Seems like Boeing might not have the documentation the NTSB is requesting[1], even though they say they do keep that documentation. I wonder if Boeing doesn't want to admit that for some legal reason, maybe they don't have a lot of documentation they say they should have.
[1] https://twitter.com/David_Slotnick/status/176545419893241038...
Then they need to do the one thing that will get Boeing's attention: ground the fleet.
Would that be what’s best for everyone?
If you’re being serious, I genuinely wonder if you realize the consequences of this drastic a decision.
The MAX fleet has been grounded multiple times now. Why would this be any different? The grounding after the door flew off was way shorter than the MCAS grounding.
The consequences of continuing to fly this aircraft is likely to continue to find issues of varying severity. It's like playing Russian roulette with 2 bullets loaded.
Because zero people are dead from this issue, it’s relatively easy to inspect for, and isn’t a design problem- unlike the max problems?
Only due to a bloody miracle. If people had been in the two nearest seats they were getting sucked straight out.
That those seats were coincidentally empty doesn't lessen the seriousness of the event.
I mean, it literally does?
If 2 people has died, it would have been a more serious event. By definition, no?
Yours is exactly the kind of attitude that gets people killed in workplaces.
I slip on a puddle, but I'm young and nimble so I catch myself. No harm done to me, not a serious incident right? I don't report the puddle. Then another guy comes alone, he's older, his reflexes aren't so good. He bounces his head off the concrete and dies. This is why all workplace safety policies tell you to treat near misses like the real thing. The only difference between them is circumstantial luck.
That person is a psychopath. The only good thing is that in a competent safety focused org someone like him would be fired instantly.
Beautiful. And what exactly led you to that insightful psychoanalysis?
Especially since I’m not saying it isn’t serious. Just pointing out that 0 < 2 < 189.
Which is quite literally true, is it not?
any number > 0 when counting deaths because of a company's malfeasance, incompetence, or any other word to describe it is serious. since you seem to like superlatives, any number > 0 is the most serious thing. your product killed 1 person in a failure or 189 in a failure is no less damning. even if your product's failure nearly killed some number > 0 is a serious thing.
So now you’re saying it wasn’t serious because there was no one killed? I’m very confused here.
I thought it was serious, just less serious than those that actually killed people, because it does show system issues at Boeing related to actually doing safe changes to their planes.
Which is a scary operational problem, but at least not a major plane design problem.
Which will kill someone (or a lot of someones!) eventually.
And got called a psychopath for it, apparently? Which doesn’t seem very polite.
So now you’re saying it wasn’t serious because there was no one killed? I’m very confused here.
Yes, you've been very confused in this entire thread. No, I did not say what you think I've said. In fact, I stated the exact opposite. You seem to have an agenda and are attempting to read that into this entire thread.
Your prior comment literally says ‘ any number > 0 when counting deaths because of a company's malfeasance, incompetence, or any other word to describe it is serious’. You say that same type of statement multiple times, using >0 every time. Instead of, perhaps, >=.
There were zero fatalities in this incident. I personally thought it was serious, but less serious than incidents which have fatalities.
Are we agreeing? Who is confused here? Am I a psychopath?
That is a completely unfair diagnosis and accusation. Respond to the thing you disagree with instead of claiming that the person you disagree with is mentally unwell.
No. It was a serious event even without casualties. If people had died, it would have been tragic, fatal, or any other adjective. If it wasn't serious, we wouldn't still be discussing it.
And I never said it wasn’t serious, did I?
great, so now we're in a "serious" != "more serious" round of pedantic discourse.
nope for me
unlike the max problems?
what do you mean unlike the MAX problems? do you think this is a different model aircraft. The MCAS related crashes with 300+ casualties was an earlier version of the MAX. The door flying off was still a MAX.
So at this point, we should be well past viewing incidents on a per incident basis, and now just see each one as yet another example of the failure/lack of Boeing's prowess on designing a safe airplane.
MCAS was a design problem, and one inherent from the start. That the FAA (kinda, due to the weird industry setup) approved.
This was an ops problem.
The common element is Boeing, not the model of plane.
The common elements are Boeing and the model of the plane.
The model of the plane is what they are currently producing at scale. What do you want to bet if that changed (and on other models) they have similar problems with those too?
Notably, this type of ops issue (managers pushing for high velocity - paperwork and quality of work be damned) is inevitable when output numbers must go up or stay the same even in the face of other pressures increasing.
We’ve all been there for sure - too many bugs coming in, so mark them ‘can’t reproduce’ the first pass through, or if we can’t figure out what is going on in the first couple minutes. Or put a hack into production to fix it now, with an actual real fix ‘on the backlog’ indefinitely. Or playing whack a mole with problems instead of investigating root causes.
It’s a burnout/realism problem.
Very tempting in ops/QA for the business - and then when something breaks, or a customer gets angry because they’re getting blown off, blame the engineer/tech/QA person and fire them instead of fix the actual cause, which is unrealistic workloads, or bad process, or management prioritization failures, etc.
If you really want to separate them out like that, but that seems pointless. The rot within Boeing seems to have culminated with the fiasco that is the MAX. It was executive decisions and the example that showed for the middle management to follow that allowed all of the issues to happen. Whether it was the lackadaisical nature of how many bolts were installed to the cover up/conspiracy of trying to hide the flight characteristics with MCAS to avoid re-certifying pilots, it's all stems from the same rot
If there are no credible consequences for unsafe practices, they will continue. If Boeing believes their planes will never be grounded unless they kill hundreds of Americans, sooner or later they will kill hundreds of Americans. (We already know from the Max 8 that killing hundreds of foreigners isn't enough to get the FAA to ground an American plane, at least not until it happens multiple times).
A poorly installed door plug may be a one-off mistake. Missing required documentation on the installation of that door plug is a more serious systemic issue. Failing to cooperate with a safety investigation is an even deeper rot. If that's not something that should result in aircraft grounding then what is? Genuine question - how bad does it have to get?
We clearly have all our eggs in one basket when nearly everyone is hesitant to enact common sense measures like grounding every commercial Boeing plane in service--at least on a rotation. Air traffic would grind to a halt. I wouldn't want to be responsible for that either. Especially when it's the friends of all the grey-hairs at GE, Boeing, and every major airline that have to make the call.
The max fleet had already been grounded multiple times, the world did not end.
It was only for a few days, and it was extremely impactful. This was only the 737-MAX fleet that was grounded, which is primarily used for regional routes. The MAX is never used or configured for cargo at this moment.
More importantly, this was only the MAX generation of the 737 fleet. Only ~15% of all 737s in service.
I interpreted the poster as suggesting that we ground all Boeing commercial airplanes. If they just meant the 737 MAX fleet, I still think this would be unproductive now that the acute MCAS issue has been addressed, but it's not as ludicrous as grounding ~60% of the world's airplanes.
They don't need to ground every commercial Boeing aircraft, only the ones that are affected. Most Boeing planes still flying aren't that new. The 767s and 777s all seem fine. Just ground the 737MAX and the SC-built Dreamliners.
I genuinely wonder if you realize the consequences of this drastic a decision.
Well, among other things, an increase in the general public safety vis-à-vis commercial air travel. Plus, I suppose, some kind of material incentive for Boeing and other airliners to take quality control seriously.
Seems like a win.
It's not at all obvious that forcing more auto travel and causing chaos in domestic air travel would result in a net benefit in safety (and otherwise) for the general public. I imagine its pretty nuanced.
Only reason I see for it is a punitive incentive for Boeing. Anything else requires more of an argument, in my perspective.
I'm deadly serious.
Aviation, for a long time, administratively speaking, has been very buddy-buddy. Lots of self-attestation and self-certification. That works as long as you can trust the mfg to actually do it. Boeing has proven with the continuous series of failures of the 737 MAX program - from top to bottom - that they are not trustworthy in that regard.
From here on out they can do everything on that airplane by not just the letter of the law, but the serif. They killed hundreds of people through greed and laziness. Simply put, fuck 'em. If they go under it's because they deserve to. Too big to fail is not a situation that should be allowed to exist. The long term resiliency of the system is worth short term pain.
(Edit: And as dylan604 pointed out in a sibling comment, the 737 MAX fleet has already been grounded on mulitple occasions)
do the one thing that will get Boeing's attention: ground the fleet
Grounding planes to satisfy a desire for vengeance is petty and a bad precedent. Let the regulators make the fly/no-fly call. I’d prefer the politicians explore a break-up of Boeing’s commercial and military wings.
It's not out of a desire for vengeance.
It's out of a desire for them to actually prove the aircraft is safe to fly and operates the way they've claimed it does.
A standard the 737 MAX has already flunked multiple times, with deadly cost.
Modern US Aviation is so incredibly safe it only makes the MAX more abhorrent.
actually prove the aircraft is safe to fly
And, importantly, the process of providing that proof must be open to the notion that it is not safe to fly. It is possible (and IMO very likely) that this aircraft is fundamentally unsound, by design, and that no amount of tweaks and fixes can change that. They made a dangerous aircraft, bullshitted their way through the approval process for commercial travel, and now must pay the price.
But what does that have to do with not bolting the door plugs back in correctly?
That they keep happening to the same airplane.
Don't forget the MCAS fiasco, as well.
Or the engine deicing you can’t leave on for more than 5 minutes because it might start a fire.
That's the point.
The problem isn't specific, it's systemic.
Systemic to manufacturing is not the same as systemic to the aircraft’s design.
In aviation, a manufacturing problem that goes uncaught is an everyone problem. QA should catch it. Ideally software and procedure should back stop things. In the Alaska Air case the pressurization alarm went off on two previous flights, which got the aircraft limited to non-ocean routes, but it was still allowed to fly. These alarms were likely due to the door unseating on prior flights, the dynamics just weren't enough to actually eject it off the rails.
Thought experiment: Let’s imagine that the Boeing design department 20 years ago had whipped out a perfect all-new airplane design and the MAX had never happened. I’ll call its replacement the “797 Pro Max.” It fixes all the things we all agree are unfortunate hacks about the 737 MAX and was designed freshly by people at least as competent as Airbus’s designers. Anyway, couldn’t this type of “so and so took off part X and forgot to properly bolt it on, and nobody made sure that removals were properly documented to ensure safety” problem happen exactly the same on a 797 Pro Max? I think the (very real) design problems really have little to nothing to do with their obvious process/manufacturing problems brought to light by the plug door incident.
Could it? Maybe.
But the 737 MAX Process/Program is known to be defective. I'll take possibly bad over surely bad any day.
You are 100% correct, and it seems there are both systemic manufacturing process issues and systemic issues with the plane design
It is possible (and IMO very likely) that this aircraft is fundamentally unsound, by design
"Fundamentally unsound" seems like a subjective judgement in an area that clearly requires numbers.
Wikipedia tells me there are 1445 of these planes in the air each flying, what, 3000 miles a day on average? The existing accident statistics would argue strongly that this plane is "safe" in an absolute context, even if it's clearly "more dangerous" than other models. The big reason people are so upset about this is that it's a safety outlier in an industry that has been extremely safe, and getting inexorably more so, over the last half century.
I'm itching to see an interview with the software development team that built MCAS. There is no way that they failed to raise questions about using input from a single sensor. It defies all logic.
They did and it is documented.
Mentioned in this film:
* https://www.pbs.org/wgbh/frontline/documentary/boeings-fatal...
It's out of a desire for them to actually prove the aircraft is safe to fly and operates the way they've claimed it does.
At this point I'm more concerned about Boeing's ability to live up to it's obligations as an aerospace company and maker of safe, compliant, no corners cut hardware.
Because even their operational characteristics are such that I'm beginning to strongly doubt that capability. If there is this much smoke...
I'd say doors flying off aircraft, while the manufacturer is unable to pinpoint the cause, is a clear indicator that the planes need to be grounded.
Zero deaths though!
A near miss taken seriously today is a fatality avoided tomorrow.
100% agree.
Hyperbole also makes it easy to dismiss the real severity of an issue by detractors.
Purely by luck. If there was a kid in the seat next to that door, it'd probably have been a fatal outcome. :(
Good validation of the 'fail early' strategy. If the door came off when they were higher up it would have been worse.
However, this failure seems to have not followed a strategy; the result was just luck.
Pretty sure there we zero deaths the first few times MCAS failed.
Grounding planes to satisfy a desire for vengeance is petty and a bad precedent.
It's not vengeance. It is a legitimate fear that Boeing currently lacks the processes in design, development, self-certification, production and quality assurances to reliably produce airworthy aircraft, backed by a number of incidents in the last years - the Dreamliner battery fires, the deadly MCAS disasters (and how they came to be), the loose rudder control screws and now the door plug incident - as well as whistleblower reports alleging widespread QC issues.
No, fire every member of the board of directors and bar them from ever serving on the board of a public corporation again.
I’d argue grounding is more serious as it inflicts pain on their customers as well.
this is a hilarious take. It's certainly more serious for their customers, but is it more serious for the responsible parties (the board of directors)? It seems clearly not.
They all have golden parachutes, I’m sure. What consequences will they actually face even if canned? I’m serious.
You know 'enough money to live very very very well' isn't enough for people who climb to the top to be on the board of such of a corporation. They care just as much about reputation, further ability to work to make more money, and more money.
Observing the whole debacle I very much doubt they care about their 'reputation'
Do you have their names memorized? If you met one dining with their family at a country club, would you know what they did?
Their personal reputations are still largely intact.
Also bar them from serving as an officer of a public company. That will hurt.
You're both thinking too small.
Force the members of the board to constantly fly on the affected models until questions are answered and fixes are delivered.
Call it "ultimate dogfooding".
Planes, even Boeing planes, are the safest form of transportation, at least in the US, if not globally. This punishment makes exactly 0 sense.
Boeings own staff said they wouldn't fly on the 737-Max.
Either they're being hyperbolic and there's zero risk to the board members, or they aren't and thus the board members have a vested interest in making sure the planes become a lot safer a lot quicker.
It's a win either way.
I like this. It's a little bit like the Hammurabi code. It's a very simple way to ensure compliance - assuming that the board member on the plane is competent enough to judge that the plane is good enough to fly on.
Why not both?
Asset seizure and jail time for execs are the only currencies of value .
NTSB cannot do that, it can only issue recommendations that could be acted on (or ignored) by the FAA.
Maybe Boeing execs are sure their FAA buddies are not going to do anything drastic like that anytime soon? It’s not like Boeing the main US military supplier can be allowed to fail right?
A Boeing spokesman disputed Homendy's account in an emailed statement to NPR. "Since the first moments following the Alaska Airlines Flight 1282 accident, we have worked proactively and transparently to fully support the NTSB's investigation," said Boeing's Connor Greenwood
By 'proactively and transparently' I assume Boeing means telling NTSB 'we don't know anything so we can't answer your questions lalala.'
"Early in the investigation, we provided the NTSB with names of Boeing employees, including door specialists, who we believed would have relevant information. We have now provided the full list of individuals on the 737 door team, in response to a recent request," Greenwood said.
Boeing throwing its employees under the bus- 'no we don't have any record of the work. Why don't you bother our plant crew instead. They would know everything because someone does, and it's not us Boeing.'
throwing its employees under the bus
The NTSB is literally asking for names. That’s what Boeing is allegedly refusing to provide.
From the GP: ">"Early in the investigation, we provided the NTSB with names of Boeing employees, including door specialists, who we believed would have relevant information. "
How is that Boeing refusing to provide employee names based on the quote in the comment you are replying. I'm assuming on good faith the GP's quote is from the TFA.
The question is not "which team is responsible for installing or removing the plug?" it is explicitly "which specific people did this specific job?".
Boeing is meant to have the answer to the second part documented - because that's how QA in this type of operation is meant to work: you document the people who did the task, and they document the exact tasks they did, you document the people who checked the task completion, and they document what they checked and the outcome of those checks.
In software terms if it helps the NTSB is asking "which engineer landed this change?" and Boeing is responding with "this is the team that maintains that code".
The reason the NTSB wants to know the exact people involved is not to assign blame. The goal, and sole reason the NTSB exists, is to determine why an accident occurred, so they can work out what needs to happen to stop it happening again. So the NTSB needs to know the exact people involved, so it can interview them, and see what they were doing and experiencing leading up to and during the maintenance work that may have contributed to the accident. These interviews are what led NTSB to find out things like sleep issues contributing to accidents, and so investigate what issues were leading to those sleep issues, etc which is why there are now strict rules about pilot flight times and scheduling changes. These interviews with the actual people involved are _extremely_ valuable for reducing recurrence of accidents.
The fact that numerous other aircraft were found with missing bolts and similar implies something systemic is occurring in the installation of these plugs (imo the core issue is the attempts to make the plugs "permanent" leading to inspection of these connection points being essentially impossible is the core issue, but also that Boeing missed the issue repeatedly shows something else is wrong). So interviewing the people doing the work will presumably shine a light on what is causing the oversights, which again, is the goal of the NTSB.
The reason the NTSB wants to know the exact people involved is not to assign blame. The goal, and sole reason the NTSB exists, is to determine why an accident occurred, so they can work out what needs to happen to stop it happening again.
Anyone who has ever worked at basically any corporation knows this is career suicide. If Boeing ever discloses who that person is, he will effectively be barred from working in aviation for the rest of his career, full stop.
What are you talking about? The NTSB regularly interviews individuals of all sort. This is not career suicide.
I'll state it another way:
If you were an airline, would you knowingly hire the same maintenance engineer who installed a door that failed and nearly killed hundreds of people?
If you were a patient, would you knowingly accept surgery from a doctor who had a documented record of making fatal mistakes in surgeries?
Once this man's name is released, he will be unhireable.
Once this man's name is released
There are multiple unfounded assumptions here.
Just because boeing tells the investigators the name of the individual the name does not “get released”. NTSB reports most of the time describe people in general terms such as “the captain of the accident flight” or “maintainer 2”.
Then the assumption is that it is a single individual, when it is most likely multiple people. (There were multiple aircrafts found with the missing screws.)
Then of course you are also assuming a gender. Not everyone who works on airplanes is a male you know.
would you knowingly hire the same maintenance engineer who installed a door that failed
Yes. Assuming that it wasn’t an intentional act of sabotage, my answer is yes. We don’t get good results by assuming that nobody makes mistakes.
> would you knowingly hire the same maintenance engineer who installed a door that failed
Yes. Assuming that it wasn’t an intentional act of sabotage, my answer is yes. We don’t get good results by assuming that nobody makes mistakes.
And in fact that's the whole point of these interviews. A safety system that fails if a single person makes a mistake indicates a failure of the safety system, not the individual that actually made the mistake. The design of the system is meant to be such that even if one of there was a mechanic that was trying to intentionally sabotage the maintenance it would not result in a safety issue.
So a few points:
1. Pilots, even those responsible for accidents, talk to the NTSB, and unless grossly negligent continue to be pilots. The people who do get blackballed are the ones that actually report unsafe behavior before accidents occur.
2. If someone was unreasonably negligent in a way that caused an accident or death, then they should not still be working in a field that impacts safety of others
3. If conditions at Boeing are what are causing these failures, then not interviewing the people who made the mistake means that the mistakes will happen again, until people actually do die.
I'd like to know if you can point to cases where people who were not entirely at fault for an accident were forever unable to work in the industry, given you're saying that everyone knows it's career suicide I would expect every NTSB report of this kind to have resulted in the responsible parties being forever unable to work in the field, so this should be a long list.
But also, if Boeing knows who this person is, and would fire them because of it, why would they not have already fired them? If they had, why would the person not have gone to the NTSB? and similar basic follow ups to your logic.
It just seems super weird that you're claiming that no one talks to the NTSB because it's career suicide, when objectively the NTSB has spent decades interviewing everyone they can find that is involved in accidents.
The NTSB asked Boeing for the names of the specific people on the team that replaced that door, and they said Boeing hasn't provided that. In Boeing's response, they didn't say they provided that, either. They said they provided "names of Boeing employees, including door specialists, who we believed would have relevant information." If they had actually provided the names of the crew that did the work, they'd have said they did exactly that rather than giving a lawyerish sidestep. I don't even think that the people who'd have done the actual repairs were even Boeing employees. Isn't a big part of the criticism that this work is farmed out? Not positive, though: that could have been work for one of the other recent Boeing catastrophes.
including door specialists, who we believed would have relevant information.
Yes, by telling the NTSB to ask the door specialists "which of you installed the door", instead of having proper documentation on who did exactly what work. If the workers can't answer the question, now Boeing can wash its hands clean and blame the workers.
I doubt the workers themselves keep track of which specific planes they worked on- and they shouldn't need to, this is project management.
I doubt the workers themselves keep track of which specific planes they worked on- and they shouldn't need to, this is project management.
Didn't they find loose/missing bolts on other aircraft? Talking to employees who worked on other planes around this time seems like it would still be extremely important for this investigation.
The aeronautical safety culture specifically avoids blaming individuals, and prefers focusing on procedural and organisational issues. If one person made a mistake, why didn't the rest of the organisation around them catch it and prevent it from causing a problem?
I don't think the NTSB is going to look kindly on Boeing if they even try to throw the techs under the bus.
... now Boeing can wash its hands clean and blame the workers.
That's not what being responsible for the final product means. ;)
Oh my lord that all sounds so seriously bad. I can't even believe this. My grandpa used to assemble landing gears in the 80s for boeing and they kept records of the torque applied to every nut and bolt, in duplicate or triplicate (2 people in assembly would check, and 1 from QA). He would be rolling in his grave right now
The Boeing guy who posted the detailed history of the plane a few weeks ago[1] said something to the effect that they discussed things in a slack-like system rather than enter in the official records system because managers would get upset at KPIs not being met.
[1] https://leehamnews.com/2024/01/15/unplanned-removal-installa...
Double bookkeeping is a bad sign. At best it’s incompetence that causes confusion and errors, and at worst it’s fraud.
I think the NTSB would probably love to interview to the crew who actually used the tools--even if nobody can figure out which exact team used the tools on this exact plane--they probably wouldn't so much as incriminate themselves as to paint a picture of incredibly shoddy quality control. Instead carefully parse that phrase "names of Boeing employees, including door specialists, who we believed would have relevant information" which are all likely management / project-management kinds of positions who are vetted by Boeing.
Did we read the same article? The article I read said the NTSB was seeking the singular person who failed to reinstall the door plug correctly and Boeing was not giving that person up.
I have no love for Boeing, but it sounded like they were trying to _prevent_ some poor line worker taking the fall.
It appears some here aren't fluent in WeaselSpeak.
NTSB wanted the names of the specific people who had removed the door plug.
Boeing then gave then the names of employees who may or may have not something to do with doors, for example, accounting, the chef and the janitor.
NTSB then said that no, they did not want that, they want the names of the specific employees who had removed/installed that specific door plug on that specific airplane.
And then Boeing replied: "Sure, here are the names of our 170.000 employees."
The End.
A&P mechanics are individually tracked, or if not, Boeing has bigger problems. Dicking around with NTSB is NOT good form.
If what the grandparent comment says is true, I agree with Boeing. I HATE Boeing and what they've done to themselves. They had such a leg up on Airbus post A380 market, and squandered it with greed, but I digress.
What good does giving the names of individuals to the NTSB do?
I'm with NASA on this one: There's a process problem and the whole team should suffer not leaving individuals to hang and dry. Except perhaps the executives that allowed this to happen.
What good does giving the names of individuals to the NTSB do?
They can give detailed testimony, eg indicating what the process was but also things like (for example) 'I spent the first half of my shift getting the door plug in place with the help of A and B, and then broke for lunch. As I returned to work a supervisor directed me to work on [something else]. I said the door plug wasn't finished but the supervisor told me it would be taken care of.'
The thing with a spreading responsibility across the whole team is that it gets reduced to an abstraction and the disciplinary measures are ultimately up to Boeing. I think finding the faults in the chain of command requires canvassing individual workers who can share their first-hand experience on the factory floor. Otherwise the whole thing gets blamed on the 'door fitting team', but there isn't any incentive to look at whether similar corner-cutting happens on the wheel teams or the fuel tank installation teams or (fill in the blank).
From what I've read about Boeing's work culture and the 737 production line, I really doubt it was just one unit that didn't pull their weight.
They can give detailed testimony
The incident report can be given this without naming the individual. Technician#2512....
And thusly I agree with your last sentence - it's not just one guy having the problem. There was a chain of failures. If someone forgot to put the plugs back, who was performing the inspection that that confirmed the plug was there? Who is the safety engineer that signs "this plane is fit to fly".
America, esp Senators, like scapegoats. Individuals we can pin the blame on and say "You screwed up! You're fired!" okay, problem solved! I fixed it!
All of Boeing has HUGE problems and naming an individual isn't going to fix it. US Gov needs to go in and review all the steps in details. What are the failurem modes? Between this and the Max, Boeing can't be trusted with its own internal processes anymore.
The NTSB can't get an interview with Technician#2512 unless they know who the fuck that is. They need to know who to talk to. Whether that name is subsequently omitted from public documents is another matter.
I'm with NASA on this one
The way to improve a process includes interviewing the specific employees involved in the issue to formulate process improvements.
I've been the subject of such an inquiry, and while uncomfortable (facing your failings) it is also incredibly valuable when done correctly.
It's fair to say "how much do we trust boeing to do their own internal investigation and properly change the process"?
I think you can get to this without externally naming individuals.
Personally, I'm more interested in "what else is messed up" than the individuals in this specific situation.
Honestly, I don't want to ride Boeing today.
It allows them the opportunity to interview specifically involved people who may be culpable or point to those who are for making decisions that impacted this scenario.
Boeing playing whack a mole with a Federal Agency is just going to be the Streisand Effect of regulatory attention.
I'm frankly ok with Boeing getting a Federally mandated enema until what's left of the firm could be carried in a sandwich bag.
What good does giving the names of individuals to the NTSB do?
It lets the NTSB ask them questions and figure out if it was a once-off error, or a systemic error.
Surely being able to gather information is a key point in identifying process problems. NTSB wont blame them but they might want to speak to them.
What if that person doesn't have the right qualification yet was told to remove the bolt?
What if management was notified that the employee doesn't follow procedures yet did nothing?
It also allows the NTSB to find out whether Boeing did track it's production line as vigorously as it should. They try to figure out where everything went wrong. If there is no paper trail, that indicates that there is a systematic security issue at hand at Boeing, where people can go in and do what they want without documenting it.
It allows the NTSB to know who to interview. That gives them a much better picture and helps validate if what Boeing says is actually true.
Greed isn't the problem here, stupidity is. A smart greedy person adds value for the long haul, enjoying both the greater financial rewards and social prestige of being an all-round good guy.
A dumb greedy person sucks a national treasure dry for a quick bump of profit ($BA has lost a ton of money for years now) and then slinks away to the sound of jeers and booing.
A smart non-greedy person isn't motivated enough to do either, so at least they're not bad.
Well, Boeing isn't providing the work documentation / reports that should exist. Boeing also does not want to admit that such documentation does not exist - the required database lookup for this surely should have completed within the last months.
I do not think this is about protecting individual employees at all. What in the recent history of Boeing makes you think they have a business in protecting employees (or their customers customers, for that matter)?
I find it much more logical to assume that ass-covering operations are in full process. Admitting "we don't have documentation" surely won't bring engineers into trouble, but potentially someone from management into jail (at least one can dream).
Seriously: If you would manufacture ... anything ..., and would be legally mandated to have work reports on file in a database, and were told the serial number of the product, date of production, date of door installation - would it take you more than two months to write an SQL query for that?
And even if so: Again I would doubt it's the engineer who no longer remembers how to write SQL queries would be identified as the person of guilt here.
It helps them root out the source of the problem. I doubt if they're out for blood. Was it a lazy tech? was it ridiculously long work hours? was it a manager pushing his employees to do fast & sloppy work? They want it to not happen again. From what I read about the plugs, the engineering of them is sound if implemented correctly, so it likely lies in faulty processes.
That sounds like it has some obvious ways for the NTSB to play along:
"Alright, sounds good. We've scheduled preliminary interviews with the 170000 employees. Here's the list of 5-minute appointment slots at our office. Please make sure your employees are on time, we expect the first batch of 28800 employees next week. We'll ask them a) whether they have anything to do with the door b) whether they want to report any other unethical practices, then schedule follow-up meetings as needed. No, we can't do this via Zoom."
Optionally one week later: "due to the concerning number of reports we've received during our preliminary interviews, the planes are grounded until we finished the interviews".
However, the article doesn't support your claim. They provided a list of everyone "on the door team", so probably a much smaller number, and they claim they can't figure out who did it because their documentation is incomplete. Which might be real, but also has an obvious solution: Ground all potentially affected planes until they're able to ensure their documentation is accurate.
No, we can't do this via Zoom.
I think an important side note you bring up here is that remote work ISN'T really feasible in many cases, and being in person creates a huge difference in results.
Well, the article somewhat supports my claim if you read between the lines (remote the WeaselSpeak).
But on a somewhat more serious note, my view on this is:
I run a small company. We produce small-business electronic devices.
If you would give me the serial number of one product produced 15 years ago, it would take me less than 2 minutes to query our database of work reports, showing which employee had produced it on what date and time, using which components, coming from which delivery lot.
It would also be impossible that someone "forgot to put that in". You have to log in. You have to scan the device to be built. You have to scan the parts. You have to scan the finished product. There is automated QA. And there is manual inspection. Repair means - scan and go to step 1. You can not delete records from this database, unless you are a system administrator, and if you are, there are offline backups.
And this is the minimum legal requirement in regards of product safety according to UL. For things that reside in homes on offices, not in the sky.
"The dog sadly has eaten our homework" should be technically and practically impossible. It can't be possible by a single entity to forget this, let alone possible for multiple different management layers departments (production, QA, Compliance Management, whatever) to all on this one day having had "bring your kid to work day", while all going out smoking pot while the kids are building the airplanes for that day :) - Either these work logs exist, or they have been intentionally (!) not produced, or they have intentionally be purged. There is no such thing as "can't find" in this regard.
To ground the planes may be good for aviation safety. But it also hurts the wrong people.
But what really needs to happen here is to someone go there, knock down the door, and ground the management until the work reports are produced, or management guilt be admitted.
It is shocking that the NTSB clearly does not have such powers, and that after more than two months of obvious stone-walling still have not been provided with any such powers. It should not even have come to the point of "If you won't provide the work reports, can we at least talk to the employees, pretty please?". They are supposed to be the regulatory authority.
Where is the A-Team when you need it?
You’re making a lot of leaps here. Neither what NTSB said nor what Boeing said remotely insinuates what you said.
Easy solution here is for every traveler to refuse to buy seats on a Boeing plane. If we honestly believe the company was at fault and has been negligent in their safety protocols, it seems like an easy answer to just not support their business.
I think you may have mistyped “Hypothetical” as “Easy.” Given Boeing made about what, 60% of the full size jets domestically, and their only competitor is backlogged for a decade or so, for people to comply with that plan would also require that about 60% of air travel just be cancelled for the next 5-10 years. Which, coincidentally, would actually bankrupt all the airlines that we’d be asking at the same time to replace 50-100% of their working airplanes with very expensive new ones.
In summary, this isn’t something we can really seriously attempt. Btw i say this as someone very disappointed in Boeing, not as a defender of their bad decisions.
"too big to fail" strikes again.
It's almost like we shouldn't have allowed things to get to the point where the world's passenger jet liners are only built by two companies. The M-D merger never should have been allowed.
This is the real learning here, but this truth can't be talked about. Boeing is a symptom, not a cause.
The FAA grounding all planes Boeing planes (of this model) would be a more practical path to the same, executed through proxy collective action.
for people to comply with that plan would also require that about 60% of air travel just be cancelled for the next 5-10 years. Which, coincidentally, would actually bankrupt all the airlines
You are saying this as if it was a bad thing.
And Boeing of course knows this, and this is exactly why they're so brazenly ignoring NTSB requests.
It's only hypothetical if people are willing to fly on Boeing planes anyway. The current level of air travel isn't necessary, neither are airlines. Sure the industry would be trashed, but if that's because passengers lost faith in both Boeing and airlines willing to keep them in the air then there really isn't anyone else to blame.
Why should we assume that air travel can't be meaningfully reduced and that passengers can't possibly decide to drive or stay closer to home?
I'm specifically referring to consumers here though, not oversight or regulation.
Consumers wouldn't be asking airlines to replace planes, they would simply be saying they're unwilling to fly on the planes airlines are offering.
Consumers don't have a concept of "too big to fail" - that's a government concern. We individually decide what we want to spend our money on, its as simple as that. If people were actually concerned with Boeing they'd stop flying on Boeing planes.
Easy solution here is for every traveler to refuse to buy seats on a Boeing plane
Most travellers don’t care about this. (I’m a frequent traveller and have aerospace engineering and pilot training. I barely care about it from the perspective of a flier.)
The leverage is with the regulators and airlines. Calling your elected is orders of magnitudes more meaningful than complaining to the gate agent or silently re-booking. (And from what I’ve heard, barely anyone is calling.)
Given Boeing's market share the move would be to stay home rather then complaining to gate agents or re-booking.
Elected officials will do almost nothing here. Any government led solution will take years and be heavily managed to ensure the stability of the airline industry, meaning the government will do very little as any meaningful change will cause economic and political damage.
the move would be to stay home rather then complaining to gate agents or re-booking
Zero marginal effect.
Elected officials will do almost nothing here
When did you last speak to your elected?
I had senior staffers from a few Senators in my house the other week. This came up. The number of calls logged on the issue was minimal. If there had been interest, something—like expanded NTSB powers—would have gone into the funding bill. That didn’t happen because it’s clear voting Americans want cheap flights, not a fight with Boeing.
If someone can’t bother to call, they won’ canvas or back a primary challenger. (They may not even vote.) That makes them safe to ignore. If someone is persistent, or more meaningfully, able to organise, that gets attention.
This is a worn drum for me because I regularly see bursts of brilliance on HN epitaphed with a political nihilism that guarantees its ignorance.
Zero marginal effect.
I'm not sure how customers deciding to stay home rather than fly on a Boeing plane would have zero marginal effect. That would leave something like half of the current flights empty.
That didn’t happen because it’s clear voting Americans want cheap flights, not a fight with Boeing.
I agree with you here completely. My point is that there is an easy solution, if anyone actually cares. We get these news cycles of topics that people seem to get wound up about in the moment when they actually don't care at all.
Where we disagree here is that elected officials couldn't fix this if they wanted to. At best they could ground all Max's for a period of time, but that won't fix the company. The government can't afford to lose Boeing, even for a period of a few years while the company gets it's shit together. Boeing has too much of an impact on both the airline industry and the military for the government to have any real room to deal with the problem.
not sure how customers deciding to stay home rather than fly on a Boeing plane would have zero marginal effect
The people who would do that are small in number and not frequent fliers. They would be summarily replaced by others on the margin due to price alone.
government can't afford to lose Boeing
We couldn’t afford to lose the auto manufacturers. Didn’t stop us from forcing them into bankruptcy, wiping their shareholders in the process.
When necessary, the U.S. government is incredibly powerful. It’s simply ordinarily restrained in its exercise. The problem is people don’t care about this issue, so an elected prioritising it over what voters do mobilise around is wasting political capital.
Not sure, many booking websites have added a toggle specifically to opt out of those planes
Asking the consumer to help dethrone a government supported monopoly is a sick joke.
I'm not sure if Boeing would be considered a monopoly, Airbus also has a large market share. Why shouldn't consumers step in to avoid traveling if they don't consider it safe?
If it is safe enough to travel, we can all stop talking about Boeing and the news can let the story die.
What a bold statement to make out loud, all at once.
In addition to making big flying things that don't seem to be as good as they were before the MD camel-fucking merger, Boeing is also a strategic defense contractor making the company TBTF. Hell, the Obama DOJ ran press interference countermanding the NTSB over the Jamacian AA331 737NG crash and Obama said he was "[the Boeing] salesman-in-chief".
I would settle for major booking sites to provide a clear filter for Airbus. Not everyone will use it but it'll go a long way for those of us that do care
So at first NTSB asked "do you know who did it?", and Boeing said "no we don't". Then NTSB asked if they at least could get the list of the employee team who would have been responsible for performing that task and that's where the disagreement is, whether the names were provided or not.
Investigators have also been seeking the names of the 25 Boeing employees who are part of the team that opens and closes door plugs. But so far, Homendy says the plane-maker has not provided those names.
"Early in the investigation, we provided the NTSB with names of Boeing employees, including door specialists, who we believed would have relevant information. We have now provided the full list of individuals on the 737 door team, in response to a recent request," Greenwood said.
I wonder if NTSB is seeking to at least interview the whole team to see what they say. Would they even remember that long ago who did what? Or I guess they are after more evidence that this kind of stuff just happens routinely. Though I think it's seems quite clear it is.
Would they even remember that long ago who did what?
The plane in question was manufactured last summer, IIRC.
Yeah, I don't know what I did last summer. Especially at work, unless you've got logs to remind me.
And if Boeing had logs, they probably would have shared them.
I hope it’s sarcasm. I have git logs to look at. You’d think Boeing would have more than that.
I mean, what was I doing on September 19, 2023? IHNFC. I could look at work logs and notes, and my personal calendar and guess. But if I did any work stuff without detailed logs, I might be able to tell you I did X or Y, but unless it was special, I wouldn't be able to tell you much in detail or why I did a routine task one way or another.
Boeing does have logs for some operations, but based on the preliminary report, and that one forum post, and this hearing, it seems highly likely that this plug opening and closing was not documented. It would be interesting to know if other openings were or were not. Unsourced reports indicated many fuselages needed rivet repair, so there could be several examples to look at.
I remember what I was doing on 19th of September 2023. Just checked my email and I can clearly recall the day. I was getting ready for a business trip the next day, which was my birthday, too.
The question is not what they have or don't have, the question is what they should have. Someone was doing the job, someone signed it off, someone clocked in to start the work, clocked out after work. Who did what can be inferred. At least you'd hope so. These people aren't building model aircraft...
Airplane maintenance is not YOLOed. Logs must exist. My mechanic logs every thing he does on my plane. Else it cannot fly legally. Lack of these logs might be a serious offense in of itself.
Oddly your mechanic is much more tightly regulated maintaining your plane than he would be if he got a job at an airplane factory.
I believe we are well into the "not fly legally" territory when it comes to Boeing and the 737 MAX
But you aren't Boeing. What you did last summer has no bearing.
Problem being that Boeing has a history of not sharing their logs and misleading the NTSB, which has cost lives in the past.
I would guess they're more interested in the processes and structures involved that allowed something like the plug door falling off to happen. The best way to find the issues is to talk to the people who deal with these processes day to day, especially in regards to these door plugs and whatever documentation about the plane may be available.
For an individual employee that usually falls into the bucket of "While I have no explicit memory of such an event. In the event that someone had instructed me to perform such a task I would have performed the task consistent with the training and procedures provided to me"
That would also be my guess, the NTSB is not generally interested in assigning blame to individuals, they’re interested in finding systemic and structural failures.
John Oliver absolutely roasted Boeing, in this week's main story: (Link won't be available until tomorrow).
Watching that, I couldn't help but remember my father (who hasn't worked for Boeing since before I was born) saying in the mid-90s:
McDonnell Douglas bought Boeing with Boeing's money, which is a great trick if you can pull it off.
Similarly all of the great software engineers I've worked with did a stint at Boeing that coincidentally ended when MD bought it.
Every MD employee I know (grand total of 2) left the company after the Boeing merger and thought Boeing ruined everything. The two people that I know were in the space sector however, so it could be different depending on where in the companies you were.
While I agree that Oliver did a pretty good job skewering Boeing in the ~33 minutes allotted I'd argue that Peter Robinson does a better and more complete job in his 2021 book Flying Blind: The 737 MAX Tragedy and the Fall of Boeing.[0]
What I find most sad about what Boeing has become is that it was so predictable. I worked as an outside contractor at various Boeing locations in Washington and Oregon installing, maintaining, and training on the operation of CNC milling machines in the mid '90s and early 2000s. I was there before and and in the early days of the merger with McDonnell Douglas. In those days the pervasive sentiment among the machinists, engineers, and managers, many of whom had spent two and three decades working for the company was that the merger was going to get people killed. Sadly, those predictions came true even if it took longer than some may have expected.
[0] https://www.penguinrandomhouse.com/books/646497/flying-blind...
“Merger”… functionally it was more like a SPAC. Boeing buys McDonnel Douglas with shares with a bonus of letting them control the board. Boeing just announced their acquisition of spirit aerosystems, same company responsible for the fuselage mishaps. Somehow I doubt they’re buying them for any of their aerospace expertise, but rather to go in and burn all their records.
The Boeing of old has been long gone since you were last there. It’s all run by MBAs now whose sole purpose is to minimize how much engineering can be done by the company.
Expect more deaths in the future. They seem very content continuing to solve systemic engineering problems with only business strategy.
its available on yt. uploaded 3 days ago.
https://www.youtube.com/watch?v=G-dJMqpGvjM
(don't know if its blocked in the US)
Blocked in Canada as well but a good VPN fixes it
search for Last.Week.Tonight.with.John.Oliver.S11E03 on https://sunxdcc.com (I think it's the correct episode.)
When you're in the thick of it, it's sort of a "frog-in-pot" effect where you just notice that things are bad and have been for a whole, but when taking a few dozen big steps back and looking at the whole thing in its gross entirety, from 1990s to now . . that was awful.
And Oliver didn't even spit in the direction of the wall-to-wall screwball comedy of fail from the BDS side of things. They've not been having a great time, and to this day the discipline of performing on fixed-price contracts seems to elude them.
Phantom Works and BGS legit have the best claim to success, but BPW is, well, tiny - they do black research stuff. And BGS . . BGS is an enigma. One big financial success of that org is def due to how Boeing's structured internally. Howayyyyyyver . . there is a reasonably-high-probability BGS cycles refurb parts as new on the regular[1]. Also supplies the greater Boeing org with an excellent stage venue for Depreciation, the Amazing Accounting Dog. Amusing cash tricks had gotten them a loooooong way in the ZIRP era . . but those days are quite gone.
[1] Something Boeing gets fined for ever other year, and not just inside BGS, either.
Why wouldn't they? It is a business secret that helps them to reduce cost and be competitive.
Because the NTSB's authority to investigate overrides US trade secret law.[1][2] The NTSB has unusually strong investigative authority, including:
(3) Require, by subpoena or otherwise, the production of evidence and witnesses;
(4) Enter any property where an accident subject to the NTSB's jurisdiction has occurred, or wreckage from any such accident is located, and take all actions necessary to conduct a complete investigation of the accident;
(5) Inspect, photograph, or copy any records or information (including medical records pursuant to paragraph (b)(2) of this section), and correspondence regardless of the date of their creation or modification, for the purpose of investigating an accident;
(6) Take possession of wreckage, records or other information if it determines such possession is necessary for an investigation; and
(7) Question any person having knowledge relevant to a transportation accident.
[1] https://www.law.cornell.edu/cfr/text/49/831.9
[2] https://www.govinfo.gov/content/pkg/USCODE-2021-title49/pdf/...
It kinda seems like the NTSB doesn't really need Boeing's cooperation. Apparently they can just waltz into a factory where an accident occurred and talk to whoever they want and look at whatever records they want.
I wonder why they aren't doing that yet?
Because it’s better to let the criminal lie to investigators before you go nuclear on them, it strengthens the case if you can document intent to mislead and lie, and removes the opportunity for lawyerly “this is all a big misunderstanding that could have been avoided if they just asked, your honor!” defenses.
The NTSB tries not to be adversarial. They're not a law enforcement agency. They analyze accidents, figure out what really happened, and produce technical reports. The goal is to prevent repeats of the same problem. Decades of this made aviation safe.
Usually, everyone in aviation is very cooperative with the NTSB. For Boeing to be uncooperative is extremely unusual. That's a strong indicator that Boeing's safety culture is dead.
The last time the NTSB encountered stonewalling was when Tesla (Musk, actually) was uncooperative about that crash where a Tesla on autopilot rammed into a large white semi-trailer, with no automatic braking at all. Musk threatened to report the NTSB to Congress. Nothing happened to the NTSB, and Tesla had to do a recall.
I don't know necessarily for the NTSB, but the usual standard for these safety agencies is that their work cannot and shall not be re-used in criminal or civil proceedings. We'd rather find the cause and improve safety than send somebody to jail if we can't have both.
It may be different in the US because Americans are so blood thirsty (e.g. they still have and use the death sentence!) but that's how such an agency is usually intended to secure co-operation that you wouldn't necessarily get if you were law enforcement.
So they don't have process records for work on an airframe. Yikes. That is worse than I expected.
This is exactly what you should expect. Documentation is corporate frauds biggest enemy. If you are going to commit crimes and kill people, it's far better that you don't have records of incompetence even if lack of records is itself a display of incompetence.
Official logs of problems can give you insight into how deep rooted and severe the issues are. Lack of documentation means there are problems but allows them to hide the depth of them. E.g. we can't know how many other door plugs were shipped without bolts
What type of fraud are you going to commit during airplane assembly?
Cutting corners where you are not allowed to cut them.
Saying you did something when you didn't, or saying you didn't do something when you did.
Yes, but generally this seems to be close to the cause of why this became a problem (that is, bad documentation may be why the bolts were not replaced to begin with). The anonymous, ostensibly internal whistleblowycomplainers said this was a process-documentation problem a while ago, before the NTSB looked into this exact problem.
There is a huge amount of context in an early whistleblower report [1]. This reported before the FAA did the likelihood that the bolts were not reinstalled and the problems with the documentation.
Per that whistleblower account, the door plug removal was not documented in the official records system ("CMES") but the required work was discussed in an unofficial system ("SAT") including whether or not an official record should be made. Boeing concluded the work could be done without an official record in CMES. Per the discussion on SAT, the official "removal" record was not needed if the operation was treated as an "opening" instead, despite the safety-critical bolts being removed in either case.
The FAA obviously will have problems with the entire system that lets factory workers do safety-critical work without official documentation, standards, or oversight. So they will want to talk to enough people to understand how that system is understood in practice on the factory floor and how it came to be.
Boeing it seems has tried to limit them to talking to people directly involved with the Alaska Air incident work. Hence the current heated pushback feom the FAA.
It may also be that Boeing is playing coy about the relevant discussion in SAT, or about the existence or nonexistence of policy distinguishing between door plug "opening" and "removal". In any case the FAA wants everything and Boeing has been trying to get away with less.
[1] https://leehamnews.com/2024/01/15/unplanned-removal-installa...
That side process is like nothing I have ever seen: Such things can, and at every reasonable place I know are, tracked as non-conformities on the corresponding work order and reviewed and approved by quality. If no work instructions exist yet, a singlenuse on is created, checked and approved before the work is done. For having the idea in the first place of allowing some side discussions on whethe or not documentation is necessary should have someone get his ass kicked. And it should be a major audit finding, which it seems it is for the FAA.
Boeing is in trouble, I'd say.
That side process is like nothing I have ever seen
There's been a story about Googlers avoiding chat history as much as possible when discussing topics that could cause trouble with discovery, and actively destroyed evidence or attempted to after they had inadvertently left history on.
https://ia601707.us.archive.org/28/items/gov.uscourts.cand.3...
Googlers avoiding chat history
Oh, so that's why they keep churning thru chat apps.
Yeah I would have thought there would be a clear line -- something like "if you are touching the airplane with a tool there needs to be an official record associated" -- and no room for further discussion around it.
Im very broad terms, that's the way of doing things I know.
Boeing, Apple and few other companies are losing their way. They do not care about customers anymore and for few extra cents they do everything within their power, including endangering customer lives.
This is how all large companies have always worked. That's why the solution of hoping they'll be nice has rarely worked out. You want companies to behave themselves? You _regulate_ them.
(There actually _is_ a partial market solution; if a company engages in sufficiently objectionable behaviour, or is sufficiently poorly run, it is unpurchasable by a lot of funds. It's a relatively low bar, though; despite being so poorly run that it is apparently unable to build planes reliably at all anymore, Boeing has an ESG score of 40. Which is _bad_, and worse than any other major aircraft manufacturer, but is not sufficient to make it untouchable.)
I don't think it necessary is. This is companies prioritizing short-term over the long term.
In a world of cheap junk made by DNURES or some other six capital letter oversea retailer it seems that a strong brand name is more valuable than ever. But so many companies are throwing it away by making the same crap that those effectively no-name companies are. So why would I pay more for the same junk. But if they had a reputation of quality I would be happy to pay the premium.
For Boeing the equation is probably a lot different. But it is clear that there is little consideration for the long-term in the market.
This is companies prioritizing short-term over the long term.
Well, it is, but realistically that is almost what the dynamics of the situation _forces_ them to do, particularly over the sorts of timeframes that aircraft manufacturers run on. Taking the 737 MAX project as a whole, to the outside observer it would seem obvious that Boeing should have designed a new-generation plane to effectively compete with the A32X family; this would, _in the long run_, clearly have paid off.
But if you're the CEO of Boeing, considering a project with a 20 year payoff period, well, in 20 years you're probably not CEO of Boeing anymore, if you're even still around at all. Selling very long-term investments to the public markets is also not necessarily easy. So "squeeze another few years out of the 60 year old design, at any cost" starts to look like an attractive option.
On: > But if they had a reputation of quality I would be happy to pay the premium.
I don't think that _really_ applies here. There are about twice as many A32Xneo orders as 737 Max orders, and it it fairly clearly the market's preferred plane, but if you want an A32Xneo today, you're going to be waiting _years_. As long as the 737 Max can get off the runway at all, it has a large captive market.
(Part of the problem here is that there are only really two companies who make planes in this size class, and again that fact is a failure of regulation; both Boeing and Airbus are products of mergers which should arguably not have been permitted.)
Yeah, but iPhones don't fall from the sky with hundreds on board. I'm hardly a defender of Apple but I don't think it really matters here
Wait, how has Apple been endangering customer lives?
It's about a matter of time Boeing disappears, forcefully by the sole aspect of having every other country stop buying Boeing and buy Airbus only. American companies need to start learning that profit seeking has its limits when it comes to using a single sensor to recalibrate your plane or not installing bolts that make your plan doors fall off mid-flight.
In fact, I find it pretty crazy, at all, that the 737 Max, turned out to be just a 737 that had been rehashed to support a much stronger engine via some incredibly complex mechanism of balancing their plane, as if mechanical systems never failed before. Planes are hard enough as they are, let alone cheapening out on designing a new airframe because you think you can get away with this sensor garbage.
Even if Airbus could suddenly double capacity over night, a duopoly already is quite bad for consumers (aka airlines). They certainly don't want to create a monopoly.
American companies need to start learning that profit seeking has its limits
It has no limits when there's no competition. That's the situation Boeing is in right now: Airbus already has more orders than it can handle. All the Boeing customers defecting to them would only mean they won't get any new planes for 10+ years.
American companies need to start learning that profit seeking has its limits
Why do only American companies need to learn this? And in the same response, explain why non-American companies haven't stopped buying Boeing, since it isn't for economic reasons (since they don't profit seek)
Airbus can’t meet demand as it is, but it seems like a golden chance for an aircraft maker in Asia to enter the market more strongly.
Wait I'm confused... From the preliminary report we know that the door plug was removed by spirit to fix their damaged rivets, and it sounds like the NTSB had documentation to support that as of when they were writing the preliminary report. Quoting from that report:
Records show the rivets were replaced per engineering requirements on Non-Conformance (NC) Order 145-8987-RSHK-1296-002NC completed on September 19, 2023, by Spirit AeroSystems personnel.
So why is the NTSB looking for Boeing personnel?
That paragraph continues ...
Photo documentation obtained from Boeing shows evidence of the left-hand MED plug closed with no retention hardware (bolts) in the three visible locations (the aft upper guide track is covered with insulation and cannot be seen in the photo). This image was attached to a text message between Boeing team members on September 19, 2023. These Boeing personnel were discussing interior restoration after the rivet rework was completed during second shift operations that day
I think number one, they're asking Boeing, because Boeing keeps the records. But also, because Boeing employees were working on the plane, and it was at a Boeing facility.
That there is no record of attaching the bolts is consistent with them not being attached, of course. But there's also no record of the plug being opened or closed, and yet it was.
Right, I get that there's no record of the door plug being opened, which is ultimately on Boeing, but the repairs for the damaged rivets, which require opening the door plug, were performed by Spirit employees.
Well, I’ll never fly with 737 MAX, that’s for sure.
If you have frequent flyer status at any airline, the higher status the better, make sure to let their customer service know. It appears that economic pressure will be the only way to eliminate these aircraft from public use, as the regulators are working with the manufacturer for ways to keep them in service indefinitely.
I guess the question for Boeing is simple: is it better to be incompetent or negligent?
Boeing might believe that they have hit rock bottom...or their PR firm might believe that. There are miles more to go before they hit bottom.
I mean, if they can't produce complete records for any airplanes what happens?
And really, who are they protecting at this point? Their insurance won't cover negligence...but their customers won't accept incompetence.
Their insurance won't cover negligence...but their customers won't accept incompetence.
Why wouldn't they? What choice do they have? It's not like they can call up Airbus and order some new planes to be delivered this year (or the next, or the next, ...).
So where are the severe consequences here?
Surely when lives are at stake there must be consequences for companies breaking the law...
is that an earnest question or are you just trying to draw attention to the fact that that's not how any of this works?
in case of the former: that's not how any of this works
Boeing seems to think dealing with the NTSB is like dealing with the FAA. Would love to be a fly on the wall in their lobbyist's offices rn.
They've screwed around with them before. Passengers and aircrews died because of it.
its giving obstruction of justice vibes
Philip Morris. Exxon(Mobile). Boeing.
Profits above all, and internal awareness of the greater unpaid costs... buried.
I know my list is incomplete, but you get the idea.
The schtick about blah blah blah "raises serious questions about quality and safety at Boeing" is downright ridiculous at this point. Almost condescending in that Boeing management literally has everyone by the balls.
We are far beyond the profound insight that something is deadly wrong at Boeing, and as a matter of national security upper management needs purged. Whoever is selecting CEOs has to go. Total house cleaning.
There was a deferred prosecution agreement with Boeing that expired shortly after the door blow out.
I saw a news item that said the DoJ was investigating whether Boeing's subsequent behavior violated the agreement.
It takes a bit of arrogance to stonewall the NTSB in light of such an agreement.
Not sure if this was edited in later, but it's in the article:
In which case the NTSB will hopefully pin the blame on the lack of a functioning system of record that tracks such events.
Easy solution: Find the common manager of everyone that could have screwed the door up, and hold them responsible.
There are two companies and multiple teams involved. It sounds like this is a process gap. One company has a process that states to remove and reinstall the doors but doesn't mention checking torque. Second company takes over and their procedure states to check fitment but not torque.
Something like that is likely what's happening here.
That's quite plausible, but at some level in the hierarchy, there is someone who has the responsibility of not letting things fall through the cracks - if no-one else, then it is the CEO.
If outsourcing is a de facto means of avoiding responsibility, then guess what the consequences are.
This may be satisfying but does nothing to prevent a recurrence. Fixing the process is much more useful if you want safer aircraft.
Why should public money fix a process that will help Boeing shareholder value?
The executive leadership should lose their own (potential?) personal money over this incident. Until that happens, nothing will get fixed.
We don't know the specific process failure. While I appreciate your anger, it's a bit premature.
It is not sufficient, in itself, to prevent a recurrence, but adjusting the incentives to encourage preventative measures is a time-honored and generally effective way of getting results. It is more effective than shrugging one's shoulders and saying "It's so complicated! It can't be helped..."
Wouldn't the be the CEO?
Presumably you’d want the lowest common manager within the power structure.
Unfortunately that's still the CEO. The problems with Boeing are company wide.
The current one's only been CEO for four years; the structural problems presumably are older. Like, they probably _should_ consider losing the CEO, but that in itself is not going to fix anything.
The CEO has been on the board for much longer than 4 years though. And I agree that losing the CEO isn’t going to fix things. But putting leadership there that places safety above share value will. And the CEO is part of that leadership that needs to change.
Dave Calhoun was a member of the Board of Directors loooooooong before he was crowned CEO. Since 2009. Dave knows where all of the bodies are buried. In fact, he was on the board, and it’s lead director, when the 346 bodies of the Lion Air and Ethiopian passengers were buried. The man has blood on his hands.
You must be new here.
But that manager worked so hard to be the person who gets to decide who to blame!
Finding someone to blame isn’t the point. That’s for the influencers, politicians and armchair commentators. Engineers should seek to find solutions; the NTSB and FAA have a terrific track record in this respect.
Can you really do that though?
You have to trust your workers to not undo some random bolts here and there at some stage.
so its worth clarifying something because 'plug door' is a confusing term as it relates to the bolts. The issue here isn't about trusting workers to do things, its about systems and processes to ensure they know what the right thing to do is and they know how to do it correctly. You CAN (and SHOULD) use things like checklists to ensure people do each job correctly. There are tens of thousands of 'jobs' in an assembly like this - no one knows/remembers exactly how to do each one correctly, nor should a system expect rely on them doing so. Here's how that happens without anyone doing something 'random' and following their instructions as they understand them:
There are doors on an aircraft - you enter through them, they have inflatable slides attached. Then there are plugs - plugs that fill a space (this is one, there are a lot, basically any penetration of the pressure vessel). If there were a space where a door could be but isn't on this model, you need to plug it (hence, door plug or...plug door). In terms of assembly, maintenance, operation, etc. they have different functions and those functions have different documentation and traceability requirements. Doors are meant to be opened and closed - that is different from being removed (i.e., 'taking the door off its hinge'). That leaves us here:
* Doors can be opened and closed (this does not require documentation because it is part of the normal function)
* Doors can be removed, which is different from opened and closed (requires documentation because it is not part of its normal function, requires inspection after reinstallation)
* Plugs cannot be opened and closed (opening and closing them is not part of their normal function so...to whit...doing so is impossible within the vocabulary/concept of documentation rules, they are not designed for regular use)
* Plugs can only be REMOVED (documentation required, inspection required just like a door removal)
Where does that leave the door plug? is undoing the bolts and pushing it up off the stop blocks opening it or is it removal? In the minds of Boeing and the FAA - that is removal. In the minds of line workers, opened a door.
Suddenly, door plug and plug door become potentially different concepts. One is a plug for a door and is discussed and documented like a plug. The other is a door that serves the purpose of a plug...and is discussed and documented like a door. What seems to have happened is that workers opened the plug , which isn't 'possible' - meaning they 'removed' the plug and treated it like opening it. That meant it didn't trigger anything about a required set of procedures to do so, didn't trigger inspection, didn't trigger documentation, didn't trigger inspection, just got closed up and moved down the line.
I've dealt with a lot of these...a personal favorite was a company I worked with having someone who couldn't read be responsible for recording each serial number he stamped on each federally tracked part in our factory. He relied on his memory of the last serial number he did the day before.
I thought the plane eas delivered with the plugs missing because a contractor failed to install them.
It’s in the article (and every other article written about this debacle).
The plug was of course installed when the plane was delivered, otherwise there would have been a door-sized hole in the side of the plane when it was delivered.
The bolts of the plug were probably originally installed, but some rework was required in the area during final assembly, which required the plug to be removed and put back, and during that process the bolts were not reinstalled. It’s (lack of) documentation of that removal-and-reinstallation that are the subject of the article we are discussing here.
Lets be clear - I do not know the answer to this.
What I have read varies. Some say the door plug was installed and bolted. Some say the door plug was installed but not bolted. Some say the door plug wasn't installed - which I suspect from a lot of prior experience is a linguistic gap between engineers and reporters on installed but not bolted.
I remember reading but can't find at the moment something suggesting that inspecting the door plugs and the bolts was a required Boeing assembly line 'job' (think 'ticket'). But none of that matters if someone, as has been reported, later uninstalled the bolts to fix something else, without creating a record of doing so, because they misunderstood the specific procedure they were undertaking.
If they really do allow line workers to interpret federal regulations themselves, that's quite a problem. But I doubt this was a decision made by someone that turns a wrench.
But what if there's absolutely no documented process involving those bolts at all? Its perfectly reasonable to ask what the process is and who is responsible. Boeing acknowledges they don't have an answer here. Is it because they never had a process for those bolts to begin with? You can't document following a process (or not following one) when there is no process at all.
The process to do something undocumented could be to plan and write down what you are about to do, record the before during and after states file the documents.
Alternately the process should be to do nothing until the system studies the action and defines the process. But even then you have a proofing run where you probably should have extra documentation. And arguably in a high safety environment- this would be preferred.
Back upstream to the source of the problem, too much rework was already being required by the time the components got to the Boeing assembly plant (i.e. the Spirit techs onsite doing repairs).
In an environment where process exceptions are the norm, people begin to deprioritize handling exceptions properly. Everything can't be critical or emergency all the time.
And once that deprioritization happens, safety critical process exceptions begin being treated like all other exceptions. Because they're all exceptions, and there are so many.
And eventually normalization of out of bounds situations via repeated team exposure leads to catastrophe.
NASA lost two shuttles via the same organizational problem.
That’s all very true, but just a casual opinion, I think Boeing's process problem is more one driven by prioritization of profits with management corroding the safety culture vs nasa procedural breakdown missing risks because of routine complacency of many previous launches.
Then Boeing management is responsible for not realizing the process was missing. Peoples lives were at stake here.
I worked on airplanes in the long ago. You have to trust that people document every bit of their work and get an inspector to sign off on it where required and get in process inspections sometimes too depending on the work. Nobody who does undocumented work on an airplane should be employed.
If you have a culture in a highly regulated industry where workers can violate those regulations and you dont notice by intention or by inaction, then yes you can be held responsible.
How weaselly.
So... Maybe documentation exists. Maybe not. Either way, maybe they did not share it.
Shouldn't the reporting make it clear how much of a non-answer this is, or are they intentionally writing news reports laced with dry humor?
It’s a big deal because aviation is one of those highly regulated industries where the documentation not existing is it self a crisis level event. Like VW emissions scandal bad. That’s if it never caused a single incident, which it obviously has.
I fly a 40-year-old Cessna. If someone replaced a light bulb in 1982, I have a record of it.
" I wonder if Boeing doesn't want to admit that for some legal reason, maybe they don't have a lot of documentation they say they should have. "
This would be a bad legal strategy. Playing this through as a lawyer:
1. You will be asked to produce it in a lawsuit
2. It will come out it does not exist but should.
3. You will be absolutely and totally excoriated in the lawsuit, in the court of public opinion, and by your regulators.
4. You will prolong the news cycle of your malicious belligerence, and it may even spike higher when it comes out the docs don't exist but should.
5. You will be forced to settle the lawsuit at very high cost, and because you were totally belligerent, you will be regulated much harder, which has a higher-than-the-lawsuit cost most likely
Meanwhile, admitting you are missing shit you should not be, because the contractors played games (or even if it is just you):
1. You will be forced to settle the lawsuit at high cost
2. You will be less excoriated because you owned up to your failure, and because you look more like a bumbling company instead of belligerent and malicious.
3. You will probably be regulated more, but probably less than you did in the first scenario because of #2
The net expected value of the first strategy is much lower than the second.
They can't prevent themselves from losing or being excoriated, they can only try to make it have less cost.
Playing for time to restore faked documentation after the fact?
That feels like it would lead to jail time, which is an even worse option
It did not happen when they lied about the 737 Max problem even after a first crash, causing another hundred deaths, the CEO retired with a bonus of 60 million dollars, the current Boeing CEO was already part of the Board then, and will happen now because of some ... papirology?
"Boeing admits knowing of 737 Max problem" - https://www.bbc.com/news/business-48174797
"...Boeing has admitted that it knew about a problem with its 737 Max jets a year before the aircraft was involved in two fatal accidents, but took no action..."
Faking paperwork after the fact is unambiguous mens rea and “inadvertently made an alarm feature optional instead of standard” is not.
If you watched the Netflix documentary you will know the conduct was much worst than that. After the first accident, and before the second accident, the Boeing CEO went on CNBC saying the airplane was safe when they were already aware of the problem. To me it looks like cause for manslaughter charges at a minimum, but maybe that is why I am not a lawyer...
Got a source on them actually lying?
"In re The Boeing Co. Derivative Litig." - https://casetext.com/case/in-re-the-boeing-co-derivative-lit...
"Downfall: The Case Against Boeing" - https://www.imdb.com/title/tt11893274/
I am not aware of a single time that's ever happened.
which of the two scenarios captures the most value for lawyers involved?
Speaking as a lawyer, we’re not incentivized to advise a course of action whose primary purpose would be to line our own pockets. Doing so would cause us to lose trust in our clients and could possibly subject us to disciplinary action. We are expected to act in our clients’ best interest, not our own.
I’m obviously not Boeing’s attorney, but given the industry they’re in and the amount of scrutiny they’re under, they don’t need their lawyers to fabricate situations that drive up their billables. They’re quite busy enough already.
There must be someone somewhere that is incentivised to take course they are taking. If it's not the lawyers, who is it and what is their incentive?
Executives still trying to find out if there’s a convenient scapegoat they missed?
This sounds like a case of Schrödinger's documentation: it may or may not exist. I think Boeing is still looking for it and doesn't want to admit they don't have it until they're absolutely, positively certain they don't.
Time is running out, and the situation doesn't make them look good, but it seems they're not ready to abandon hope just yet.
I can imagine that for each plane could exist millions of documents, hidden away on different servers. Best-case scenario they could claim that a subcontractor was order to create it and lost it.
From experience I saw a company where people would have single copies of documents stored on hard drives, personal cloud drives, memory sticks, etc. They were always able to find what they needed, but there were a few close calls.
This is where being under so much pressure to produce the documentation, somebody ends up magic-ing it into existence. I wonder if they even have a chain of custody that would highlight that forms, etc, were retroactively created?
I am an investigative reporter, and I take the same approach toward public records. If it ever existed in digital form, there is almost always a stray copy somewhere — regardless of the agency’s records retention schedule. The challenge is figuring out where it is.
Just to point out that, despite the natural state of documentation being a superposition of "exists" and "doesn't exist", for that specific one there is a relative short (hundreds of pages) manual that says in no misleading terms exactly where the documents must be.
Just speaking from my experience here: I worked for a company that was comparable in role to Boeing. I was prohibited from retaining any documentation about my work that was not court ordered. Files, notes, emails, scribbles on a napkin all of it had to be destroyed.
Having a friend who has represented whistleblowers, etc, yes, this happens.
Sometimes for good reason (you are on a classified project, etc). Sometimes for bad reason (we don't want anyone to be able to prove anything).
The latter is something bad lawyers suggest. It basically never works to get the company off the hook. I'm not going to say "never never", but most of the time it leads to a situation where it's easy to convince a jury you are malicious and evil.
Even without a jury, i will simply put your peers who don't do that on the stand and make you look like you have a non-standard policy of hiding things.
Or i'll find the human who asked why. Because in any company of any size, people eventually ask each other why they are being asked to do this, and someone will say the wrong thing ("You know why we do this"). Most of them will not lie for the company because they don't buy it either.
etc
This sort of hiding strategy goes wrong in many many ways, and only goes "right" in a remarkably small set of circumstances.
Step 3 on your first scenario takes years to happen. More than enough for rich people to cash out their gains and move away.
Sure, that's fair.
I would say 'that is an unethical but 'reasonable' strategy for a rich CEO or whatever as an individual' (where reasonable here is 'probably would work' not 'morally sound').
It is an unreasonable one for the company as the company.
"That's correct, Senator. We don't know," Homendy replied. "And it's not for lack of trying."
They straight up said, we don't know.
And we don't know what we don't know, Senator.
Feel like a Cheney "known unknowns and unknown unknowns" meme would be fitting here.
I always felt bad for Rumsfeld (not Cheney) being the target of so much mockery for that comment. I disliked him style and decisions as Secretary of Defense, but that was one of the smartest and most realistic things he said. It's amazing to me how many people derided it as meaningless garbage when it self-evidently true and provided a worthwhile insight into the complexities of strategic decision-making.
He was lying about weapons of mass destruction.
The context is that he'd previously said we had to invade Iraq because of the imminent threat of the weapons of mass destruction.
So he's using a trivially true and non-interesting statement about "unknown unknowns" to evade questions about previous statements where he claimed to know something.
In other words, it was garbage response. He deserves mockery, scorn and a criminal trial.
I’m not sure that’s quite accurate, although it’s not that far off either. The full context is here:
https://web.archive.org/web/20160406235718/http://archive.de...
His “unknown unknowns” response was, to me, a basically fair if evasive response to whether there is any evidence of a direct link between Baghdad and terrorists as far as supplying WMDs. He essentially said “we don’t know what we don’t know.”
To me the more damning answer is the follow up later in the conference, where he strongly implied that he has evidence but can’t disclose it. That just misled the public and is far worse than the “unknown unknowns” comment in my view.
He'd already said for months previous that he knew Iraq had WMDs and were planning to supply terrorists.
Rumsfeld
McNamara
"known unknowns" and "unknown unknowns" are concepts that came out from the project management world. It's not a thing that Rumsfeld invented.
Homendy is NTSB, not Boeing. As far as I can tell, Boeing has not admitted top not knowing, nor have they provided the documentation.
I recall reading (probably a Twitter thread) a while back that showed entries in one Spirit Aero work logging system that showed the plug had been unbolted, and that there was no corresponding entry in the QA system that's required whenever a plug is removed. My gut feel its that someone was rule-bending, and they probably unbolted and slid the plug out of the way of the rivet holes they needed to fix, but didn't want to admit to "opening" the plug and having the QA audit records and self justified that they "didn't actually open it" when they unbolted and moved it (and failed to rebolt it when they put it back).
This thread seems pretty credible and seemingly consistent with what little official information is available
see comments by "throwawayboeingN704AL"
I can't find any such comments (nor the user) unfortunately. What did they say?
It's an anonymous comment posted here: https://leehamnews.com/2024/01/15/unplanned-removal-installa... . It was posted before any official information was released and seems to track with information that was subsequently released.
Thanks - that's exactly what I was remembering.
(Terminology as described further upthread at that link: CMES is an official record system for the plane. SAT is described as "Like Slack" and not an official record of the plane and its maintenance)
"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."
I wonder if the system recording the actions could have knowledge of these types of dependencies between actions, so it could refuse to record a log which is physically impossible (replaced a seal that — due to a plug not being opened — you cannot physically access).
It's not clear to me - was the seal replacement documented in CMES?
Is there not some dependency tree such that a cascade of sign-offs are required when one thing is changed? Clearly, changing the seal has dependencies which should automatically be flagged.
Search for that user in the comments here;
https://leehamnews.com/2024/01/15/unplanned-removal-installa...
She is the NTSB chair, not Boeing.
That does seem most likely. The putative insider blog post about the production incident essentially said the same thing: the contractors/managers were exploiting a loophole to avoid recording the work in such a way that it would trigger a required review step (or somesuch, I forget the details). Not a big leap from there to "didn't get recorded at all", and from there to "lots of other stuff isn't recorded either".
Boeing is in so, so much trouble here.
Their situation feels analogous to my memories of the initial offshoring boom in tech, when you could pitch plans that didn't factor time zone or QA into the budget and nobody cared.
Can they be subpoenaed? Then they will be forced to comply, or dump all the dirty laundry.
If this is true, this is pretty bad. An audit paper trail, at the very least, should be necessary.
Interesting to see how Boeing seems to be operating more and more like a US hedge fund (or any other criminal organization for that matter).