Alaska Airlines explosive decompression 1/5/23

skyking -- thanks for the note about Seattle Times. That story (first link below) links to a comment from an anonymous whistleblower at Boeing (not confirmed) which describes what happend in great detail. Go to the second link below and search the web page for the two comments by "throwawayboeingN704AL". Well worth the read.

Seattle Times Story: https://archive.ph/mc6UT

Article w/comment by whistleblower: https://archive.ph/l0G9z#selection-5777.4-5777.25
 
DavidWhite said:
That doesn’t inspire much confidence!
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You just need to read the last few paragraphs. Everything else is just griping about the company by a disgruntled employee. The bottom line is that he claims an order was inadvertantly written to open the door instead of remove the door ro replace a seal and therefore no order was written to reinstall the door and bolts so they were never there. I don't doubt that he does or did work for boeing but he is missing alot of details about who wrote the open order and what exactly was in the order. It seems that he is missing those details and making many assumptions based on things he doesn't really know. Maybe he is right or maybe he doesn't have access to all the facts and information.
 
kmacht said:
I don't doubt that he does or did work for boeing but he is missing alot of details about who wrote the open order and what exactly was in the order. It seems that he is missing those details and making many assumptions based on things he doesn't really know. Maybe he is right or maybe he doesn't have access to all the facts and information.
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Maybe he doesn't want to be identified and fired.
 
I'm no engineering genius, but the design called for the bolts to be in place. If I understand things properly, only one bolt needed to be in place to prevent the door shifting and no longer aligning with the structural lugs. It seems to me that a quick glance at the door lugs would have seen that the bolts were not in place, but perhaps nobody had the time to follow the maintenance checklist.

"Checklists, who needs 'em? I could do this with my eyes closed!"
 
DavidWhite said:
That doesn’t inspire much confidence!
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By the way, I just noticed that the thread title has the wrong year in it. There should be three dots at the upper right of the opening post if you want to correct it.
 
3393RP said:
Maybe he doesn't want to be identified and fired.
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If he has half a brain, there is zero chance, zero, of him being fired, if he goes to the FAA.
So he's either a troll, or he's part of the problem.
 
Kenny Phillips said:
If he has half a brain, there is zero chance, zero, of him being fired, if he goes to the FAA.
So he's either a troll, or he's part of the problem.
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There is an awful lot of judgmental language in those anonymous comments, making it hard to sort out fact from fiction. If Boeing gives the NTSB access to those quality management systems (CMES/SAT) they should get to the bottom of it, but it may be a very long time before the findings are published.

The FAA's heavy handed action in halting expansion of production does lend some credence to the anonymous comments, and obviously, this is all just guesswork on my part.
 
AviationObserver said:
There is an awful lot of judgmental language in those anonymous comments, making it hard to sort out fact from fiction. If Boeing gives the NTSB access to those quality management systems (CMES/SAT) they should get to the bottom of it, but it may be a very long time before the findings are published.

The FAA's heavy handed action in halting expansion of production does lend some credence to the anonymous comments, and obviously, this is all just guesswork on my part.
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Hopefully, the FAA will be able to determine the truth or falsity of the allegations.
 
Kenny Phillips said:
If he has half a brain, there is zero chance, zero, of him being fired, if he goes to the FAA.
So he's either a troll, or he's part of the problem.
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There's also zero chance he wouldn't face some sort of repercussions from becoming a whistleblower. Concealed workplace harassment, social isolation, public criticism, etc.

I admire people that do it. It's not an easy path. These comments by federal employees Gary Shapley and Joe Ziegler are instructive. Ignore the issues of their involvement and we can prevent this from becoming political.

Special Agent Ziegler stated, “DOJ-Tax have a clear target on me and my supervisors back and I believe that they are just waiting for an opportunity to pounce on us. My own agency retaliated against me and threatened me with criminal conduct in response to an internal email I sent to IRS leadership, even years after of essentially being left on an island when it came to this investigation.”

Supervisory Special Agent Shapley stated, “The senior leaders who are my immediate supervisors are currently making the mistake of retaliating against me for simply reporting outside the chain of command what I genuinely believed was wrong and could not be addressed internally. IRS senior leadership is allowing this retaliation and possibly assisting. My direct supervisor has not spoken with me in six weeks. Suddenly, all kinds of unusual scrutiny came down on me and my agents.”
 
Kenny Phillips said:
If he has half a brain, there is zero chance, zero, of him being fired, if he goes to the FAA.
So he's either a troll, or he's part of the problem.
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Might want to check with a certain former Alaska mechanic about that…
 
Couple things I found poking around today. I should be clear that I don't know if Pierson is sincere in his efforts, although he seems to be in the interview. There is a list of squawks on 737-MAX-9 a/c in service linked below. Don't know if that's excessive, and it obviously depends on how many are in service.

The interview, about 2 weeks ago, is 23 minutes. Found myself wondering how much is Pierson promoting himself vs genuine concern for aviation safety. Curious if others here know any more about him.

nypost.com

Ex-senior Boeing manager warns flyers to avoid 737 MAX 9 jets: ‘I would absolutely not fly a MAX airplane’

“I would absolutely not fly a MAX airplane,” one-time senior Boeing manager Ed Pierson said, while former Boeing and FAA engineer Joe Jacobsen said: “I would tell my family to avo…
nypost.com nypost.com

Incident Reports

An aviation incident report is a formal document that details a specific event or occurrence involving an aircraft that may have posed a safety risk or deviated from normal operations. These reports are crucial for maintaining and improving aviation safety, as they help identify potential...
www.foundationforaviationsafety.org www.foundationforaviationsafety.org
 
AviationObserver said:
The interview, about 2 weeks ago, is 23 minutes. Found myself wondering how much is Pierson promoting himself vs genuine concern for aviation safety.

nypost.com

Ex-senior Boeing manager warns flyers to avoid 737 MAX 9 jets: ‘I would absolutely not fly a MAX airplane’

“I would absolutely not fly a MAX airplane,” one-time senior Boeing manager Ed Pierson said, while former Boeing and FAA engineer Joe Jacobsen said: “I would tell my family to avo…
nypost.com nypost.com

Incident Reports

An aviation incident report is a formal document that details a specific event or occurrence involving an aircraft that may have posed a safety risk or deviated from normal operations. These reports are crucial for maintaining and improving aviation safety, as they help identify potential...
www.foundationforaviationsafety.org www.foundationforaviationsafety.org
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These days self aggrandizement is part and parcel of most public figures, and Pierson is no exception.
 
As someone that's been using hyperbole and exaggeration for effect in regular communications for 20+ years, I'm cynically annoyed that nearly everyone on Internet/TV uses it more.
 
Juan Browne has a video on this now.

Yet another development in this saga Boeing has withdrawn a requested safety exemption for the LEAP engines used on MAX aircraft. This applies to the MAX-7 and MAX-10 certification efforts, but seemingly all MAX aircraft have this problem.

Seems that very hot bleed air fed into the engine cowling (anti-icing system) can cause failure of non-metallic parts in the cowling, resulting in "departure from the airplane". Is that like the "rapid unscheduled disassembly" that occurs when a rocket explodes?

Here's the AD from last year addressing this issue: https://services.casa.gov.au/airworth/airwd/ADfiles/OVER/B737/2023-15-05.pdf

I guess this has been now judged to be important enough to pulll the exemption request. Can't help but wonder how much the FAA had a hand in deciding to pull the request...

Boeing Withdraws Request for a 737-7 Safety Exemption

Boeing has withdrawn its request for an exemption from several important safety requirements to get the smallest variant of the 737 MAX series authorized for passenger travel.
airwaysmag.com airwaysmag.com
 
AviationObserver said:
Seems that very hot bleed air fed into the engine cowling (anti-icing system) can cause failure of non-metallic parts in the cowling, resulting in "departure from the airplane".
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The MAX 8 & 9 aircraft were introduced into service starting in May 2017. This overheating issue has never occurred in operation.

During the certification process of the Max 7 & 10, the failure mode was discovered and the AD was issued. The mitigation procedure is a limitation that the engine anti-ice must be off when not in icing conditions.

Previously, the only limitation was the the engine A/I could not be on above 10°C TAT. When we were in an out of clouds we'd often leave the engine A/I on during the periods that we weren't in the clouds or precipitation. Now we have to turn it off until we're about to go back into the icing conditions.

Since the MAX 8 & 9 are already certified, their operation continues under the revised procedure from the AD. The MAX 7 & 10 can't be certified under the AD so they have to either have the issue fixed or receive an exemption to allow certification under the AD procedure while the fix is developed. Once developed, that fix will be applied to all MAX aircraft.
 
From the report (2nd paragraph)

The separation of the MED plug from the airplane adversely affected the pressurization performance of the airplane...

Who writes this stuff???
 
AviationObserver said:
I transcribed the comments by the supposed whistleblower in a PDF file. Copy and paste from the web page, with minor tweaks for character set/punctuation.
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The NTSB prelim report seems to add at least some credence to allegations by this supposed whistleblower. Specifically, that rework on damaged rivets required opening the door plug.
 
I still wonder, other comments here to the contrary, if the door was being no longer sealed properly, which lead to the pressurization issues that were noted before the failure of the plug. It just seems too obvious that this plane had more than one issue noted beforehand with keeping pressurization. If not the plug, and if the issues kept occurring, what did cause it after mechanics waved a magic wand and called it blessed a couple of times? The plug sealing is, to my mind, a possible smoking gun to that previous issue. I'll dig into the NTSB report later. Renton is going to be a pretty glum place on the south shores of Lake Washington.

NTSB Prelim is in the CNN story below -


Not to mention what the cockpit went through: "The captain said that, while climbing through about 16,000 ft, there was a loud bang,” the report said. The flight crew said their ears popped, and the captain said his head was pushed into the heads-up display (HUD) and his headset was pushed up, nearly falling off his head. The FO [first officer] said her headset was completely removed due to the rapid outflow of air from the flight deck.”

And further damage to the plane outside of the photos we've all seen: "deformation of the doorframe of the forward lavatory, and buckling and displacement of the sidewall panels and trim throughout the airplane."

1707251304848.png1707251421819.png
 
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Violating my own rule here: don't speculate.

The photo of stop pin damage shows a screw on the plug, and a matching shiny pad on the fuselage. I'm wondering if after the plug is in place, these screws are adjusted to create pressure on the pad (each of 12 stop pads), thus forcing positive contact with the gasket between plug and fuselage.

If that was done, and retaining bolts were missing, and as the door giggled its way upwards towards failure, would that leave vertical scratches on the pad? There are some vertical marks there, but they don't look very deep or significant. Could this indicate that the 12 screws were not properly tightened?

Yeah, pure speculation and could easily be wrong. Those marks could be consistent with the screws being properly tightened too.

Sorry, couldn't help it.

StopPinArrows.png
 
skyking3286 said:
The plug sealing is, to my mind, a possible smoking gun to that previous issue.
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FYI: If the plug caused the previous pressurization indication problems, the volume of air leaking by the plug would have so high, and so loud, it would have been easy to find the problem.
AviationObserver said:
Could this indicate that the 12 screws were not properly tightened?
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No. In order to install the plug, the stop pads must have enough room to pass in front of the stop pins. They become lined up once the plug is fully installed. The gap between the pins and pads is pre-determined to allow for fit in an un-pressurized condition. As the fuselage pressurizes the pins and stop contact each other. It my understanding the pin/stop gap is determined by the aircraft's cabin differential vs altitude range. So whether there should be pin/stop contact at 16,000 feet I do not know. But I believe the purpose of the stop bolts is to retain the plug until the pressurization causes the pins and stops to contact.
 
So the bolts/hardware were not re-installed.

Good job there Renton.
 
Bell206 said:
In order to install the plug, the stop pads must have enough room to pass in front of the stop pins. They become lined up once the plug is fully installed. The gap between the pins and pads is pre-determined to allow for fit in an un-pressurized condition.
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That's what I was unclear on. Never having seen any documents on the process, I was left to fantasize about the process :)
 
skyking3286 said:
I still wonder, other comments here to the contrary, if the door was being no longer sealed properly, which lead to the pressurization issues that were noted before the failure of the plug. It just seems too obvious that this plane had more than one issue noted beforehand with keeping pressurization. If not the plug, and if the issues kept occurring, what did cause it after mechanics waved a magic wand and called it blessed a couple of times? The plug sealing is, to my mind, a possible smoking gun to that previous issue.
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The 737 has two automated pressurization controllers plus a method for controlling pressurization manually. Only one automated controller is needed at a time so the two controllers alternate primary and alternate on each subsequent flight.

When the primary controller fails in flight, the alternate controller takes over and a green ALTN annunciator indicates that the primary has failed and the alternate controller is operating normally. If both controllers fail, a yellow AUTO FAIL annunciator indicates that the pilots much revert to manual control.

From what I've seen so far, the previous pressurization incidents were just the green ALTN annunciator and the alternate controller worked for the remainder of each flight.

If the problem was caused at an air leak significant enough that the primary controller could not maintain pressurization then neither the alternate controller, nor the manual method, would not have been able to, either.

There is no indication for the plug being out of position or detached. The door is prevented from moving off the retaining pads by four independent stop pins/bolts, any one of which can do the job alone.
 
Well, this is sobering ……

Boeing has not turned over important records to investigators probing the door plug blowout on a 737 Max earlier this year, investigators say. That, Boeing signaled Wednesday afternoon, is because there are no records
 
WDD said:
Well, this is sobering ……

Boeing has not turned over important records to investigators probing the door plug blowout on a 737 Max earlier this year, investigators say. That, Boeing signaled Wednesday afternoon, is because there are no records
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Oh I bet there’s records, but they must be bad enough to take the lumps by saying there are none.
 
Bill said:
Oh I bet there were records, but they must be bad enough to take the lumps by getting rid of them and saying there are none.
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FIFY

This part is utter BS:
NTSB investigators do not know who on the Boeing assembly line removed and reinstalled the door plug...​
You mean to tell me Boeing doesn't know who was at work that day and they have no time and attendance records and no accounting of who charged the rework charge number and no one signed an approval for the work??!! I gotta admit, it takes some serious cajones to lie like that.

I'll note that what Boeing said is actually "if" there are no records.
Boeing followed up with a statement: "With respect to documentation, if the door plug removal was undocumented there would be no documentation to share.​
So we're supposed to think that Boeing does undocumented R&R on an airliner? I'm sure their potential customers (if any are left) are going to love that one!
 
Half Fast said:
no accounting of who charged the rework charge number and no one signed an approval for the work??!!
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Half Fast said:
So we're supposed to think that Boeing does undocumented R&R on an airliner?
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FYI: It happens. Even at smaller Part 145 shops items can be left off the paperwork for various reasons. Is that acceptable? No. Are there processes in place to prevent that? Yes. But they are not foolproof. No different than how doctors leave stuff inside people after an operation. Sheet happens.
 
"Boeing followed up with a statement: "With respect to documentation, if the door plug removal was undocumented there would be no documentation to share."

um.

Did someone at Boeing really say that?

well, duh

If the removal was undocumented, of COURSE there would be no documentation to share...

Maybe I'm just misreading...
 
Story in the WSJ today about DOJ opening criminal probe into this event. Regardless of the outcome, that's going to make it harder for NTSB to get information out of Boeing.

The DOT IG is also opening a probe into FAA employee involvement in this, which will cause some in the FAA to clam up about what happened.

I'm not saying there shouldn't be accountability here...just that the existence of these probes will make NTSB's job more difficult...
 
I’m getting the impression that the Boeing factory is run more sloppily than the worst GA shop I’ve used. When a mechanic left bolts off stuff in my humble piston plane, at least I had documentation- a logbook entry to show that something had been installed,and it was signed and dated. Boeing’s factory takes important stuff off, modifies it, omits the bolts, and doesn’t keep any documentation!
 
NoHeat said:
I’m getting the impression that the Boeing factory is run more sloppily than the worst GA shop I’ve used. When a mechanic left bolts off stuff in my humble piston plane, at least I had documentation- a logbook entry to show that something had been installed,and it was signed and dated. Boeing’s factory takes important stuff off, modifies it, omits the bolts, and doesn’t keep any documentation!
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Well, they say they don't have any documentation. So far, they haven't even provided the names of the people responsible for documenting the work! Eventually a few whistle blowers will come forward, once they can broker immunity.
 
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