Boeing at X-Roads?
https://www.regulations.gov/document/FAA-2024-0463-0001
Summary
The FAA proposes to adopt a new airworthiness directive (AD) for certain The Boeing Company Model 737–8, 737–9, and 737–8200 airplanes. This proposed AD was prompted by a report of a non-conforming installation of spoiler wire bundles that led to unintended spoiler motion, including one instance of spoiler hardover. Further investigation identified the potential for a hardover of more than one flight spoiler on the same wing, which can exceed full lateral control capability leading to loss of control of the airplane. This proposed AD would require a one-time inspection of the clearance between the spoiler control wire bundles and the adjacent structure, and applicable on-condition actions. The FAA is proposing this AD to address the unsafe condition on these products.
The FAA proposes to adopt a new airworthiness directive (AD) for certain The Boeing Company Model 737–8, 737–9, and 737–8200 airplanes. This proposed AD was prompted by a report of a non-conforming installation of spoiler wire bundles that led to unintended spoiler motion, including one instance of spoiler hardover. Further investigation identified the potential for a hardover of more than one flight spoiler on the same wing, which can exceed full lateral control capability leading to loss of control of the airplane. This proposed AD would require a one-time inspection of the clearance between the spoiler control wire bundles and the adjacent structure, and applicable on-condition actions. The FAA is proposing this AD to address the unsafe condition on these products.
I can accept that the security camera videos are not retained long term. They are not meant for that.
Regarding the actual work, however, it seems inconceivable that this cannot be readily traced. Who noticed it ? They must have written it up somehow to get it fixed. Who was the job given to ? There can only be a few contenders. Where are the payroll timesheets for those staff ? Has anybody asked them ? It was an oddball work item so must surely be remembered after just a few months. From the laconic answers being given by all up to and including Calhoun, I get no feeling of trying to be helpful and useful at all. I would have expected Boeing to have everything known together on this within hours of identifying that the hatch blew off.
Many years ago, at a small operator, a serious incident of an airliner forced landing led, all of next day, to all work diverted to pulling together every fuel docket, every flight plan, every work order, every part changed, every tech log entry, everything, going back months. And everybody mentioned spoken to. Can Boeing not do that ?
Regarding the actual work, however, it seems inconceivable that this cannot be readily traced. Who noticed it ? They must have written it up somehow to get it fixed. Who was the job given to ? There can only be a few contenders. Where are the payroll timesheets for those staff ? Has anybody asked them ? It was an oddball work item so must surely be remembered after just a few months. From the laconic answers being given by all up to and including Calhoun, I get no feeling of trying to be helpful and useful at all. I would have expected Boeing to have everything known together on this within hours of identifying that the hatch blew off.
Many years ago, at a small operator, a serious incident of an airliner forced landing led, all of next day, to all work diverted to pulling together every fuel docket, every flight plan, every work order, every part changed, every tech log entry, everything, going back months. And everybody mentioned spoken to. Can Boeing not do that ?
I can accept that the security camera videos are not retained long term. They are not meant for that.
Regarding the actual work, however, it seems inconceivable that this cannot be readily traced. Who noticed it ? They must have written it up somehow to get it fixed. Who was the job given to ? There can only be a few contenders. Where are the payroll timesheets for those staff ? Has anybody asked them ? It was an oddball work item so must surely be remembered after just a few months. From the laconic answers being given by all up to and including Calhoun, I get no feeling of trying to be helpful and useful at all. I would have expected Boeing to have everything known together on this within hours of identifying that the hatch blew off.
Many years ago, at a small operator, a serious incident of an airliner forced landing led, all of next day, to all work diverted to pulling together every fuel docket, every flight plan, every work order, every part changed, every tech log entry, everything, going back months. And everybody mentioned spoken to. Can Boeing not do that ?
Regarding the actual work, however, it seems inconceivable that this cannot be readily traced. Who noticed it ? They must have written it up somehow to get it fixed. Who was the job given to ? There can only be a few contenders. Where are the payroll timesheets for those staff ? Has anybody asked them ? It was an oddball work item so must surely be remembered after just a few months. From the laconic answers being given by all up to and including Calhoun, I get no feeling of trying to be helpful and useful at all. I would have expected Boeing to have everything known together on this within hours of identifying that the hatch blew off.
Many years ago, at a small operator, a serious incident of an airliner forced landing led, all of next day, to all work diverted to pulling together every fuel docket, every flight plan, every work order, every part changed, every tech log entry, everything, going back months. And everybody mentioned spoken to. Can Boeing not do that ?
While there may well be co-workers who know (but were not involved), they don't want to be identified as rats (the IAM would likely crucify them) so they aren't talking either.
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The people who did (or didn't, as the case may be) do the door work certainly know they did it, but if there is no paperwork (see my early postulation that they called it a door instead of a door plug to avoid the paperwork), management has no way of positively identifying who those people were. And those involved are running scared and not talking to anyone. At best, they know they'll likely be fired, and since the DOJ has opened a criminal investigation, they could possibly end up in jail.
While there may well be co-workers who know (but were not involved), they don't want to be identified as rats (the IAM would likely crucify them) so they aren't talking either.
While there may well be co-workers who know (but were not involved), they don't want to be identified as rats (the IAM would likely crucify them) so they aren't talking either.
I've read on some other platforms that aviation organizarion heavyweights have criticized the criminal probe of the incident. Though there isn't any basis to dispute the correctness of upholding just culture as a matter of policy, the Deferred Prosecution Agreement (DPA) is a fact, and strongly suggests the need for a criminal probe of the door plug incident. And that is the case even if one believed that no criminal probe of the two MAX crashes should have been conducted (given the seriousness of Boeing's improper actions leading up to the crashes, a criminal probe and the charges addressed by the DPA do appear proper, imho).
Though this SLF attorney has not followed all the assembly and structure details of the door plug as discussed in great detail on the thread about the incident, it does appear that the major facts of what occurred - and did not occur - are known. What's left, relating to identities of individual workers, is mostly if not completely related to internal Company employee and labor relations. Is there more to uncover within the zone of interests just culture is meant to protect?
In this situation, reports that the criminal probe has caused people to "get and stay underground" probably have to be credited. But with the major facts about how the improper door plug work was done already known, and with Boeing's MAX failures and then later problems as a backdrop, it seems concern for just culture in this instance already has been superseded.
Even AD'd ones were only in the mid to high 90% range - still meaningfully less than 100% (doesn't say much for the regulatory processes in a few countries). The airframer or engine manufacturer has no way make an operator incorporate a service bulletin - only the mechanism for that is for the regulators to issue an AD (although an FAA AD technically only applies to US operators, it's standard practice for all the other regulatory agencies to copy the FAA or EASA AD's verbatim.
The number of accidents where an AD was issued with a leisurely timeline for completion, but where a relevant accident occurred before deadline, is considerably greater than zero. FAA gives a lot of deference to industry complaints and every so often the combination of that and an unhurried approach to making required changes winds up destroying airframes and killing people.
Not saying there aren't any, but I sure can't recall any...
The FAA didn't AD the door 'fix' until after that accident.
Allegedly, MacDac lobbied the LA FAA office to not issue an AD and let them take care of it because an AD would 'look bad'. A bad
-up by the feds, but not due to a relaxed compliance timeline.
Allegedly, MacDac lobbied the LA FAA office to not issue an AD and let them take care of it because an AD would 'look bad'. A bad
-up by the feds, but not due to a relaxed compliance timeline.
We often got "CMRs" (Certification Maintenance Requirements) levied during the aircraft cert process for just that reason. CMRs can't be extended, except by the authority that granted the airworthiness certificate, unlike typical maintenance activities which can be extended by local airworthiness types.
Operators absolutely hate CMRs - if an aircraft has a CMR due but isn't at a maintenance facility, it's AOG until they can get a crew out to wherever the aircraft is located to perform the CMR task. Naturally operators try to plan for this and have the aircraft scheduled into an appropriate facility, but things like weather diversions can really play havoc.
Not related - different parts of the FAA are involved in on-going maintenance practices than who determine AD compliance intervals. In fact, the Seattle FAA Office had long had issues with their inability to control 'local' authorities granting extensions to recommended maintenance intervals.
We often got "CMRs" (Certification Maintenance Requirements) levied during the aircraft cert process for just that reason. CMRs can't be extended, except by the authority that granted the airworthiness certificate, unlike typical maintenance activities which can be extended by local airworthiness types.
Operators absolutely hate CMRs - if an aircraft has a CMR due but isn't at a maintenance facility, it's AOG until they can get a crew out to wherever the aircraft is located to perform the CMR task. Naturally operators try to plan for this and have the aircraft scheduled into an appropriate facility, but things like weather diversions can really play havoc.
We often got "CMRs" (Certification Maintenance Requirements) levied during the aircraft cert process for just that reason. CMRs can't be extended, except by the authority that granted the airworthiness certificate, unlike typical maintenance activities which can be extended by local airworthiness types.
Operators absolutely hate CMRs - if an aircraft has a CMR due but isn't at a maintenance facility, it's AOG until they can get a crew out to wherever the aircraft is located to perform the CMR task. Naturally operators try to plan for this and have the aircraft scheduled into an appropriate facility, but things like weather diversions can really play havoc.
That one was just a mess and an accident I really don't like pondering deeply, because of the way it unfolded on the crew and passengers.
The number of accidents, injuries, deaths, and soiled pants due to unexpected change in a pilot's seat position ...
https://www.theguardian.com/business...h-latam-flight
Seriously, one of my friends gave up GA because of that.
https://www.theguardian.com/business...h-latam-flight
Seriously, one of my friends gave up GA because of that.
The number of accidents, injuries, deaths, and soiled pants due to unexpected change in a pilot's seat position ...
https://www.theguardian.com/business...h-latam-flight
Seriously, one of my friends gave up GA because of that.
https://www.theguardian.com/business...h-latam-flight
Seriously, one of my friends gave up GA because of that.
The Boeing advice for operators to check they are complying with the maintenance procedures is a sensible precaution. If it turns out that seat movement was the cause of this event, they are ahead of the curve; if not, no harm done.
Airbus went through this loop with a military A330 pitch down event. The question was whether it was a tech problem, which could have affected the entire Airbus fleet, or whether it was a human factors issue. Turned out to be the latter…
True. The baggage handler who closed the door couldn't read English, was not trained on the door, had no supervision, and was not aware that there was a sight glass to confirm the door was latched correctly.
Part of an operator being granted authorization to operate that aircraft type is getting their maintenance plan approved by the local authority (important point here - that it's done 'locally' - nothing goes back to certification office such as SACO). To start with, that plan is usually based on the manufactures MPD - often verbatim. At entry into service, the MPD is typically pretty conservative - with relatively short maintenance intervals because the manufacturer simply doesn't now how some things are going to react in daily use in the field. So there are provisions to 'escalate' (extend) those intervals once the operator gets sufficient experience with the aircraft to see what really needs to done and how often to maintain the aircraft. To get a task 'extended', the operator puts together something showing that their experience shows the maintenance task doesn't need to be done as often as specified in the MPD - the local authority reviews that data and grants or denies the extension - again nothing goes back to the original certification office (even if the operator is based in the same local as the original cert office, it's a different 'branch' of the FAA and they don't really communicate). I believe in some cases, a task escalation can be approved by a designee (think DER), not part of the regular regulatory authority. The only exception is CMRs (Certification Maintenance Requirements) - CMRs cannot be escalated except by the original certification authority. Operators hate CMRs - best case they are a lot of paperwork, worst case an operation event such as a diversion can leave an aircraft AOG, requiring remote maintenance or a special, non-revenue positioning flight to get it back to where the task can be performed (expensive and a big paperwork hassle).
In the case of the Alaska jackscrew, the jackscrew maintenance interval had been legally escalated from something like 1,000 hours to something like 5,000 hours (which of course turned out to be excessive).
And yes, I do think the process is flawed - as a minimum the certificating authority should be informed of task escalations in excess of a certain percentage of the MPD numbers - with the authority and ability to reject escalations that appear excessive - especially for flight critical systems.
Dennis Tajer, the head of the APA, has stuck the knife in. From https://www.bbc.co.uk/news/business-68573686
"It's as if I'm watching a troubled child" is how Captain Dennis Tajer describes flying a Boeing 737 Max.The head of the Allied Pilots Association, the pilots union for American Airlines, insists he would never board an aircraft if it were not safe. But he says he can no longer take the quality of the plane he's flying for granted. "I'm at an alert status that I've never had to be in on a Boeing airplane," he says. "Because I don't trust that they've followed the processes that have previously kept me safe on Boeing airplanes for over three decades."
That's just the beginning of a long article. It's probably much too long for most passengers to read in full, but if they get to the bit where Tajer says "I don't trust...the processes that have previously kept me safe on Boeing airplanes", the damage is done. It has to influence passenger choices when they make travel plans.
"It's as if I'm watching a troubled child" is how Captain Dennis Tajer describes flying a Boeing 737 Max.The head of the Allied Pilots Association, the pilots union for American Airlines, insists he would never board an aircraft if it were not safe. But he says he can no longer take the quality of the plane he's flying for granted. "I'm at an alert status that I've never had to be in on a Boeing airplane," he says. "Because I don't trust that they've followed the processes that have previously kept me safe on Boeing airplanes for over three decades."
That's just the beginning of a long article. It's probably much too long for most passengers to read in full, but if they get to the bit where Tajer says "I don't trust...the processes that have previously kept me safe on Boeing airplanes", the damage is done. It has to influence passenger choices when they make travel plans.
Last edited by Nick H.; 17th Mar 2024 at 19:12.
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The people who did (or didn't, as the case may be) do the door work certainly know they did it, but if there is no paperwork (see my early postulation that they called it a door instead of a door plug to avoid the paperwork), management has no way of positively identifying who those people were. And those involved are running scared and not talking to anyone. At best, they know they'll likely be fired, and since the DOJ has opened a criminal investigation, they could possibly end up in jail.
While there may well be co-workers who know (but were not involved), they don't want to be identified as rats (the IAM would likely crucify them) so they aren't talking either.
While there may well be co-workers who know (but were not involved), they don't want to be identified as rats (the IAM would likely crucify them) so they aren't talking either.
I think Boeing (leadership) are scared about what the involved employees and their managers will say about what exactly happened and other non-compliance issues in the factory. Remember the DPA (Differed Prosecution Agreement) was still valid at the time of Alaska Airlines incident. Boeing (not IAM) will crucify them and use them as scapegoats as they did with the head of the 737 MAX this year. They did the same thing with the chief pilot Mark Forkner after the 737 MAX crashes.
First post of the whistleblower (throwawayboeingN704AL):throwawayboeingN704AL
January 16, 2024Current Boeing employee here – I will save you waiting two years for the NTSB report to come out and give it to you for free: the reason the door blew off is stated in black and white in Boeings own records. It is also very, very stupid
and speaks volumes about the quality culture at certain portions of the business.
A couple of things to cover before we begin:
Q1) Why should we believe you?
A) You shouldn’t, I’m some random throwaway account, do your own due diligence. Others who work at Boeing can verify what I say is true, but all I ask is you consider the following based on its own merits.
Q2) Why are you doing this?
A) Because there are many cultures at Boeing, and while the executive culture may be throughly compromised since we were bought by McD, there are many other people who still push for a quality product with cutting edge design. My hope is that this is the wake up call that finally forces the Board to take decisive action, and remove the executives that are resisting the necessary cultural changes to return to a company that values safety and quality above schedule.
With that out of the way… why did the left hand (LH) mid-exit door plug blow off of the 737-9 registered as N704AL? Simple- as has been covered in a number of articles and videos across aviation channels, there are 4 bolts that prevent the mid-exit door plug from sliding up off of the door stop fittings that take the actual pressurization loads in flight, and these 4 bolts were not installed when Boeing delivered the airplane, our own records reflect this.
The mid-exit doors on a 737-9 of both the regular and plug variety come from Spirit already installed in what is supposed to be the final configuration and in the Renton factory, there is a job for the doors team to verify this “final” install and rigging meets drawing requirements. In a healthy production system, this would be a “belt and suspenders” sort of check, but the 737 production system is quite far from healthy, its a rambling, shambling, disaster waiting to happen. As a result, this check job that should find minimal defects has in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations (so both actual doors for the high density configs, and plugs like the one that blew out). That is a hideously high and very alarming number, and if our quality system on 737 was healthy, it would have stopped the line and driven the issue back to supplier after the first few instances. Obviously, this did not happen. Now, on the incident aircraft this check job was completed on 31 August 2023, and did turn up discrepancies, but on the RH side door, not the LH that actually failed. I could blame the team for missing certain details, but given the enormous volume of defects they were already finding and fixing, it was inevitable something would slip through- and on the incident aircraft something did. I know what you are thinking at this point, but grab some popcorn because there is a plot twist coming up.
The next day on 1 September 2023 a different team (remember 737s flow through the factory quite quickly, 24 hours completely changes who is working on the plane) wrote up a finding for damaged and improperly installed rivets on the LH mid-exit door of the incident aircraft.
A brief aside to explain two of the record systems Boeing uses in production. The first is a program called CMES which stands for something boring and unimportant but what is important is that CMES is the sole authoritative repository for airplane build records (except on 787 which uses a different program). If a build record in CMES says something was built, inspected, and stamped in accordance with the drawing, then the airplane damn well better be per drawing. The second is a program called SAT, which also stands for something boring and unimportant but what is important is that SAT is *not* an authoritative records system, its a bullentin board where various things affecting the airplane build get posted about and updated with resolutions. You can think of it sort of like a idiots version of Slack or something. Wise readers will already be shuddering and wondering how many consultants were involved, because, yes SAT is a *management visibilty tool*. Like any good management visibilty tool, SAT can generate metrics, lots of metrics, and oh God do Boeing managers love their metrics. As a result, SAT postings are the primary topic of discussion at most daily status meetings, and the whole system is perceived as being extremely important despite, I reiterate, it holding no actual authority at all.
We now return to our incident aircraft, which was written up for having defective rivets on the LH mid-exit door. Now as is standard practice kn Renton (but not to my knowledge in Everett on wide bodies) this write-up happened in two forms, one in CMES, which is the correct venue, and once in SAT to “coordinate the response” but really as a behind-covering measure so the manager of the team that wrote it can show his boss he’s shoved the problem onto someone else. Because there are so many problems with the Spirit build in the 737, Spirit has teams on site in Renton performing warranty work for all of their shoddy quality, and this SAT promptly gets shunted into their queue as a warranty item. Lots of bickering ensues in the SAT messages, and it takes a bit for Spirit to get to the work package. Once they have finished, they send it back to a Boeing QA for final acceptance, but then Malicious Stupid Happens! The Boeing QA writes another record in CMES (again, the correct venue) stating (with pictures) that Spirit has not actually reworked the discrepant rivets, they *just painted over the defects*. In Boeing production speak, this is a “process failure”. For an A&P mechanic at an airline, this would be called “federal crime”.
Presented with evidence of their malfeasance, Spirit reopens the package and admits that not only did they not rework the rivets properly, there is a damaged pressure seal they need to replace (who damaged it, and when it was damaged is not clear to me). The big deal with this seal, at least according to frantic SAT postings, is the part is not on hand, and will need to be ordered, which is going to impact schedule, and (reading between the lines here) Management is Not Happy. 1/2
Second post of the whistleblower (throwawayboeingN704AL):
throwawayboeingN704AL
January 16, 20242/2
However, more critical for purposes of the accident investigation, the pressure seal is unsurprisingly sandwiched between the plug and the fuselage, and you cannot replace it without opening the door plug to gain access. All of this conversation is documented in increasingly aggressive posts in the SAT, but finally we get to the damning entry which reads something along the lines of “coordinating with the doors team to determine if the door will have to be removed entirely, or just opened. If it is removed then a Removal will have to be written.” Note: a Removal is a type of record in CMES that requires formal sign off from QA that the airplane been restored to drawing requirements.
If you have been paying attention to this situation closely, you may be able to spot the critical error: regardless of whether the door is simply opened or removed entirely, the 4 retaining bolts that keep it from sliding off of the door stops have to be pulled out. A removal should be written in either case for QA to verify install, but as it turns out, someone (exactly who will be a fun question for investigators) decides that the door only needs to be opened, and no formal Removal is generated in CMES (the reason for which is unclear, and a major process failure). Therefore, in the official build records of the airplane, a pressure seal that cannot be accessed without opening the door (and thereby removing retaining bolts) is documented as being replaced, but the door is never officially opened and thus no QA inspection is required.
This entire sequence is documented in the SAT, and the nonconformance records in CMES address the damaged rivets and pressure seal, but at no point is the verification job reopened, or is any record of removed retention bolts created, despite it this being a physical impossibility. Finally with Spirit completing their work to Boeing QAs satisfaction, the two rivet-related records in CMES are stamped complete, and the SAT closed on 19 September 2023. No record or comment regarding the retention bolts is made.
I told you it was stupid.
So, where are the bolts? Probably sitting forgotten and unlabeled (because there is no formal record number to label them with) on a work-in-progress bench, unless someone already tossed them in the scrap bin to tidy up.
There’s lots more to be said about the culture that enabled this to happened, but thats the basic details of what happened, the NTSB report will say it in more elegant terms in a few years.
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Typical journo
The concerns of the APA chief obviously are valid.
But neither the observations and/or assessments he offered (as attributed to him in the published item), nor anything else in the article changes the situation at all.
First, since the occurence of the two MAX accidents, it has been widely known that the handling characteristics of the aircraft left something to be desired. Even after it returned to line service following the grounding, various threads on this forum questioned the airplane's longitudinal stability. And the so-called "roller coaster manuever", which some aviator posters had referenced as having been a relevant response to MCAS over-activation, to the best of my recollection (and attempts to "keep up" on the forum), never received a consignment to the box marked "discarded flight manuevers - Do Not Use."
So saying that the aircraft known as the 737 MAX is a problem child just isn't anything new. The fact that a chief of a major aviation labor organization is saying so might be newsworthy, but what really does it change? Reputational damage has occurred already and this reporting makes it only slightly worse at the margin if at all.
Second, nothing else in the article is anything more than rewarmed-over left-overs from three or four past expiry dates.
The forum gets slammed on occasion, here and elsewhere, for wild and/or ill-informed posts. Though SLF/attorney only that I am, I'm saying turnabout is fair play.
But neither the observations and/or assessments he offered (as attributed to him in the published item), nor anything else in the article changes the situation at all.
First, since the occurence of the two MAX accidents, it has been widely known that the handling characteristics of the aircraft left something to be desired. Even after it returned to line service following the grounding, various threads on this forum questioned the airplane's longitudinal stability. And the so-called "roller coaster manuever", which some aviator posters had referenced as having been a relevant response to MCAS over-activation, to the best of my recollection (and attempts to "keep up" on the forum), never received a consignment to the box marked "discarded flight manuevers - Do Not Use."
So saying that the aircraft known as the 737 MAX is a problem child just isn't anything new. The fact that a chief of a major aviation labor organization is saying so might be newsworthy, but what really does it change? Reputational damage has occurred already and this reporting makes it only slightly worse at the margin if at all.
Second, nothing else in the article is anything more than rewarmed-over left-overs from three or four past expiry dates.
The forum gets slammed on occasion, here and elsewhere, for wild and/or ill-informed posts. Though SLF/attorney only that I am, I'm saying turnabout is fair play.