The evidence just keeps piling up:
https://www.bbc.co.uk/news/business-68220627
The whole Boeing & Spirit quality management system is broken, or at the very least not fit for purpose.

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Bob Smith
Member of Seti PIPPS (Pluto is a Planet Protest Society)
Somewhere in the (un)known Universe?

The evidence just keeps piling up:
https://www.bbc.co.uk/news/business-68220627
The whole Boeing & Spirit quality management system is broken, or at the very least not fit for purpose.

The photographic exvidence.

An image from the National Transportation Safety Board report of the door plug. Blue circles, which the agency added to the photograph, indicate where the bolts appeared to be missing. Credit...National Transportation Safety Board

The evidence just keeps piling up:
https://www.bbc.co.uk/news/business-68220627

"...may not have been properly secured..."

may have not?

https://avherald.com/h?article=51354f78&opt=0

The NTSB reported: "The two vertical movement arrestor bolts, two upper guide track bolts, forward lower hinge guide fitting, and forward lift assist spring were missing and have not been recovered." and continued: "Contact damage was noted on the lower sides of the 12 stop pins and fittings on the MED plug. Corresponding contact damage was noted on the 12 stop pads and fittings attached to the fuselage. Overall, the damage was consistent with the MED plug translating upward, outboard, and aft during the separation." and further stated: "Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads."

On September 1, 2023, records show that NCR 1450292531 was created noting five damaged rivets on the edge frame forward of the left MED plug. See figure 14 for rivet locations. Documents and photos show that to perform the replacement of the damaged rivets, access to the rivets required opening the left MED plug (see figure 15). To open the MED plug, the two vertical movement arrestor bolts and two upper guide track bolts had to be removed.

The manufacturing/human performance group has done a complete records review from the time the event airplane left the Boeing factory to the time of the accident and found no evidence that the left MED plug was opened after leaving Boeing’s facility.

The NTSB report https://www.ntsb.gov/investigations/Documents/DCA24MA063%20Preliminary%20report.pdf says the photo "(Source: Boeing. Image Copyright © Boeing.
Reproduced with permission.)" With all the bashing in this thread I hope they aren't upset their copyrighted material is being bandied about without proper credit.

Figures 11 and 13 are photos of the locations of the missing bolts. Not only are the bolts missing, but there appears to be no marks on the paint that would normally be associated with a bolt having been tightened in a hole.
Figure 16 shows the plug in place at the Boeing factory, and it looks as if the three bolts in view are missing - and they are getting ready to re-fit the interior panels following the re-fitting of some rivets. Why the "£%^&*() didn't the person taking the photo not flag this up?
OK, so Spirit may have missed the bolts during the assembly of the fuselage, but given the opportunity they had why didn't Boeing notice?

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Bob Smith
Member of Seti PIPPS (Pluto is a Planet Protest Society)
Somewhere in the (un)known Universe?

OK, so Spirit may have missed the bolts during the assembly of the fuselage, but given the opportunity they had why didn't Boeing notice?

There's no clear separation of responsibility between Spirit and Boeing. Spirit delivered airframes to Boeing's assembly line with known manufacturing defects (e.g. damaged rivets). There, these defects were reworked by Spirit employees in-time during final assembly, for which parts (e.g. door plug) had to be partially dismantled again.

[EDIT to add:] A trade-off between adherence to deadlines (assembly line throughput) and component maturity before delivery for final assembly was made in favor of the deadlines. I am sure that such considerations are also made daily by managers on every Airbus final assembly line. The trick is to make this trade-off so that in the end all aircraft leave production without any defects within planned schedule.

I read somewhere that the Airbus A220 (former Bombardier CS100/300) is a efficient, modern aircraft but its final assembly (as planned by Bombardier) takes two weeks instead of one for a Boeing 737 Max or A320. Perhaps the design and time- and cost-efficient final assembly of aircraft requires quite a bit of “rocket science”.

As I read in the NTSB report, the bolts were present after the initial build. They were removed to facilitate the repair of the rivets.

The question is: why didn't the repair process include the creation of a checklist of all the consequential sub-processes required during the repair, and a check / signoff that they had all been reversed during re-assembly?

As I read in the NTSB report, the bolts were present after the initial build. They were removed to facilitate the repair of the rivets.

The question is: why didn't the repair process include the creation of a checklist of all the consequential sub-processes required during the repair, and a check / signoff that they had all been reversed during re-assembly?

See https://setiathome.berkeley.edu/forum_thread.php?id=85359&postid=2131800 and https://setiathome.berkeley.edu/forum_thread.php?id=85359&postid=2131816

Add, Boeing at Renton had a procedure to remove/replace a door plug. Boeing at Renton never needed to just open but not remove a door plug so no checklist existed. Spirit did. Shift change and software change from Spirit to Boeing and ... .
I'm sure the final report will be very long in the human factors department. The majority of it has been written years ago for some other mode of transport.

Yes. Human failure to manage the technology that human beings have invented.

It's a sort of correlate to the Peter Principle: the management branch of the species has promoted itself to a level which it is no longer capable of managing. I think that applies to a large proportion of the topics we find ourselves discussing here - war, climate, politics, economics, the UK postal service, to name but a few.

I think a lot of it comes from managing by assertion based on ideology, rather than data and understanding. It seems to be difficult to break out of that mindset.

I think a lot of it comes from managing by assertion based on ideology, rather than data and understanding. It seems to be difficult to break out of that mindset.

This seems to me to be a universally valid attribution of causes for the biggest problems and conflicts in society today.

Backed into a corner:

How Boeing Lost Its Way

Boeing is [irredeemably] broken?


Can you fly safe?...
Martin

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See new freedom: Mageia Linux
Take a look for yourself: Linux Format
The Future is what We all make IT (GPLv3)

And as I said before, that's what happens when bean counters take control as they're only worried about the bottom line and nothing else.

Really... Can Regulation and Oversight safely replace good morals and conscience and conscientiousness?

... Or do the neoliberals have us all doomed?...


Fly safe?
Martin

---

See new freedom: Mageia Linux
Take a look for yourself: Linux Format
The Future is what We all make IT (GPLv3)

Changing the culture of a company for the better is a long uphill struggle. The attitudes of all employees, at all levels needs to be changed, dead-weight staff need to be moved to other places outside the organisation (not just those at shop-floor level, but right up the tree to the very top). It's painful, and must be followed through to completion as stopping part-way can actually cause a regression to below the existing level.

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Bob Smith
Member of Seti PIPPS (Pluto is a Planet Protest Society)
Somewhere in the (un)known Universe?

Tis not the corporate bean counter, tis the employee bonus for hitting the magic production number. Just the same thing as hit Wells Fargo with employee commissions for opening fake accounts.

If you don't learn your lessons you keep making the same mistakes.

Ah, this: https://www.businessinsider.com/boeing-disaster-american-businesses-greedy-broken-stock-market-wall-street-2024-2

Desperate:

NTSB Preliminary Report Alaska #1282 Door Plug Blowout

For the sake of a "Plug Door" or a "Door Plug"...

Do you believe in God?

Or can you trust your life to a dyslexic dog?...

... And really... Why were those uniquely two seats unoccupied?


Fly safe?

Really?!
Martin

(Full qudos to the crew, and blind luck, for averting complete total all-dead disaster. )

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See new freedom: Mageia Linux
Take a look for yourself: Linux Format
The Future is what We all make IT (GPLv3)

The fact that the crew & passengers survived, the aircraft landed without damage, and the plug was found intact is helping the investigation no end.

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Bob Smith
Member of Seti PIPPS (Pluto is a Planet Protest Society)
Somewhere in the (un)known Universe?

... And really... Why were those uniquely two seats unoccupied?

A wild theory: Due to recent incidents with cabin pressure, the airline decided not to occupy these two seats, suspecting that the door plug's seal could be a possible cause.

(Full qudos to the crew, and blind luck, for averting complete total all-dead disaster. )

Does a blown out door plug actually have the potential to lead to a total disaster, such as tearing the airframe apart due to sudden decompression?

Airframe destruction is not that probable due to rapid decompression following the loss of one of these plugs, unless it causes damage to another part of the fuselage.

(Note - This accident was the loss of a plug, which was supposed to "permanently" fixed in place. A plug door is a type of door that plugs into a normal doorway, which may, or may not, have an opening control, but has most, if not all the normal hinges and locks - normal passenger doors are indeed plug doors)

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Bob Smith
Member of Seti PIPPS (Pluto is a Planet Protest Society)
Somewhere in the (un)known Universe?