Alaska Airlines explosive decompression 1/5/23

nrpetersen said:
Clarify for this non A&P - For these six critical fasteners, it looks to me like they are each loaded in shear and retained by common low-profile shear nuts, which in turn are supposed to be cotter keyed. Shear nuts may have a torque spec (yes?) but the real problem is the lack of cotter keys.
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Not sure. It could be a self-locking nut using a fiber insert, like the AN365, MS21044, or an all-metal lock nut like the AN363. The lock nuts would make sense from the manufacturing/cost point of view, as they would take less time to install and fewer tools. Used to be able to buy tons of all-metal stop nuts at Boeing Surplus.

Looking at the door design, access to the back side of the guide track is a bit restricted. Assuming the head of the bolt is on the cabin side, installing a cotter pin on the other side might be more difficult.
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Looks like two roller pins at the top basically hold the thing in place, with bolts through the track to keep it from coming out, and two lower locking bolts at the bottom. But even if the door is shedding nuts, the bolts should stay in place (assuming the drawing is accurate, and the bolt head is on the inside so the bolt head is higher). Should be able to lose the upper locking nuts and not cause a problem, UNLESS BOTH THE LOWER BOLTS ARE GONE.

To me, it sounds more like all the bolts just plain weren't there. A potential scenario is someone deciding the plug had to come out for a short time (one story is that Boeing was installing the interior, the other is that it was necessary for rigging), and someone stuffed it back in place without securing it. As an ad-hoc shop activity, QC might not even have gotten installed.

Alternately, none of them had nuts, and the bolts worked themselves out.

Ron Wanttaja
 
DavidWhite said:
A factually incorrect article. There has been a 121 accident that had fatalities since then, and there was the lady on the Southwest plane.

PenAir 3296 and Southwest 1380.

Still, two in 15 years is pretty damn good.
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The article limits the claim of no fatalities to "crashes" and major US airlines, and the two you pointed out aren't in those specifics. But it also mentions two deaths, saying

"Since that crash 15 years ago next month, large U.S. airlines have suffered two fatal accidents that killed two people. Not two fatal accidents a year, like the 2000s, or two per million flights, like the 1960s. Just two".

I think that references SW 1380 and the ramp worker ingested into the engine of an AA/Piedmont Embraer 170 last January. The Delta ramp worker that died in San Antonio in June was ruled a suicide, so that doesn't count in accident reporting.
 
wanttaja said:
To me, it sounds more like all the bolts just plain weren't there.
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Per the NTSB the 4 retaining bolts and hardware were missing. And with it under spring tension I doubt even if only the bolts were installed without nuts, all 4 bolts could "walk" out. Plus it would only take 1 bolt to hold the door in place.
 
wanttaja said:
To me, it sounds more like all the bolts just plain weren't there.
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I asked my buddy Occam and that's what he told me. I'm going with that. Somebody in Wichita or Renton straight up didn't put the bolts back on. Ol blancolirio showed a picture of the MAX getting wifi slapped on the roof by whoever, and shows they got those plugs removed for fuselage access. It looks like folks up and down the manu/fitting chain are using those plugs as bona fide doors left and right.
 
hindsight2020 said:
Spirit Aero, not Alaska. Spirit Aero is basically how Boeing cuts labor costs and shifts (up until now anyways) legal blame when things go heading one-eight-ooh-sh%t. :biggrin:. It's basically a Boeing sockpuppet account; the industry is aware of it, the public just isn't, as intended. Builds 70% of an airliner, boasts about non-OEM status with a straight face. lulz.

According to the inter-fu, they [the former] build 70 pct of that stretch guppy POS. It's entirely plausible that fuselage gets shipped to Renton with the interior insulation and panels fitted, which would imply Spirit installs the plug. See above, no free lunch in life, not even for Boeing.
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Spirit builds the empty cigar, with windows and doors installed. I can confirm that it has no insulation when it arrives in Renton. That's stuff is installed on the first "flow day". Spirit's contribution is nothing like 70%. I also wouldn't call them a sock puppet. Boeing sold off the production, along with the rights to the fuselage design (which I feel was a bad decision). Any changes have to be requested (and paid for).

The wings are built in Renton, the tail surfaces come from various sub contractors. Flight deck monuments are made by the company, cabin monuments (lavs, galleys, etc) are mostly also built by the company. Systems, wiring, engines, landing gear, interiors, etc. I'd say Spirit's portion is 40%.
 
So how does the bolts not being there square up with both United and AS seeing loose hardware?
 
skyking3286 said:
So how does the bolts not being there square up with both United and AS seeing loose hardware?
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May be an indicator of sloppy procedures. No one is checking that the door hardware is properly re-installed when they remove the door plugs. In a lot of cases, sounds like they're just not re-tightening the assembly properly, but in at least one case, it appears they left the bolts off entirely.

From the diagram, it looks like there isn't much load on those bolts. The shank is just there to keep the door from sliding...it doesn't actually hold the door on. Bolt tension in this application, other than indication of bad workmanship, is probably immaterial...as long as self-locking nuts are used, or the cotter pin installed, so it doesn't drop out entirely.

Ron Wanttaja
 
Friend of mine and his whole family are scheduled to fly out on Alaska this weekend for a very complex trip. He's sweating this issue, and having his flight cancelled at the last moment. Told me that a friend of HIS who was "in the know" says the return to service is taking longer as they're finding more problems as they dig into the airplanes.

Classic "friend of a friend" rumor. Yet, the incident happened ten days ago, and there's been no notice any of the planes have returned to service....

Ron Wanttaja
 
Here's some 737 fuselages going down the track between Wichita and Everett (shot at Bradshaw, NE).

 
Ron, looking at the design it’s hard not to think that a cotter pin would have worked just as well. Of course now I think a self-locking nut followed by a castle nut and cotter!
 
Half Fast said:
Concur. One arbitrator compared legacy Boeing engineers to the legacy McD managers as Boy Scouts going up against hunter-killer assassins.

But I'll expand on that a bit. Stonecipher and others who moved from McD into Boeing executive slots were acolytes of Jack Welch. Welch's scorched-earth approach to raising profits and stock prices has been the downfall of several companies, and that philosopy has wrecked Boeing. Welch's methods work (for a little while) when you're building toasters; they're entirely inappropriate for building airliners.




Exactly. And that's the heart of the problem.

Boeing's org structure is fatally flawed for addressing this problem, because they have engineers answering to program managers. At LockMart, at least my part of it, that's not the case. Program engineering teams report to a program chief engineer, who works with the program manager but not for the program manager. The program chief engineers, depending on the size and nature of the program, report to the chief engineer department manager (me, before I retired) or to a line-of-business chief engineer. The CE dept manager and the LOB CEs report to an engineering VP, and he reports up the corporate chain ultimately reaching the CTO. The CTO reports to the CEO.

In that way, engineering management and program management only converge at the CEO, and God help anyone who can't resolve a conflict before it reaches that level. The program managers have no authority to override an engineering decision, so the PM and the CE must collaborate. There's often a lot of conflict here, and sometimes it gets elevated a level, but done properly conflict is healthy and provides a fire that burns off the dross and refines the gold.

In fact, just last night a fellow retiree and I were discussing all this. We both recalled many instances where we had stopped a delivery or blocked a flight test until engineering concerns could be addressed, and never once were we overridden. There would be questions and follow-on discussions, of course, but no PM ever even tried to say "Screw the engineers; ship it."





I saw execs make similar statements a couple of times. I never saw one progress any further in his career afterward.
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Atlantic has a recent article which is a good wrapup:

What’s Gone Wrong at Boeing​

https://www.theatlantic.com/ideas/a...opy-link&utm_medium=social&utm_campaign=share

"Putting profit over product has been bad for Boeing’s products. The irony now painfully apparent is that it’s been bad for Boeing’s profits too".
 
Piperonca said:
Atlantic has a recent article which is a good wrapup:

What’s Gone Wrong at Boeing​

https://www.theatlantic.com/ideas/a...opy-link&utm_medium=social&utm_campaign=share

"Putting profit over product has been bad for Boeing’s products. The irony now painfully apparent is that it’s been bad for Boeing’s profits too".
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I think that's pretty much what I said. :biggrin:

This Stonecipher quote is quite telling:
This new orientation was encapsulated by something that Harry Stonecipher, who had been CEO of McDonnell Douglas and was CEO of Boeing from 2003 to 2005, said: “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm.”​

Stonecipher is a fool, both in business management, having wrecked two aerospace businesses, and in his personal life, having wrecked a 50-year marriage.

Platitudes and buzzword programs won't fix Boeing. A restructuring of the organization is needed, starting with a thorough housecleaning in the management ranks and even in the BoD. Only the stockholders and the customers can force that sort of change.
 
Half Fast said:
A restructuring of the organization is needed, starting with a thorough housecleaning in the management ranks and even in the BoD. Only the stockholders and the customers can force that sort of change.
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Maybe the DoD needs to motivate the BoD.
 
The first company I worked for had a saying, “No engineer will work under a non-engineer.” That pretty much limited the upper management opportunities for accountants and MBAs unless they also had an engineering degree. They kept that corporate culture all the way up to the company president - I don’t know what happened after that at the corporate level above his/her head.

An attitude like that permeates all the way down the org charts. It’s too bad Boeing is becoming “just another company”.
 
Half Fast said:
I think that's pretty much what I said. :biggrin:

This Stonecipher quote is quite telling:
This new orientation was encapsulated by something that Harry Stonecipher, who had been CEO of McDonnell Douglas and was CEO of Boeing from 2003 to 2005, said: “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm.”​

Stonecipher is a fool, both in business management, having wrecked two aerospace businesses, and in his personal life, having wrecked a 50-year marriage.

Platitudes and buzzword programs won't fix Boeing. A restructuring of the organization is needed, starting with a thorough housecleaning in the management ranks and even in the BoD. Only the stockholders and the customers can force that sort of change.
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CEO going to Federal Prison would have helped…
 
Matthew said:
The first company I worked for had a saying, “No engineer will work under a non-engineer.” That pretty much limited the upper management opportunities for accountants and MBAs unless they also had an engineering degree. They kept that corporate culture all the way up to the company president - I don’t know what happened after that at the corporate level above his/her head.

An attitude like that permeates all the way down the org charts. It’s too bad Boeing is becoming “just another company”.
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There's nothing wrong with accountants.
 
NealRomeoGolf said:
There's nothing wrong with accountants.
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Nope, not at all.

But at my company, they were not going to be able to reach the top position. That's what made it an "engineering" company. That differed a lot from my next stop, at a small company where the owner was a salesman. That was a very different dynamic when it came to product development.
 
NealRomeoGolf said:
There's nothing wrong with accountants.
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That is absolutely true; however, while accountants should be near the top of a corporate organization, they should never, ever be in control. That's because accountants are more concerned about the "bottom line" than the "product line". The "product line" is what either makes or breaks a company, and if it is of superior quality, the "bottom line" becomes profitable and the company thrives.
 
Half Fast said:
This Stonecipher quote is quite telling:
This new orientation was encapsulated by something that Harry Stonecipher, who had been CEO of McDonnell Douglas and was CEO of Boeing from 2003 to 2005, said: “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm.”​

Stonecipher is a fool, both in business management, having wrecked two aerospace businesses, and in his personal life, having wrecked a 50-year marriage.
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I'll tell you, Stonecipher was absolutely *hated* by many of the Seattle Boeing engineers, and it was a hatred that never died. I was still seeing cartoons about him on the wall when I retired, ~12 years after he left the company. Most common one was a nice bit of Photoshop that depicted him and Phil Condit (Boeing president) as Laurel and Hardy. Wish I'd taken a copy when I retired.

Schadenfreude supreme in 2005. Because of various scandals...none of them involving line engineers, admin people, or the aircraft assemblers...we all had to attend off-site "Ethics Refreshers". Among my co-workers, I drove ~20 miles to the Tacoma Dome, where they used the Jumbo-Tron (or whatever they were calling it) to tell us to be good ethical employees, don't dip our wicks at work, or demand bribes, or hide stuff from the government, or whatever. NONE of it was remotely applicable to most of us. Much of the "training" was Harry Stonecipher on the Jumbo-tron, looking as large as Big Brother, telling us to be good worker drones.

Then a few weeks later, Stonecipher's affair with his secretary hit the news....

The joke back then was that every time a Boeing executive saw a pretty girl, all the engineers had to line up for penicillin shots....

Ron Wanttaja
 
Capngrog said:
That is absolutely true; however, while accountants should be near the top of a corporate organization, they should never, ever be in control. That's because accountants are more concerned about the "bottom line" than the "product line". The "product line" is what either makes or breaks a company, and if it is of superior quality, the "bottom line" becomes profitable and the company thrives.
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One must remember the 12th article in the Klingon Rules for Rapid Prototyping: "While the Warrior-Commander may keep a few Ferengis to handle administrative and accounting issues, the Ferengi must never be allowed to forget who is in charge."


Ron Wanttaja
 
When I was made Chief Engineer for the USAF on the C-17, I met Stonechiper at a Senior Leadership meeting when we were starting to try and clean up the mess McDonnell-Douglas (and the USAF for that matter) had made of the program.

My Boss and I both came to the conclusion to keep him as far away from the program as possible. As we had been given a pretty free hand from the Secretary of Defense to do whatever was required to do to either fix it or throw the program in the trash, never had to deal with him. As far as we could tell, he had little to do with the program the whole time we were involved. One reason probably being we had a set of specific technical and engineering objectives that had to be met and the agreement with the DoD was fix it with the money we gave you and no more or the program would be cancelled.
 
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wanttaja said:
Schadenfreude supreme in 2005. Because of various scandals...none of them involving line engineers, admin people, or the aircraft assemblers...we all had to attend off-site "Ethics Refreshers". Among my co-workers, I drove ~20 miles to the Tacoma Dome, where they used the Jumbo-Tron (or whatever they were calling it) to tell us to be good ethical employees, don't dip our wicks at work, or demand bribes, or hide stuff from the government, or whatever. NONE of it was remotely applicable to most of us. Much of the "training" was Harry Stonecipher on the Jumbo-tron, looking as large as Big Brother, telling us to be good worker drones.

Then a few weeks later, Stonecipher's affair with his secretary hit the news....
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Ron, that experience is certainly not unique to Boeing. I used to work for Wells Fargo.
 
Yearly ethics training was still very much a thing when I left the company in 2022.
99% of the employees could never get into a position where any of it applied to them.
 
aftCG said:
Yearly ethics training was still very much a thing when I left the company in 2022.
99% of the employees could never get into a position where any of it applied to them.
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That describes ninety percent of the annual trainings I take.
 
I think it was 100 years ago, the whole organization took a rah rah training exercise called Zero Defects. I would guess the result was zero effect as the only way to have zero defects was to have zero work. I mentioned that and was told to “Shut up and color your workbook”.
 
Homendy gave a closed door briefing to Senators today (1/17), and spoke with reporters afterwards. Sounds like they haven't yet determined whether the four retaining bolts were installed when the MAX 9 took off from PDX. From the article:

“They have very bright lighting. They’re doing targeted photography,” Homendy said. “They might take some metal shavings and put them under the electron microscope.”

www.wicz.com

Federal investigator hasn't determined whether bolts were installed on the 737 Max part that blew off an Alaska flight

By Gregory Wallace, Pete Muntean and Curt Devine, CNN
www.wicz.com www.wicz.com
 
aftCG said:
Yearly ethics training was still very much a thing when I left the company in 2022.
99% of the employees could never get into a position where any of it applied to them.
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I worked for a corporation that had 1500 workers do sensitivity training because one employee referred to a person of color as Buckwheat and it was overheard by a client manager. Seems it was a joke between friends but it was a ugly and costly mistake ...
 
Daleandee said:
I worked for a corporation that had 1500 workers do sensitivity training because one employee referred to a person of color as Buckwheat and it was overheard by a client manager. Seems it was a joke between friends but it was a ugly and costly mistake ...
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Our sensitivity training one year noted that there are a number of terms that a reasonable person doesn’t use to refer to others, even if that’s how they refer to themselves.

The exception was “hermaphrodite”. We are not allowed to use that term except to refer to someone who refers to themselves that way.
 
Wow. Times have changed. I remember a guy getting pulled into a manager’s office for calling a co-worker a “communist whore”. He corrected the manager by saying, “I never called her a communist.”

Good thing sensitivity training hadn’t been invented yet or we all would have been in class.
 
Matthew said:
Good thing sensitivity training hadn’t been invented yet or we all would have been in class.
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Many eons ago, I worked for a manufacturer of large computers with blue three letter names attached to the cabinets. The number of f-bombs, swear words, and off color comments that flew around in that environment rivaled my Navy days. I certainly remember my manager poking his head in my office and asking me how this Fing project is coming along, or when will that GD report be published.

We have come a long way.
 
Bill said:
Many eons ago, I worked for a manufacturer of large computers with blue three letter names attached to the cabinets. The number of f-bombs, swear words, and off color comments that flew around in that environment rivaled my Navy days. I certainly remember my manager poking his head in my office and asking me how this Fing project is coming along, or when will that GD report be published.

We have come a long way.
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But, is anything better?
 
Mikey52 said:
But, is anything better?
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I would hope so but you never know. In those days, it was easy to get a read on a person, they weren’t holding back for fear of having to “go visit HR.”

Now, everyone acts nice, but has the thinking behind the veil changed? Dunno.
 
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