who tossed the Standard Procedures books into a burn barrel and probably the company president.

About the same time my company honchos fired all the drawing check group. Then complained that the drawings were now inconsistent enough that our customers noticed and engineers should get together after hours to coordinate drawing practices, like the ones that were in, yes, the Standard Procedures, which the drawing check group was very familiar with and very economical in making corrections.

I'm pretty sure Global Nav was making a humorous observation rather than a specific implementation requirement.

How about TQM - Total Quality Management, tenderly referred to as Time to Quit and Move?

I also recall as part of 5S they took away all the typewriters from all the secretaries (having renamed the position to office assistant) which was great as many of the processes used the no-carbon required multipart forms with the different colors for different groups. After all, there are word processors and laser printers and no doubt one could feed a 5 part carbonless form into the manual feeder, right? Dumb, dumb, dumb.

Every one of these many efforts was intended to repair all problems within companies. So why isn't there just one method?

ISO 9000 came out because having a badge on the front door was a sign of something good, a lot like the Better Business Bureau sticker is; it signifies the company hasn't gotten kicked out while also being a source of income for the certifying agency.

It's clear that Boeing production needs an overhaul, one which will be unpleasant for a portion of the workforce. Not that the new system will be worse to use, but it will be different.

I talked with a guy whose job was re-vamping production at another company and he found a shop foreman seemed to be the center of trouble. Some investigation showed the foreman kept his own ledger of factory activity which did not match what was in the main management system. As a result there was much conflict. As I recall the foreman wasn't malicious, nor did he have difficulty entering information into the main management system - he just didn't trust it as much as his own notes. Unfortunately for the factory, his own notes would become out-of-sync with the production schedule. The final cure was the production consultant coming in after hours, permission of management of course, with a bolt cutter to remove the lock from this foreman's desk and taking all the ledgers. The foreman capitulated, the main management system was now fully updated by the foreman and vice versa and life improved for everyone. But doing that isn't in the ISO 9000, the TQM, the Value Analysis, or any other handbook.

Boeing doesn't seem to have a core procedure problem - there are plenty of procedures. It has a people problem and they need to bring in outsiders who are good at identifying and unknotting people problems. Once those are fixed the production procedures will be easy. If the people problems remain knotted, it won't matter what "SMSing" they use as the latest bandaid.
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Old 27th Feb 2024, 20:06
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I canít or wouldnít comment on how iso9001 works or should work in a large avation company but I own a (very) small engineering business in the uk.

For me the certificate isnít worth the paper it is written in. For starters, if you want iso9001 you can pay a man to write you lots of stuff with a lot of folders that can get you a certificate with one visit that can last upto 5 years. These are by non UKAS accredited companies and arenít UKAS approved certificates.

we chose to go the other way and use a UKAS certified body for ours. So the cert last 3 years with surveillance visits every year. Or they did. Since Covid they have got wise and now charge additional cost for in person visits. Otherwise the default (for someone like us) is remote audits over Microsoft teams. So when they ask to see documents you can show them whichever ones you choose. They donít have free roam of the place like before.

the last update on ISO9001 was I believe to take a lot of the documentation out of the system. I know we did. Policies for many things and procedures went in the bin. We just have to document we meet the standard. For example we no longer have an audit procedure, we just need to prove we do the audits (or have some paper that shows we have done them). The worst bit is that a lot of companyís want us to be ISO9001 to be able to supply but donít care if our cert is UKAS accredited or not.

I previously worked in automotive for a large tier 1/2 supplier to the OEMís in the uk and we worked to TS16949. That wasnít much better. The auditors would walk around and you could pretty much steer them to any process you liked. If you wanted to hide something, you could.

Personally in my (limited) non aviation experience these are just a fancy badge for the letterheads and a cash cow for the companies auditing. Sadly I donít believe it was always like this.
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Old 27th Feb 2024, 22:27
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Originally Posted by MarineEngineer
ISO 9000 is a series of Quality Management tools, five, not 9000. And it does require good processes. Is your post just American jingoism?

ISO is international, so please don't accuse me of British jingoism.
I wasn’t accusing anybody of anything, or casting any personal comments at all. Please forgive me, if I was taken that way.
Large organizations I’ve been close to made a lot of their ISO 9000 certification efforts and “achievements”, as if it proved anything. At most these organization poured time and money into such things with no substantial benefit except being able to make the claim. I have nothing against the intent nor the potential benefits of truly following ISO 9000 processes, either. But, in truth, it was mostly an expensive exercise in hypocrisy, at least in the large and very prominent organizations and companies I was very close to, some of which are regularly at the center of our threads.
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Old 28th Feb 2024, 06:37
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Originally Posted by scifi
It might be more related to the fact that Cannabis is legal in that state...!
I doubt it started with that but could well believe it was a factor in the end game.
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Old 28th Feb 2024, 22:10
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The confusion about up or down movement of the door-plug could be in where the roller and where the guide is mounted. The roller is on the door frame and the guide on the door-plug and since the guide is open at the bottom the door-plug must move up to clear the frame mounted roller. Hence in closed position there is a small gap (with a gasket) at the top between the door frame and door-plug to allow this upwards movement. So the lift-assist springs would apply a force that would open the door-plug and not one that would keep it in place. This also have the ressult that all 4 (missing) bolts (including the ones on the spring guides) stops the door-plug from moving upwards.
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