A reader at respected airline industry site Leeham News offered a comment that suggests they have access to Boeing’s internal quality control systems, and shares details of what they saw regarding the Boeing 737 MAX 9 flown by Alaska Airlines that had a door plug detach inflight, causing rapid decompression of the aircraft.
The takeaway appears to be that outsourced plane components have so many problems when they show up at the production line that Boeing’s quality control staff can’t keep up with them all.
Current Boeing employee here – I will save you waiting two years for the NTSB report to come out and give it to you for free: the reason the door blew off is stated in black and white in Boeings own records. It is also very, very stupid and speaks volumes about the quality culture at certain portions of the business.
…With that out of the way… why did the left hand (LH) mid-exit door plug blow off of the 737-9 registered as N704AL? Simple- as has been covered in a number of articles and videos across aviation channels, there are 4 bolts that prevent the mid-exit door plug from sliding up off of the door stop fittings that take the actual pressurization loads in flight, and these 4 bolts were not installed when Boeing delivered the airplane, our own records reflect this.
…As a result, this check job that should find minimal defects has in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations (so both actual doors for the high density configs, and plugs like the one that blew out). That is a hideously high and very alarming number, and if our quality system on 737 was healthy, it would have stopped the line and driven the issue back to supplier after the first few instances.
…Now, on the incident aircraft this check job was completed on 31 August 2023, and did turn up discrepancies, but on the RH side door, not the LH that actually failed. I could blame the team for missing certain details, but given the enormous volume of defects they were already finding and fixing, it was inevitable something would slip through- and on the incident aircraft something did. I know what you are thinking at this point, but grab some popcorn because there is a plot twist coming up.
The next day on 1 September 2023 a different team (remember 737s flow through the factory quite quickly, 24 hours completely changes who is working on the plane) wrote up a finding for damaged and improperly installed rivets on the LH mid-exit door of the incident aircraft.
…Because there are so many problems with the Spirit build in the 737, Spirit has teams on site in Renton performing warranty work for all of their shoddy quality, and this SAT promptly gets shunted into their queue as a warranty item. Lots of bickering ensues in the SAT messages, and it takes a bit for Spirit to get to the work package. Once they have finished, they send it back to a Boeing QA for final acceptance, but then Malicious Stupid Happens! The Boeing QA writes another record in CMES (again, the correct venue) stating (with pictures) that Spirit has not actually reworked the discrepant rivets, they *just painted over the defects*. In Boeing production speak, this is a “process failure”. For an A&P mechanic at an airline, this would be called “federal crime”.
…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.
The commenter concludes, “Where are the bolts? Probably sitting forgotten and unlabeled (because there is no formal record number to label them with) on a work-in-progress bench, unless someone already tossed them in the scrap bin to tidy up.”
The information was first flagged by aviation watchdog JonNYC.
..unvetted (every other synonym for that as well,) commenter here:https://t.co/R3KdqDHION
And now I'm seeing a couple other usually credible, usually careful folks positing same idea.
As always– more so than usual– no idea myself.
— JonNYC (@xJonNYC) January 22, 2024
Boeing outsources a lot of the production of components for its aircraft because it’s cheaper as part of an overall shift in strategy that dates to CEO Harry Stonecipher who had been CEO of McDonnell Douglas,
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.
One of the major suppliers is Spirit AeroSystems, which used to be part of Boeing and was spun out and sold to private equity in 2005. That’s whose work is at issue here.
This story suggests a one-off mistake with this particular part on this particular aircraft, though also that production issues are common. That doesn’t square with a theory that bolts could have come loose from flying a poorly-designed aircraft, or that Boeing 737-900ERs are being inspected too. Those have the same door plug because the MAX 9 is built on the same airframe. It may or may not square with finding loose door plugs on other Boeing 737 MAX 9s.
So this story is far from ‘official’ but it seems knowledgeable from someone who suggests they’re a whistleblower inside of Boeing. A story in Politico this morning suggests that Boeing’s new team of lobbyists has their work cut out for them. It certainly appears so, but perhaps work needs to start at the board and C-suite level.