Non-Military Aviation

[Shyster]

Not sure if the door panel itself is made in Malaysia, but the fuselages—including the installation of the doors and door plugs—are made by Spirit AeroSystems in Kansas. The fuselages are then shipped by rail to Boeing in Seattle, where the wings, tails, engines, interiors, etc. are installed. It's not clear to me whether Boeing opens the door plugs at Seattle as part of the remaining assembly. I've seen conflicting reports that they do and they don't. I've also seen pictures online where one of the subcontractors that installs the wifi systems on the 737 had the door plug open and was using that as an entrance during installation. So I can see multiple ways the plugs could end up loose:

1. Spirit installed the plugs but didn't torque the bolts, assuming that Boeing would do that later, but Boeing assumed the bolts were all torqued to spec from Spirit and didn't check.

2. Boeing opened the door plugs as part of its own work and failed to torque them to spec when Boeing closed them back up.

3. The wifi subcontractor opened the door plugs and assumed that Boeing would later torque them to spec, but Boeing either failed to do so or didn't realize the plugs had been opened.

I would bet money this is a situation where there were multiple assumptions that someone else had checked or would check the bolts, but those assumptions were all wrong, and consequently bolts were left loose.

[tifosi77]

*gasp*

Maybe that's what caused MH370 to go missing.

[dodint]

Compelling reading from an unidentified source:

throwawayboeingN704AL
January 16, 2024
Current 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
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.

https://leehamnews.com/2024/01/15/unpla ... ent-509962

[NTP66]

You know, I have never been a fan of Boeing, which my previous post history will confirm - and this does not help. Honestly, despite them being different aircraft (MAX 8), I regret the return flights I chose for this summer's vacation now.

[dodint]

I'm in the camp of 'Boeing was a once great American icon that was bought by McDonnell Douglas and promptly flown into the ground."

[NTP66]

I think most who pay a little more attention than the average person are of the same opinion, honestly. It's a comment that I repeatedly find myself reading online.

[dodint]

I watched a documentary recently about Boeing and that's kind of how it went. Full of pride and confidence until 1997 when those that maximize shareholder value showed up.

[NTP66]

I assumed it was the case, but I can't cancel my tickets with United for a refund, just travel credits, so I'll just roll with it this time around. It honestly bothers me that this will force me to go back to using American whenever possible.

[tifosi77]

Has a very 'Starship Troopers' feel. You cannot fail to properly torque down bolts if there are no bolts to torque down.

*big brain"

[NTP66]

2 passenger planes hit over 800 mph on recent flights due to strong winds. That's over 200 mph more than a typical plane ride.

A Virgin Atlantic flight from Washington, DC, to London landed 45 minutes ahead of schedule. Meanwhile, a United Airlines flight from Newark, New Jersey, arrived in Lisbon 20 minutes early.

These winds pushed Virgin's Boeing 787 to a ground speed of 802 mph and United's Boeing 787 to 838 mph.

The speed of sound is 767 mph. While they were flying faster than the speed of sound, the planes didn't break the sound barrier, The Washington Post reported.

Pretty cool.

[NTP66]

[dodint]

https://www.independent.co.uk/news/unit ... 09063.html




Another bad look for Boeing it seems. 777 drops a wheel on takeoff at SFO

[MR25]

I hope the owner of that Corolla gets much much more from Boeing than what their car was worth.

[Shyster]

It wouldn't be Boeing's responsibility. That 777-200ER left the factory over 20 years ago, and the way the airline industry works is that airlines and not manufacturers are responsible for maintenance and repairs. That car is on United.

[dodint]

Yeah, that's why I said 'look.' It's not their fault in this case but every time a part falls off a Boeing and destroys something it's notable.

[tifosi77]

Yikes, I know that area well. It's half a mile from the dog daycare place we used when we lived up there, and I drove by that parking lot 2x a day.

The flight path from that runway pair goes right over the junction of the 101 and 380 freeways, and just beyond that two large shopping malls/centers and an open-air BART station. If there had been a warning light that delayed gear retraction even by a few seconds on climbout, that could've been an ugly incident.

[dodint]

I almost made a joke that you probably lived in that Corolla at some point and would come along to tell us how you've been nearly killed.

[tifosi77]

'Almost' is the best word in the English language isn't it?

[dodint]

I didn't think you'd do it if I tipped my hand. Worth it.

The root of the ribbing is that you're well-traveled. There are worse things for a kid from Altoona.

[tifosi77]

Look, I'm just saying Corollas aren't the most comfortable cars in the world.

[dodint]

No room for a grow shed.

[dodint]

Passed my FAA Written Exam for Private Pilot today. Missed 4 questions, earned a 93%. I was pretty annoyed walking out of the test center because I studied very hard and was expecting a 97% or greater. Oh well. When I got home I looked up my deficiency ACS codes and 3/4 of the questions I missed were based on reference material that any person would just look up in real life (one of them was the inspection interval for your emergency transmitter). So rote memorization garbage, like the bar exam. I'm less upset about it now.

Next steps are setting up my sim rig again and doing radio work through the summer. Then I'll start actually flying this fall, Augustish.

[Kaiser]

That's exactly the kind of **** that drove me away from continuing in aviation. All work and no play.

[dodint]

Well, the main reason I'm doing this is because I anticipate the work/play ration to be higher than it is for sportscar racing.

[NTP66]