NTSB says Boeing is withholding key details about door plug on Alaska 737 MAX 9
npr.org
npr.org
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...
Boeing is in trouble, I'd say.
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...
Oh, so that's why they keep churning thru chat apps.
It is a bit as if people forgot what their job is about.
[1] https://twitter.com/David_Slotnick/status/176545419893241038...
They straight up said, we don't know.
Rumsfeld
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.
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).
see comments by "throwawayboeingN704AL"
(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."
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.
https://leehamnews.com/2024/01/15/unplanned-removal-installa...
> Boeing also acknowledged the possibility that the documents the NTSB is seeking may not exist.
> "If the door plug removal was undocumented there would be no documentation to share," Greenwood said in his statement. "We will continue to cooperate fully and transparently with the NTSB's investigation."
In which case the NTSB will hopefully pin the blame on the lack of a functioning system of record that tracks such events.
You have to trust your workers to not undo some random bolts here and there at some stage.
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.
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.
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.
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.
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.
> You have to trust your workers to not undo some random bolts here and there at some stage.
Why? We don't trust surgeons to remove correct limbs, why we should trust some contractors thrice removed from actual accountability? There are checklists for a reason.
> "If [it] was undocumented there would be no documentation to share..."
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?
How surprising that hobbyist act like hobbyist. When real money gets involved, all of sudden inconvenient things no longer are "critical" so no documentation is needed for them. What a coincidence...
Something like that is likely what's happening here.
If outsourcing is a de facto means of avoiding responsibility, then guess what the consequences are.
The executive leadership should lose their own (potential?) personal money over this incident. Until that happens, nothing will get fixed.
Boeing is in so, so much trouble here.
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.
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.
"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.
"Downfall: The Case Against Boeing" - https://www.imdb.com/title/tt11893274/
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?
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.
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.
> 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.
The NTSB is after Boeing.
The plane in question was manufactured last summer, IIRC.
And if Boeing had logs, they probably would have shared them.
What a coincidence that single mechanic is more accountable than a "committee".
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.
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...
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.
(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.)
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.
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.)
Capitalism, by definition, has no conscience.
Regulation provides the layer (sometimes facade) of moral and ethical control.
The two forces are generally opposed, but, hopefully, balance out to keep our society and environment tenable.
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
If you’re being serious, I genuinely wonder if you realize the consequences of this drastic a decision.
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)
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.
That those seats were coincidentally empty doesn't lessen the seriousness of the event.
If 2 people has died, it would have been a more serious event. By definition, no?
nope for me
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.
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?
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.
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.
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?
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.
This was an ops problem.
The common element is Boeing, not the model of plane.
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.
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.
Only reason I see for it is a punitive incentive for Boeing. Anything else requires more of an argument, in my perspective.
As to whether this "punishes" Boeing I have to confess that I absolutely, positively, do not give a shit if this counts as "punishment" and quite frankly the entire C-level of the company and any board members / stockholders that had a hand in degrading their QC to this degree, should be held criminally liable and punished as such. So that's where I stand on punitive incentives: they're a good thing.
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?
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.
> If you’re being serious, I genuinely wonder if you realize the consequences of this drastic a decision.
It would be best for everyone who isn't Boeing. But we all know that the second it would happen, Boeing would run crying to politicians they own how unfair this action is/how it endangers their market position/how it threatens national security.
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 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.
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.
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.
But the 737 MAX Process/Program is known to be defective. I'll take possibly bad over surely bad any day.
┌──────────────────┬──────────────────┐
│ Bad Design │ Bad Design │
│ │ │
│ Good Process │ Bad Process │
├──────────────────┼──────────────────┤
│ Good Design │ Good Design │
│ │ │
│ Good Process │ Bad Process │
└──────────────────┴──────────────────┘"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.
Mentioned in this film:
* https://www.pbs.org/wgbh/frontline/documentary/boeings-fatal...
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...
However, this failure seems to have not followed a strategy; the result was just luck.
Hyperbole also makes it easy to dismiss the real severity of an issue by detractors.
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.
Their personal reputations are still largely intact.
> Their personal reputations are still largely intact.
Well person who would be attending country club would know that they raised shareholders value and more than likely helped to them to gain X millions of Dollars.
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".
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.
Execs will 100% do the dangerous thing to make more money even if it puts themselves in immediate danger. Execs rarely have a well developed understanding of risk, and will happily take an 80% risk with the downside being dying.
They are gamblers, not rational.
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?
Surely when lives are at stake there must be consequences for companies breaking the law...
in case of the former: that's not how any of this works
If it is safe enough to travel, we can all stop talking about Boeing and the news can let the story die.
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.
I guess while the government is at it, they could mandate that Boeing refund all their money for those planes, which might save the airlines from bankruptcy, at the cost of Boeing itself going out of business, which thanks to being too big to fail (Nobody seriously would want Airbus to have a global monopoly on planes) would end up best-case as a GM situation where the government takes over ownership for a while.
Still, for the next couple decades, air travel would just be much more expensive due to scarcity of available seats on most routes.
There are basically zero good outcomes possible here, not with your plan, nor any other, to be honest.
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?
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.
Boeing is a massive corporation with both public and private contracts, employing a huge number of almost entirely well meaning employees. The government has allowed too many carve outs and exceptions as the company grew and now have no choice but to stay mostly quiet while the cracks in the company leadership and potentially culture put not only passengers and the airline industry at risk, but the very military we may need to be at full fighting force if Russia, China, Iran and co, etc decide to escalate.
You are saying this as if it was a bad thing.
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.
> If people were actually concerned
Yeah, and tbh I think (and am glad) we aren't at that level of concern, yet. I really hope we don't get there. I can think of several ways we could get there, though. I really frigging hope that a lot of reinspections and triple-quadruple-checking of things avoids any further disasters that cost lives.
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.)
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.
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.
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.
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.
> 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?
> 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.
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.
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.
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)
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.
Profits above all, and internal awareness of the greater unpaid costs... buried.
I know my list is incomplete, but you get the idea.
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.
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, ...).
> McDonnell Douglas bought Boeing with Boeing's money, which is a great trick if you can pull it off.
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.
https://www.youtube.com/watch?v=G-dJMqpGvjM
(don't know if its blocked in the US)
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...
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.
This is just another repeat of the 787 outsourcing disaster which also ended with Boeing buying a bunch of their suppliers and bringing other work back in-house.
Just more financial shell games to screw labor.
I don't know about you but I'd prefer everyone building my airplane be highly paid with a management chain of former engineers. Not the cheapest labor a subcontractor can find managed by bean-counting accountants.
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.'
The NTSB is literally asking for names. That’s what Boeing is allegedly refusing to provide.
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.
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.
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.
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.
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.
> 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.
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.
It is deliberately done this way to avoid the issue you describe. If people knew talking to the NTSB could get them doxxed and fired it would make cooperation impossible.
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.
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.
That's not what being responsible for the final product means. ;)
I don't think the NTSB is going to look kindly on Boeing if they even try to throw the techs under the bus.
[1] https://leehamnews.com/2024/01/15/unplanned-removal-installa...
I have no love for Boeing, but it sounded like they were trying to _prevent_ some poor line worker taking the fall.
The NTSB will not identify the person responsible even to Boeing, let alone anyone else.
There is no "taking the fall" for talking to the NTSB. If it were otherwise a great many investigations would be impossible. Besides which the whole point of having a certified aircraft manufacturing process is to avoid making issues any one person's responsibility because all humans make mistakes. Allowing one person's mistake to endanger an aircraft means the process has failed, not the individual.
FWIW Airline pilots and ATC also have an ASRS reporting system: Aviation Safety Reporting System. It is blameless as well. Everyone makes mistakes, period. If you punish every pilot or controller who makes a mistake naturally they will try to cover up all such mistakes and that leads to worst outcomes. All the big airlines follow the rules and do not punish pilots for issues reported via the system. At worst you will get sent for some training to address problem areas.
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.
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.
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.
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.
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.
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.
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.
What if management was notified that the employee doesn't follow procedures yet did nothing?
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.
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 lets the NTSB ask them questions and figure out if it was a once-off error, or a systemic error.
"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.
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?
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.
(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/...
I wonder why they aren't doing that yet?
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.
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.
Under normal circumstances you're right, if nobody broke any rules nobody's fucked, and they're really more interested in seeing how the rules can shape behavior better going forward. I also think at this point that train has left the station.