11 ms·

Alaska Airlines flight 1282 NTSB preliminary report [pdf]

266 points by tomalpha 3y ago

mef 3y ago
anyone have a copy hosted? it's currently overloaded and not responding
- hipadev23 3y ago
  I believe this video mostly covers it: https://youtu.be/3m5qxZm_JqM https://youtu.be/3m5qxZm_JqM
  - ilyagr 3y ago
    This is old satire. It's good satire, but don't expect to find actual information here.
- geoffeg 3y ago
  https://aviationsourcenews.com/wp-content/uploads/2024/02/Report_DCA24MA063_193617_2_6_2024-2_15_26-PM.pdf https://aviationsourcenews.com/wp-content/uploads/2024/02/Re...
mcmatterson 3y ago
The fact that a critical piece of the evidence was cell phone photos sent between workers coordinating door re-assembly doesn't exactly instill a whole lot of confidence in their permit-to-work process. I didn't like it when it was medical teams doing shift handover via a Google Doc, and I don't like it when it's a matter of flight safety either. Or, as Homer might eruditely say: "guess I forgot to put the bolts back in" [1] [1] (https://www.youtube.com/watch?v=IiNPLIauEig https://www.youtube.com/watch?v=IiNPLIauEig)
- gowings97 3y ago
  The data/photos should be in the ERP/MES.
- ipython 3y ago
  This is a puzzling attitude to me. Every time we technologists see a crappy proprietary solution being used for a problem, the first exclamation is, "why not use <commodity solution X>? That's so dumb, they spent $10k on that tool when they could have spent $100 on X!" There must be a middle ground here- the paradox is that Google, Apple, etc have this ability to generate user friendly software and hardware at scale. But they aren't considered "battle proven". The expensive proprietary systems that are used instead tend to be hard to use and brittle, so what's the middle ground?
  - deleted 3y ago
    [deleted]
  - michael1999 3y ago
    The issue here isn't using google chat, the accusation is that this was Spirit and Boeing conspiring to not record these in the proper work order system under the pretence that this work was being done by Spirit as-if-it-were pre-delivery. Read https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte... And then this from the doc: "The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework." https://s3.documentcloud.org/documents/24410269/report_dca24ma063_193617_2_6_2024-2_15_12-pm.pdf https://s3.documentcloud.org/documents/24410269/report_dca24...
    - ethbr1 3y ago
      A key point I read somewhere in the accusations is that non-Boeing contractors (e.g. Spirit) by policy cannot have access to CMES. Consequently, you have a system of record that a major party to work doesn't have access to. As we've all seen, this leads to "actual coordination" being instead done in a system all involved parties do have access to (SAT). Which inevitably leads to a desync between CMES (SOR by fiat) and SAT (SOR in practice).
      - calebpeterson 3y ago
- imoverclocked 3y ago
  > The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework. I mean, there is already a ton of documentation and process surrounding the construction of an airplane. Adding more process doesn't safety make. Having a safety culture without the fear of retaliation, on the other hand, makes a world of difference.
  - TillE 3y ago
    That line stood out to me, because it implies that no proper "manufacturing document" was used for the work. If that's true, that's very bad; unapproved maintenance procedures have been the cause of multiple crashes.
  - seo-speedwagon 3y ago
    If the door was removed (which the NTSB report and the whistleblower post linked elsewhere around here say must have happened) there should be documentation for, at minimum, the removal and reattachment. If the door was not removed but was opened and closed, there should be documentation for both of those actions instead. I don't know if this should be considered "adding more process" because it has been standard process for a very long time. All work done on an airplane is authorized, by someone, and after completion is recorded, by someone. Discrepancies and deviations from this standard operating procedure are a big deal.
spdustin 3y ago
Also posted on DocumentCloud, since NTSB servers aren't responding (as of this comment) https://s3.documentcloud.org/documents/24410269/report_dca24ma063_193617_2_6_2024-2_15_12-pm.pdf https://s3.documentcloud.org/documents/24410269/report_dca24...
deleted 3y ago
[deleted]
guardiangod 3y ago
>[evidences] indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads. Ok >Photos from the interior repair that show the lack of bolts Huh. Well that's conclusive.
- ezfe 3y ago
  Photos may not have been after conclusion of repair so technically not conclusive. However it certainly lines up.
  - Rapzid 3y ago
    Not the photos but the fact that the bolts are missing and there are are no witness marks indicating they were present when the door ejected.
  - flaminHotSpeedo 3y ago
    The report makes it clear that the photo was taken after the rivet rework was complete, immediately before restoration of the interior
    - ezfe 3y ago
      Correct, however again the photo doesn't prove that the next step wasn't putting in the locking bolts. I don't disagree with the conclusion, but the photo merely *supports* the conclusion, rather than proving it.
nostromo 3y ago
> Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads. Ooofff. No bolts at all! How did this pass Boeing QA?
- krona 3y ago
  > How did this pass Boeing QA? https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte...
  - jbverschoor 3y ago
    Just comment out the tests and they pass
    - belter 3y ago
      Instead of Software Development becoming more like Aeronautical Engineering, every day, Aeronautical Engineering becomes more like Software Development...
      - renewiltord 3y ago
        Well, to be clear, I don't usually put people in danger. There's a lot these engineers could learn from software engineers: who are really the highest performance at engineering as a craft. One base rule: Above all, kill no one.
        matheweis 3y ago
        I think that software engineers put people in danger more often than they would like to believe; have a look at the UK Postal Service scandal for a great example of a seemingly innocuous bit of software absolutely destroying numerous lives.
newZWhoDis 3y ago
Seems to solidly confirm the leak.
aftbit 3y ago
> The accident airplane was required to be equipped with a CVR that retained, at minimum, the last 2 hours of audio information, including flight crew communications and other sounds inside the cockpit. >The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording. Classic. If they use CD quality audio at 1411kbps, they can store 2 hours of audio in about 1.2 GB. Given how cheap flash is these days, why not 20x that so that we don't have to rely on people pulling circuit breakers after accidents? If there's some concern about robustness and recertification, why not require all aircraft to carry two CVRs, one of the old "robust" style for kinetic accidents, and one that's less robust but has 20x the capacity, so we can record a full day after less violent accidents?
- cjbprime 3y ago
  The largest US pilots union opposes it on pilot privacy grounds. (To be clear, I think having an expectation of vocal privacy while you are in charge of an airliner is absurd.)
  - samstave 3y ago
    Define. What EXACTLY does a pilot need privacy for?
  - ekianjo 3y ago
    [flagged]
    - gruez 3y ago
      HN isn't a monolith, and it certainly has better representation of anti-union sentiment (ie. they don't all get downvoted to oblivion) compared to other discussion forums (eg. reddit).
    - cjbprime 3y ago
      I (person who blamed the pilots union above) actually like unions. I could probably even say good things about pilot unions; I would say that part of the reason US airlines have fewer accidents than some other wealthy countries is the effect the unions have had on resisting attempts to work pilots through dangerous levels of fatigue, and on ensuring pilots can report dangerous situations and have them comprehensively fixed without retaliation. I don't have faith in "market forces" to do those things, and consider the state of aviation in some other countries to be a living experiment showing why. The opposition to cockpit recording is bonkers, though.
jbverschoor 3y ago
> In a revision to the Flight Crew Operations Manual, issued on January 15, 2024, Boeing confirmed that the door functioned as designed. Smells like CISCO
deleted 3y ago
[deleted]
aftbit 3y ago
Depressurization happened around 17:12:33 PST but the aircraft continued to climb until 17:13:41 PST, and the autopilot was configured for 10k ft at 17:13:56 PST. Why did it take the pilots a full minute to begin an emergency descent after the failure? I would expect that the nature of the accident would be clear nearly immediately, at least in the need to descend the aircraft.
- throwworhtthrow 3y ago
  You can't leave your assigned altitude/trajectory without coordinating with ATC. Otherwise you may collide with another plane, which would make a bad situation worse.
  - mazugrin2 3y ago
    Sure you can, and they likely did start descending before contacting ATC. But before they did any of that, they had to spend some time donning their oxygen masks and doing a few other "memory items" before then descending.
    - michaelt 3y ago
      In this instance the report explicitly says:- > Both flight crew said they immediately donned their oxygen masks. They added that the flight deck door was blown open and that it was very noisy and difficult to communicate. > The flight crew immediately contacted air traffic control (ATC), declared an emergency, and requested a lower altitude. The flight was assigned 10,000 ft. The captain said he then requested the rapid decompression checklist, and the FO executed the required checklist from the Quick Reference Handbook (QRH). As the FO completed the checklist, the captain flew the airplane as they coordinated with ATC to return to the PDX airport. The flight landed on runway 28L without further incident and taxied to the gate. So in this particular instance, when the depressurisation happened at a comparatively low altitude, the pilots did get ATC clearance before descending.
  - lisper 3y ago
    In an emergency you can do anything you think is necessary to address it. Source: I’m a private pilot.
dzdt 3y ago
The report seems to mesh with and confirm many details of the anonymous insider account at https://leehamnews.com/2024/01/15/unplanned-removal-installation-inspection-procedure-at-boeing/#comment-509962 https://leehamnews.com/2024/01/15/unplanned-removal-installa.... The bolts were not reinstalled following work on the plug rivets/seal. The official system doesn't record that work was done requiring the bolts to be removed.
- stefan_ 3y ago
  [flagged]
  - 188320356 3y ago
    The report is 19 pages.
  - advisedwang 3y ago
    It's a preliminary report, they deliberately avoid including conclusions that might be reversed later but would do harm by inclusion at this stage.
  - WheatMillington 3y ago
    Where are you seeing a 100+ page report?
  - lambda 3y ago
    Yeah, this is a preliminary report, they only report direct factual findings that they have collected so far, and as they mention in this report, they haven't yet examined the electronic manufacturing records that the insider was referring to. The NTSB is not quick to jump to conclusions; they are very thorough, and they collect and sort through a lot of evidence. It's not surprising that there's information out sooner that says more for such a high profile incident; but once the NTSB final report comes out, it will be quite detailed and thorough, and cover all of this and more.
- lambda 3y ago
  Yep, biggest new thing here is discussion of witness marks showing no evidence of the bolts, and photo before the rivet repair showing that at least two of the bolts were present, and photo after the rivet repair during installation of the insulation showing at least 3 bolts missing. So this all just serves to confirm that report, and what people suspected for a while; the bolts were just missing, removed for removing the door plug for the rivet rework and never reinstalled.
belltaco 3y ago
>The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording In addition to local storage, why isn't the audio(along with location, altitude and some sensor information) also streamed using something like Starlink or Inmarsat to a secure location where you can store more data for cheaper and with more redundancy?
- sv123 3y ago
  $$$
- outworlder 3y ago
  Starlink is a consumer system. Won't happen without a specialized product. Inmarsat is expensive. And we are talking about streaming audio from all planes currently in flight.
  - belltaco 3y ago
    > Starlink is a consumer system Not true. https://arstechnica.com/information-technology/2022/10/starlink-unveils-airplane-service-musk-says-its-like-using-internet-at-home/ https://arstechnica.com/information-technology/2022/10/starl... https://cleantechnica.com/2022/07/06/fcc-approves-starlink-for-planes-ships-trucks/ https://cleantechnica.com/2022/07/06/fcc-approves-starlink-f...
- skywhopper 3y ago
  This is an old system that works well and reliably for pretty much every incident. I’m not aware of another case of this sort of thing (relevant flight recorder data being overwritten) happening in recent years anyway. If you spend time constantly upgrading systems like this you’re asking for a higher failure rate, for very little gain. That said, there’s a standard and reliable 25-hour flight voice recorder that solves this problem. But it’s only used outside the US. That’s a regulatory inertia situation and I suspect this incident will speed changes in this area. However, finally, and particularly in relation to your proposal of streaming cockpit voice recordings to some cloud server. There is some resistance to this (and to longer recordings in general) from air crew on privacy grounds. The privacy issue is less about how much personal info is revealed in a crash situation and more about how easy it would be for a bad actor in management —or whatever operations group runs the audio storage—to listen in on conversations. And you can be sure this would happen if something like your system were implemented without the appropriate regulatory controls (and tbh even with them it would probably still happen).
spdustin 3y ago
Looks like the anonymous whistleblower on Airline Pilot Central Forums [0] was legit. [0]: https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte...
- yborg 3y ago
  I'm guessing twice as much corporate effort is currently being deployed to find this guy than is being applied to fixing Boeing's quality system.
gtmitchell 3y ago
A very thorough preliminary report. I've worked for a long time in quality systems, and this is a perfect example of a systemic failure. They've got work being handed off between Boeing employees and 3rd party contractors with insufficient controls in place to verify that very basic tasks are being performed. I'd be curious to know how many non-conformances they typically see during assembly of a plane and whether management is actually allowing the quality department sufficient independence to investigate these issues and fully resolve them. I'm guessing that the production personnel are under tremendous time constraints and are constantly pressure the quality assurance people to sign off on whatever paperwork is holding up the line, no matter the safety implications. Also, I think a lot of middle and upper level management needs to lose their jobs over this. I hope this mess ends up in textbooks and gets beaten into the head of every MBA student in the country.
- lp4vn 3y ago
  >I'd be curious to know [...] whether management is actually allowing the quality department sufficient independence to investigate these issues and fully resolve them If management in the aerospace industry works like management in the software industry, then I guess they are pushing for results as agressively as possible without much concern about safety or anything else.
  - cezart 3y ago
    At a company I worked in, we had a joke about this: "Good thing we don't build nuclear reactors". In some software projects the level of rush, and the fact that bugs sometimes would leak into production was kinda horrifying. It would've been way more so, if it would've been the kind of project that could kill people in case of failure. Like it happened in Chernobyl with nuclear reactors, or at Boeing with planes. I can't really imagine what these engineers feel when they rush this kind of work knowing what's at stake.
    - toast0 3y ago
      Quality is always a trade-off. If you're deeply into economics, you wonder about the trade-offs of cost to find defects before shipping, difference in cost of addressing defects before and after shipping including costs of mitigation from consequences of defects, % of defects that will never be found after shipping (and are therefore a real cost savings), and in the long game costs of having a reputation for shipping product with defects that could have been reasonably detected. In a lot of software organizations with rapidly changing and undocumented requirements, there's a good chance defects will go unnoticed until they're no longer relevant, so spending a lot to find them before they're shipped is a waste. Mitigation of many software defects is simple, but some aren't; hopefully you know which changes are expensive to fix if wrong, so you can more thoroughly vet those. In Aerospace, addressing defects after shipping is very expensive, and mitigating the effects of defects is only approximate; you can't restore passengers from backup, economic damages don't really make families whole, but should be an incentive not to let reasonably detectable defects be shipped.
ultimoo 3y ago
I look forward to reading a report from NTSB's internet outage.
Hansenq 3y ago
If people are looking for additional in-depth reading on how this happened, The Air Current did a great write-up on this systemic mistake using internal Boeing sources a month ago that the NTSB report fully supports: https://theaircurrent.com/aviation-safety/127-days-the-anatomy-of-a-boeing-quality-failure/ https://theaircurrent.com/aviation-safety/127-days-the-anato...
hn8305823 3y ago
I wonder how close the door plug was to hitting the tailplane or vertical stabilizer/rudder?
- reddit_clone 3y ago
  Considering all those scary scenarios, what happened was probably the most favourable outcome. It could have been a major disaster hundred different ways..
  - mikeyouse 3y ago
    It sure could have -- the plane was still climbing which puts that plug door almost directly in line with the horizontal stabilizers; https://i.cbc.ca/1.7077373.1704733027!/fileImage/httpImage/gfx-dd-alaska-airlines-incident-mobile.jpg https://i.cbc.ca/1.7077373.1704733027!/fileImage/httpImage/g...
    - kayfox 3y ago
      Not as much when taking into account the actual direction of the wind, which would be more inline with the aircraft.
deleted 3y ago
[deleted]
WatchDog 3y ago
> The flight crew reported that the cockpit door had opened during the depressurization event. In a revision to the Flight Crew Operations Manual, issued on January 15, 2024, Boeing confirmed that the door functioned as designed. Interesting for terrorists. Cause a rapid decompression, and get easy access to the cockpit.
- bradfa 3y ago
  Causing rapid decompression is quite hard. Opening a normal door is very difficult during flight except at very low altitudes.
- mihaaly 3y ago
  They may go then and blow the whole thing up good insted of such half measures. Sufficiently rapid decompressions may not that reliable and predictable to carry out so I can control the plane afterward easy kind of feats.
- ledauphin 3y ago
  yeah, this is a significant hole in the locked cockpit door plan.
- mlindner 3y ago
  If they cause a rapid decompression they incapacitate themselves and won't be able to use the cockpit. Also how do you cause a rapid decompression without a gun of some kind?
mihaaly 3y ago
What is the analogy of leaving out all bolts from that door? 'Forgetting' to put in any of the screws holding a gas tank in place in a car? 'Missing' all welds in one of a skyscraper's lower columns? An 'oversight' of providing rendundant instruments in an airplane with natural tendency to stall? What a hopeless shitshow is going on there behind the company gates that these kind of things can happen in succession? A duck forgot how to swimm, an eagle forgot how to fly, Boieing forgot how to build airplanes?
- addaon 3y ago
  > 'Missing' all welds in one of a skyscraper's lower columns? Or just throwing the rebar in at random maybe? [0] [0] https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D-how-the-lack-of-proper-systems-puts-a-contractor-at-risk-and-created-%E2%80%9Cthe-nightmare-on-las-vegas-boulevard%E2%80%9D-for-mgm/ https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D...
  - mihaaly 3y ago
    Oh Jesus! I seriously thought my hypothetical example is extreme, but apparently not!
  - sofixa 3y ago
    > According to an article in the Las Vegas Sun, “Some of the steel, known as rebar, was so badly positioned that it stuck out of the concrete floor and was sawed off to conceal the mistake.” In addition, “Harmon workers reportedly moved rebar without first getting an OK from the structural engineer . . . .which is a major no-no in the construction chain of command. WTF! How was there no punishment for everyone involved in this?
johnflan 3y ago
You gotta wonder how the technician explained away the four leftover bolts after
Jefferyhanson 3y ago
[flagged]
userbinator 3y ago
A lot of comments here are going on about process, as if humans are mindless and otherwise perfectly controllable robots... I'm going to be contrarian and say that this is exactly the sort of thing that happens when you train humans to be robots: They lose all signs of common sense and critical thinking, and what's worse is that on top of that, they'll still have their inherent imperfection. Normally the former would counteract the latter, but not if you only make them rigidly follow some process all the time. They stop thinking about what they're doing. They stop paying attention to all the other things in their environment they would've noticed, and even if they do, they won't question it because they'll just assume someone else also following a rigid process will take care of it. They won't think "this door plug should've been bolted in place now that the work that needed it opened is done, but where are the bolts?" I'm not saying to throw out all the process and make them figure everything out, but I think there has to be a balance, similar to how overautomation and reliance on that has also lead to avoidable incidents in aviation.
- projektfu 3y ago
  Potentially the result when you rob workers of the right to pride in workmanship. The most common complaint from old Boeing people who have left is that after the merger the McDonnell-Douglas people took over and the company switched from pride in engineering and quality of workmanship to cost cutting and bean counting. Also, shortly after the merger the corporate HQ moved, reflecting the priorities of the CEO. It has since moved again, apparently to be better for lobbying.
  - p_l 3y ago
    The original move was also related to lobbying potential. But the CEO who started the moves etc. was a Boeing lifer.
    - projektfu 3y ago
      The original move to Chicago was for lobbying? I figured it was more of moving where the CEO wanted to live.
dreamcompiler 3y ago
Summary: Fuselage was delivered to Boeing with some damaged rivets near the door plug. They had to remove the door plug to fix the rivets. Then they reattached the door plug but forgot to reattach the 4 bolts that would keep it in place. Possibly because of a shift change at the plant. There was noticeable damage to the door plug's mechanical fittings from the violence of it being blown out of the plane. But the holes where the bolts belonged were pristine. That would not have been true if the holes had had bolts in them.
flaminHotSpeedo 3y ago
> The accident airplane was required to be equipped with a CVR that retained, at minimum, the last 2 hours of audio information, including flight crew communications and other sounds inside the cockpit ... The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording How the fuck is this still a problem on brand new aircraft?
- alberto180 3y ago
  [dead]
TurkishPoptart 3y ago
"....after the left mid exit door (MED) plug departed the airplane leading to a rapid decompression" Lol, they said the door plug "departed" instead of "blew the f** off"

266 points by tomalpha 3y ago

mef 3y ago

anyone have a copy hosted? it's currently overloaded and not responding

hipadev23 3y ago
I believe this video mostly covers it: https://youtu.be/3m5qxZm_JqM https://youtu.be/3m5qxZm_JqM
- ilyagr 3y ago
  This is old satire. It's good satire, but don't expect to find actual information here.
geoffeg 3y ago
https://aviationsourcenews.com/wp-content/uploads/2024/02/Report_DCA24MA063_193617_2_6_2024-2_15_26-PM.pdf https://aviationsourcenews.com/wp-content/uploads/2024/02/Re...

mcmatterson 3y ago

The fact that a critical piece of the evidence was cell phone photos sent between workers coordinating door re-assembly doesn't exactly instill a whole lot of confidence in their permit-to-work process. I didn't like it when it was medical teams doing shift handover via a Google Doc, and I don't like it when it's a matter of flight safety either. Or, as Homer might eruditely say: "guess I forgot to put the bolts back in" [1] [1] (https://www.youtube.com/watch?v=IiNPLIauEig https://www.youtube.com/watch?v=IiNPLIauEig)

gowings97 3y ago
The data/photos should be in the ERP/MES.
ipython 3y ago
This is a puzzling attitude to me. Every time we technologists see a crappy proprietary solution being used for a problem, the first exclamation is, "why not use <commodity solution X>? That's so dumb, they spent $10k on that tool when they could have spent $100 on X!" There must be a middle ground here- the paradox is that Google, Apple, etc have this ability to generate user friendly software and hardware at scale. But they aren't considered "battle proven". The expensive proprietary systems that are used instead tend to be hard to use and brittle, so what's the middle ground?
- deleted 3y ago
  [deleted]
- michael1999 3y ago
  The issue here isn't using google chat, the accusation is that this was Spirit and Boeing conspiring to not record these in the proper work order system under the pretence that this work was being done by Spirit as-if-it-were pre-delivery. Read https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte... And then this from the doc: "The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework." https://s3.documentcloud.org/documents/24410269/report_dca24ma063_193617_2_6_2024-2_15_12-pm.pdf https://s3.documentcloud.org/documents/24410269/report_dca24...
  - ethbr1 3y ago
    A key point I read somewhere in the accusations is that non-Boeing contractors (e.g. Spirit) by policy cannot have access to CMES. Consequently, you have a system of record that a major party to work doesn't have access to. As we've all seen, this leads to "actual coordination" being instead done in a system all involved parties do have access to (SAT). Which inevitably leads to a desync between CMES (SOR by fiat) and SAT (SOR in practice).
    - calebpeterson 3y ago
imoverclocked 3y ago
> The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework. I mean, there is already a ton of documentation and process surrounding the construction of an airplane. Adding more process doesn't safety make. Having a safety culture without the fear of retaliation, on the other hand, makes a world of difference.
- TillE 3y ago
  That line stood out to me, because it implies that no proper "manufacturing document" was used for the work. If that's true, that's very bad; unapproved maintenance procedures have been the cause of multiple crashes.
- seo-speedwagon 3y ago
  If the door was removed (which the NTSB report and the whistleblower post linked elsewhere around here say must have happened) there should be documentation for, at minimum, the removal and reattachment. If the door was not removed but was opened and closed, there should be documentation for both of those actions instead. I don't know if this should be considered "adding more process" because it has been standard process for a very long time. All work done on an airplane is authorized, by someone, and after completion is recorded, by someone. Discrepancies and deviations from this standard operating procedure are a big deal.

spdustin 3y ago

Also posted on DocumentCloud, since NTSB servers aren't responding (as of this comment) https://s3.documentcloud.org/documents/24410269/report_dca24ma063_193617_2_6_2024-2_15_12-pm.pdf https://s3.documentcloud.org/documents/24410269/report_dca24...

deleted 3y ago

[deleted]

guardiangod 3y ago

>[evidences] indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads. Ok >Photos from the interior repair that show the lack of bolts Huh. Well that's conclusive.

ezfe 3y ago
Photos may not have been after conclusion of repair so technically not conclusive. However it certainly lines up.
- Rapzid 3y ago
  Not the photos but the fact that the bolts are missing and there are are no witness marks indicating they were present when the door ejected.
- flaminHotSpeedo 3y ago
  The report makes it clear that the photo was taken after the rivet rework was complete, immediately before restoration of the interior
  - ezfe 3y ago
    Correct, however again the photo doesn't prove that the next step wasn't putting in the locking bolts. I don't disagree with the conclusion, but the photo merely *supports* the conclusion, rather than proving it.

nostromo 3y ago

> Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads. Ooofff. No bolts at all! How did this pass Boeing QA?

krona 3y ago
> How did this pass Boeing QA? https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte...
- jbverschoor 3y ago
  Just comment out the tests and they pass
  - belter 3y ago
    Instead of Software Development becoming more like Aeronautical Engineering, every day, Aeronautical Engineering becomes more like Software Development...
    - renewiltord 3y ago
      Well, to be clear, I don't usually put people in danger. There's a lot these engineers could learn from software engineers: who are really the highest performance at engineering as a craft. One base rule: Above all, kill no one.
      - matheweis 3y ago
        I think that software engineers put people in danger more often than they would like to believe; have a look at the UK Postal Service scandal for a great example of a seemingly innocuous bit of software absolutely destroying numerous lives.

newZWhoDis 3y ago

Seems to solidly confirm the leak.

aftbit 3y ago

> The accident airplane was required to be equipped with a CVR that retained, at minimum, the last 2 hours of audio information, including flight crew communications and other sounds inside the cockpit. >The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording. Classic. If they use CD quality audio at 1411kbps, they can store 2 hours of audio in about 1.2 GB. Given how cheap flash is these days, why not 20x that so that we don't have to rely on people pulling circuit breakers after accidents? If there's some concern about robustness and recertification, why not require all aircraft to carry two CVRs, one of the old "robust" style for kinetic accidents, and one that's less robust but has 20x the capacity, so we can record a full day after less violent accidents?

cjbprime 3y ago
The largest US pilots union opposes it on pilot privacy grounds. (To be clear, I think having an expectation of vocal privacy while you are in charge of an airliner is absurd.)
- samstave 3y ago
  Define. What EXACTLY does a pilot need privacy for?
- ekianjo 3y ago
  [flagged]
  - gruez 3y ago
    HN isn't a monolith, and it certainly has better representation of anti-union sentiment (ie. they don't all get downvoted to oblivion) compared to other discussion forums (eg. reddit).
  - cjbprime 3y ago
    I (person who blamed the pilots union above) actually like unions. I could probably even say good things about pilot unions; I would say that part of the reason US airlines have fewer accidents than some other wealthy countries is the effect the unions have had on resisting attempts to work pilots through dangerous levels of fatigue, and on ensuring pilots can report dangerous situations and have them comprehensively fixed without retaliation. I don't have faith in "market forces" to do those things, and consider the state of aviation in some other countries to be a living experiment showing why. The opposition to cockpit recording is bonkers, though.

jbverschoor 3y ago

> In a revision to the Flight Crew Operations Manual, issued on January 15, 2024, Boeing confirmed that the door functioned as designed. Smells like CISCO

deleted 3y ago

[deleted]

aftbit 3y ago

Depressurization happened around 17:12:33 PST but the aircraft continued to climb until 17:13:41 PST, and the autopilot was configured for 10k ft at 17:13:56 PST. Why did it take the pilots a full minute to begin an emergency descent after the failure? I would expect that the nature of the accident would be clear nearly immediately, at least in the need to descend the aircraft.

throwworhtthrow 3y ago
You can't leave your assigned altitude/trajectory without coordinating with ATC. Otherwise you may collide with another plane, which would make a bad situation worse.
- mazugrin2 3y ago
  Sure you can, and they likely did start descending before contacting ATC. But before they did any of that, they had to spend some time donning their oxygen masks and doing a few other "memory items" before then descending.
  - michaelt 3y ago
    In this instance the report explicitly says:- > Both flight crew said they immediately donned their oxygen masks. They added that the flight deck door was blown open and that it was very noisy and difficult to communicate. > The flight crew immediately contacted air traffic control (ATC), declared an emergency, and requested a lower altitude. The flight was assigned 10,000 ft. The captain said he then requested the rapid decompression checklist, and the FO executed the required checklist from the Quick Reference Handbook (QRH). As the FO completed the checklist, the captain flew the airplane as they coordinated with ATC to return to the PDX airport. The flight landed on runway 28L without further incident and taxied to the gate. So in this particular instance, when the depressurisation happened at a comparatively low altitude, the pilots did get ATC clearance before descending.
- lisper 3y ago
  In an emergency you can do anything you think is necessary to address it. Source: I’m a private pilot.

dzdt 3y ago

The report seems to mesh with and confirm many details of the anonymous insider account at https://leehamnews.com/2024/01/15/unplanned-removal-installation-inspection-procedure-at-boeing/#comment-509962 https://leehamnews.com/2024/01/15/unplanned-removal-installa.... The bolts were not reinstalled following work on the plug rivets/seal. The official system doesn't record that work was done requiring the bolts to be removed.

stefan_ 3y ago
[flagged]
- 188320356 3y ago
  The report is 19 pages.
- advisedwang 3y ago
  It's a preliminary report, they deliberately avoid including conclusions that might be reversed later but would do harm by inclusion at this stage.
- WheatMillington 3y ago
  Where are you seeing a 100+ page report?
- lambda 3y ago
  Yeah, this is a preliminary report, they only report direct factual findings that they have collected so far, and as they mention in this report, they haven't yet examined the electronic manufacturing records that the insider was referring to. The NTSB is not quick to jump to conclusions; they are very thorough, and they collect and sort through a lot of evidence. It's not surprising that there's information out sooner that says more for such a high profile incident; but once the NTSB final report comes out, it will be quite detailed and thorough, and cover all of this and more.
lambda 3y ago
Yep, biggest new thing here is discussion of witness marks showing no evidence of the bolts, and photo before the rivet repair showing that at least two of the bolts were present, and photo after the rivet repair during installation of the insulation showing at least 3 bolts missing. So this all just serves to confirm that report, and what people suspected for a while; the bolts were just missing, removed for removing the door plug for the rivet rework and never reinstalled.

belltaco 3y ago

>The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording In addition to local storage, why isn't the audio(along with location, altitude and some sensor information) also streamed using something like Starlink or Inmarsat to a secure location where you can store more data for cheaper and with more redundancy?

sv123 3y ago
$$$
outworlder 3y ago
Starlink is a consumer system. Won't happen without a specialized product. Inmarsat is expensive. And we are talking about streaming audio from all planes currently in flight.
- belltaco 3y ago
  > Starlink is a consumer system Not true. https://arstechnica.com/information-technology/2022/10/starlink-unveils-airplane-service-musk-says-its-like-using-internet-at-home/ https://arstechnica.com/information-technology/2022/10/starl... https://cleantechnica.com/2022/07/06/fcc-approves-starlink-for-planes-ships-trucks/ https://cleantechnica.com/2022/07/06/fcc-approves-starlink-f...
skywhopper 3y ago
This is an old system that works well and reliably for pretty much every incident. I’m not aware of another case of this sort of thing (relevant flight recorder data being overwritten) happening in recent years anyway. If you spend time constantly upgrading systems like this you’re asking for a higher failure rate, for very little gain. That said, there’s a standard and reliable 25-hour flight voice recorder that solves this problem. But it’s only used outside the US. That’s a regulatory inertia situation and I suspect this incident will speed changes in this area. However, finally, and particularly in relation to your proposal of streaming cockpit voice recordings to some cloud server. There is some resistance to this (and to longer recordings in general) from air crew on privacy grounds. The privacy issue is less about how much personal info is revealed in a crash situation and more about how easy it would be for a bad actor in management —or whatever operations group runs the audio storage—to listen in on conversations. And you can be sure this would happen if something like your system were implemented without the appropriate regulatory controls (and tbh even with them it would probably still happen).

spdustin 3y ago

Looks like the anonymous whistleblower on Airline Pilot Central Forums [0] was legit. [0]: https://www.airlinepilotforums.com/safety/146074-boeing-internal-whistleblower-re-max-door.html https://www.airlinepilotforums.com/safety/146074-boeing-inte...

yborg 3y ago
I'm guessing twice as much corporate effort is currently being deployed to find this guy than is being applied to fixing Boeing's quality system.

gtmitchell 3y ago

A very thorough preliminary report. I've worked for a long time in quality systems, and this is a perfect example of a systemic failure. They've got work being handed off between Boeing employees and 3rd party contractors with insufficient controls in place to verify that very basic tasks are being performed. I'd be curious to know how many non-conformances they typically see during assembly of a plane and whether management is actually allowing the quality department sufficient independence to investigate these issues and fully resolve them. I'm guessing that the production personnel are under tremendous time constraints and are constantly pressure the quality assurance people to sign off on whatever paperwork is holding up the line, no matter the safety implications. Also, I think a lot of middle and upper level management needs to lose their jobs over this. I hope this mess ends up in textbooks and gets beaten into the head of every MBA student in the country.

lp4vn 3y ago
>I'd be curious to know [...] whether management is actually allowing the quality department sufficient independence to investigate these issues and fully resolve them If management in the aerospace industry works like management in the software industry, then I guess they are pushing for results as agressively as possible without much concern about safety or anything else.
- cezart 3y ago
  At a company I worked in, we had a joke about this: "Good thing we don't build nuclear reactors". In some software projects the level of rush, and the fact that bugs sometimes would leak into production was kinda horrifying. It would've been way more so, if it would've been the kind of project that could kill people in case of failure. Like it happened in Chernobyl with nuclear reactors, or at Boeing with planes. I can't really imagine what these engineers feel when they rush this kind of work knowing what's at stake.
  - toast0 3y ago
    Quality is always a trade-off. If you're deeply into economics, you wonder about the trade-offs of cost to find defects before shipping, difference in cost of addressing defects before and after shipping including costs of mitigation from consequences of defects, % of defects that will never be found after shipping (and are therefore a real cost savings), and in the long game costs of having a reputation for shipping product with defects that could have been reasonably detected. In a lot of software organizations with rapidly changing and undocumented requirements, there's a good chance defects will go unnoticed until they're no longer relevant, so spending a lot to find them before they're shipped is a waste. Mitigation of many software defects is simple, but some aren't; hopefully you know which changes are expensive to fix if wrong, so you can more thoroughly vet those. In Aerospace, addressing defects after shipping is very expensive, and mitigating the effects of defects is only approximate; you can't restore passengers from backup, economic damages don't really make families whole, but should be an incentive not to let reasonably detectable defects be shipped.

ultimoo 3y ago

I look forward to reading a report from NTSB's internet outage.

Hansenq 3y ago

If people are looking for additional in-depth reading on how this happened, The Air Current did a great write-up on this systemic mistake using internal Boeing sources a month ago that the NTSB report fully supports: https://theaircurrent.com/aviation-safety/127-days-the-anatomy-of-a-boeing-quality-failure/ https://theaircurrent.com/aviation-safety/127-days-the-anato...

hn8305823 3y ago

I wonder how close the door plug was to hitting the tailplane or vertical stabilizer/rudder?

reddit_clone 3y ago
Considering all those scary scenarios, what happened was probably the most favourable outcome. It could have been a major disaster hundred different ways..
- mikeyouse 3y ago
  It sure could have -- the plane was still climbing which puts that plug door almost directly in line with the horizontal stabilizers; https://i.cbc.ca/1.7077373.1704733027!/fileImage/httpImage/gfx-dd-alaska-airlines-incident-mobile.jpg https://i.cbc.ca/1.7077373.1704733027!/fileImage/httpImage/g...
  - kayfox 3y ago
    Not as much when taking into account the actual direction of the wind, which would be more inline with the aircraft.

deleted 3y ago

[deleted]

WatchDog 3y ago

> The flight crew reported that the cockpit door had opened during the depressurization event. In a revision to the Flight Crew Operations Manual, issued on January 15, 2024, Boeing confirmed that the door functioned as designed. Interesting for terrorists. Cause a rapid decompression, and get easy access to the cockpit.

bradfa 3y ago
Causing rapid decompression is quite hard. Opening a normal door is very difficult during flight except at very low altitudes.
mihaaly 3y ago
They may go then and blow the whole thing up good insted of such half measures. Sufficiently rapid decompressions may not that reliable and predictable to carry out so I can control the plane afterward easy kind of feats.
ledauphin 3y ago
yeah, this is a significant hole in the locked cockpit door plan.
mlindner 3y ago
If they cause a rapid decompression they incapacitate themselves and won't be able to use the cockpit. Also how do you cause a rapid decompression without a gun of some kind?

mihaaly 3y ago

What is the analogy of leaving out all bolts from that door? 'Forgetting' to put in any of the screws holding a gas tank in place in a car? 'Missing' all welds in one of a skyscraper's lower columns? An 'oversight' of providing rendundant instruments in an airplane with natural tendency to stall? What a hopeless shitshow is going on there behind the company gates that these kind of things can happen in succession? A duck forgot how to swimm, an eagle forgot how to fly, Boieing forgot how to build airplanes?

addaon 3y ago
> 'Missing' all welds in one of a skyscraper's lower columns? Or just throwing the rebar in at random maybe? [0] [0] https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D-how-the-lack-of-proper-systems-puts-a-contractor-at-risk-and-created-%E2%80%9Cthe-nightmare-on-las-vegas-boulevard%E2%80%9D-for-mgm/ https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D...
- mihaaly 3y ago
  Oh Jesus! I seriously thought my hypothetical example is extreme, but apparently not!
- sofixa 3y ago
  > According to an article in the Las Vegas Sun, “Some of the steel, known as rebar, was so badly positioned that it stuck out of the concrete floor and was sawed off to conceal the mistake.” In addition, “Harmon workers reportedly moved rebar without first getting an OK from the structural engineer . . . .which is a major no-no in the construction chain of command. WTF! How was there no punishment for everyone involved in this?

johnflan 3y ago

You gotta wonder how the technician explained away the four leftover bolts after

Jefferyhanson 3y ago

[flagged]

userbinator 3y ago

A lot of comments here are going on about process, as if humans are mindless and otherwise perfectly controllable robots... I'm going to be contrarian and say that this is exactly the sort of thing that happens when you train humans to be robots: They lose all signs of common sense and critical thinking, and what's worse is that on top of that, they'll still have their inherent imperfection. Normally the former would counteract the latter, but not if you only make them rigidly follow some process all the time. They stop thinking about what they're doing. They stop paying attention to all the other things in their environment they would've noticed, and even if they do, they won't question it because they'll just assume someone else also following a rigid process will take care of it. They won't think "this door plug should've been bolted in place now that the work that needed it opened is done, but where are the bolts?" I'm not saying to throw out all the process and make them figure everything out, but I think there has to be a balance, similar to how overautomation and reliance on that has also lead to avoidable incidents in aviation.

projektfu 3y ago
Potentially the result when you rob workers of the right to pride in workmanship. The most common complaint from old Boeing people who have left is that after the merger the McDonnell-Douglas people took over and the company switched from pride in engineering and quality of workmanship to cost cutting and bean counting. Also, shortly after the merger the corporate HQ moved, reflecting the priorities of the CEO. It has since moved again, apparently to be better for lobbying.
- p_l 3y ago
  The original move was also related to lobbying potential. But the CEO who started the moves etc. was a Boeing lifer.
  - projektfu 3y ago
    The original move to Chicago was for lobbying? I figured it was more of moving where the CEO wanted to live.

dreamcompiler 3y ago

Summary: Fuselage was delivered to Boeing with some damaged rivets near the door plug. They had to remove the door plug to fix the rivets. Then they reattached the door plug but forgot to reattach the 4 bolts that would keep it in place. Possibly because of a shift change at the plant. There was noticeable damage to the door plug's mechanical fittings from the violence of it being blown out of the plane. But the holes where the bolts belonged were pristine. That would not have been true if the holes had had bolts in them.

flaminHotSpeedo 3y ago

alberto180 3y ago
[dead]

TurkishPoptart 3y ago

"....after the left mid exit door (MED) plug departed the airplane leading to a rapid decompression" Lol, they said the door plug "departed" instead of "blew the f** off"