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.
I like some of the comments, but come on!!! The problem with complex aircraft is what is really wrong! Yes the aircraft had 3 write ups ! Now you go to the trouble shooting manual for air condition. You run through the trouble shooting steps for that warning light . Chapter 21 Air conditioning. By he way, that warning light thinks the air cond system has poor performance. Now the mechanics consult the ETOPS Manual as this aircraft is set up to fly long flights from a landing strip. News Flash a different department of the FAA is in charge of this department . They think different then what most people think of when they think FAA. My problem with this is most of the trouble shooting trees have a statement at the end, unable to find a fault, follow your airline program.
This is the consequence of the loss of work ethic in this country coupled with the fall out of DEI. Boeing no longer aspires to be great and innovative, instead they operate as entitled and spend countless resources hiring and promoting DEI. I’ve built dozens of high performing teams in my career and today it is nearly impossible as the result of wokeism. The equity mindset which is communism wrapped in a bow has permeated everything from aeronautics to universities. It will be the death knell of this country and the Chicoms are chuckling as America implodes.
Let me summarize the story and save future readers time… Someone simply forgot to put in the door bolts.
Forbes had an excellent article about Boeing corporate culture after the McDonnell Douglas buy out. In the end, McDonell Douglas management took over Boeing, replacing the engineers and pilots who ran the company with bean counting accounts. This ongoing problem with the Max reminds me of the DC-10 and the drama of the rear cargo door. McDonnell Douglas has been warned that the rear door latching mechanism was insufficient and an accident waiting to happen. Engineers had recommended replacing the latching mechanism with a hydraulic system over the under powered electronic, as well as adding rear cabin venting to equalize cabin pressure if the door opened in filing. They also warned that a blow out could cause a loss of flight control because the cables controlling the tail assembly went right through the area. The bean counters refused . Too expensive. Then came the Windsor incident, where an AA 10 rear cargo door blew out over Windsor, Canada at 10,000 feet. The rear cabin floor collapsed because of no venting and the control cables were damaged but the pilots kept control and landed. The engineers made the same recommendations but the bean counters scoffed and instead McDonell Douglas added a tiny window so that ground crew could check the locking mechanism. And then came the Turkish Airlines flight out of Paris. Another blow out which destroyed the rear cables and a few hundred people lost their lives. Then contrast that history with the L1011 and you see the difference when the guys who build and fly the planes make them. That Max is typical McDonell Douglas, made on the cheap and held together with hope and prayers.
This is what happens when you have non-union built aircraft, and you reward them with bonuses when they fall behind. Then fly the plain to Washington to be completed by union workers !!!
I am an ex. Boeing MRB engineer and I can see how this door plug failed
There was an inspection buy off at at spirit aero systems. This got signed off by inspection
Without looking at the door plug.
Spirit needs to be audited for all the work they do in aerospace.
Boeing should have noted what happened to McDonnel-Douglas before hiring from there for their CEO. It is a business, yes, but not quite as forgiving as say, GM or Ford. Or Steelcase.
The attitude at McDonnel-Douglas ended up with their closure. Emulating it at Boeing does not seem to be a good move.
This all comes down to three letters: MBA. Boeing and Intel used to be run by engineers. But not enough people believe that engineers can run companies. Instead you need MBAs. After all MBAs understand the importance of cost cutting and maximizing profits. So the MBAs at Boeing spun out Spirit AreoSystems and subcontracted as much of the design and manufacturing as they could. That is why the 787 Dreamliner was many years behind schedule and why Boeing decided that they could stuff bigger engine cowls on the 737 Maxes and fix the instability with some software that they didn’t tell anyone about.
The same thing happened at Intel. Intel also went down the tubes when the stopped being run by engineers and run by MBAs. The MBAs saw the company as a cash cow and stopped investing in expensive R&D electing not to use the state of the art EUV lithography. Intel also missed the smart phone revolution, the low power RISC architecture and mostly missed GPU acceleration. Intel had the resources to dominated all those fields but left them for scrappier startups which are now out preforming them.
Beware of MBAs. They look good in suits but they don’t get technology.
William,
and a big part of the problem w/ the MAX is that it doesn’t have a computerized system to manage all of those warning lights as every other modern commercial aircraft has.
Engineers can sit at their desks and sort through all of the possible scenarios and program that into computers but when pilots have to sort through that complexity while something wrong is happening in flight, it becomes overwhelming and that happened on the AS flight.
Part of the process the NTSB and FAA faces with the MAX is ending the exemptions that Boeing has repeatedly gotten for the MAX to comply w/ all requirements for modern aircraft regulations.
This accident is about much more than just nuts and bolts failing but gets to the heart of the fact that the MAX is a massively redesigned version of an aircraft that doesn’t comply with many modern aircraft requirements.
As I have seen it from being on the inside, the removel prosses as it stands currently is in shops hands to write which then deviates away from the original IP/work order and dose not often include the many processes/steps of build or inspections there of.
Boeing took steps to remove quality out of as much of the build process as they could and now here they are, with record defects, doors/plugs being sucked out/off the planes and so on.
Originally the removal process was left to the quality inspector to write and when quality wrote the removal it was written to include all in-procees inspections coming off and back in per Boeing specs and per dwg.
As listed above this is no longer the case.
Then you have the FAA not doing its job and has allowed Boeing to dictate to the FAA vs the FAA doing its job of over site enforcement and its own inspection, the FAA allowed Boeing to remove many quality inspections. Boeing used to be a 100 percent in-process inspection in the completed build process it no longer is. Boeing has been allowed to pic and choose which inspections they now include in the build process.
So enclosing until Boeing is forced to bring back all of its in-process inspections there malfunction/failure issues will only grow. Until Boeing is forced brings back a very large amount of all their outsourced work as none of their out sourced vendor’s either build to or are held to building to Boeings own specs and drawings or processes as they are not part of Boeing.
I suggest SKU-encoded mailing labels 2″ x 1″ in size. And affixed to all bolt heads. No exceptions.
When a company and its board prioritize short-term profit margins above all else, it often leads to a significant shift in leadership dynamics. A notable example of this is the transition of a CFO to a CEO role. While financial acumen is undoubtedly valuable, a singular focus on cost-cutting can harm a company’s long-term vision and heritage.
A case in point is the downfall of Nortel. This was a company that, under the leadership of a CEO whose priorities were misaligned and who reportedly engaged and got paid across multiple countries, saw its century-old legacy crumble in a matter of months. The subsequent appointment of a CFO as an emergency CEO primarily focused on reducing expenses, and finally, sent this hundred-year-old company to the graveyard.
This brings me to the current situation at Boeing. The CEO’s performance, in my opinion, warrants serious reconsideration. Like Wells Fargo’s decisive action against their former CEO, there should be substantial consequences for leadership failures. The current CEO must go, not only should there be no extravagant separation packages, but previous compensations, such as stock options, ought to be reevaluated and possibly recalled.
Setting a precedent for accountability at the top is essential. Leaders should bear the responsibility for their actions, especially when those actions jeopardize the company’s integrity and future. We must learn from past examples and strive for leadership that upholds the company’s values and long-term interests.
Spot on & well said, @Joseph Zhou.
@Greg,
Yes, former Boeing Chairman & CEO Dennis A. Muilenburg was shown the door in 2019 as a consequence of the two 737-8 MAX crashes in late 2018 & early 2019, & his bungling of public relations.
However, his replacement as CEO, Dave Calhoun, was a Boardroom insider, having joined the board in 2009 & being named “Non-Executive Chair” prior to Muilenburg’s departure from Boeing in 2019 (the Board Chair & CEO positions were separated in 2019 prior to Muilenburg’s departure).
Moreover, Calhoun’s career includes 26 years at General Electric (GE; 1980-2001), where he rose to Vice Chair of its Board before leaving GE in 2006.
Finally, with Boeing’s reputation for commercial aircraft engineering excellence (alas, just one of many other serious problems across its major programs/divisions, see for example KC-46A tanker, Starliner), the last thing this company needs is to be led by someone whose career includes 26 years at GE, most of which were during the now largely discredited Jack Welch era & as if that isn’t enough of a taint itself, Calhoun’s previous “Day Job” as Senior Managing Director and head of Private Equity Portfolio Operations at The Blackstone Group.
Sorry, but having a “Finance Guy” running the show is NOT what Boeing needs to restore its reputation – especially an insider whose term on Boeing’s Board began ~15 years ago.
Change is good & Boeing needs to embrace change if it truly wants to begin the long & difficult journey towards restoring its reputation.
In fact, expecting the same people (including someone who oversaw from the Board beginning in 2009 & has been its CEO for 3-full years) “to fix” what they broke is a fool’s errand.
*that’s Boeing’s reputation for commercial aircraft excellence in tatters in the above.
Apologies for the editing error.
I cannot think of a company who, after M&A, didn’t cut quality to payoff the overpayment they made when acquiring the company. When we were a quality seller selling quality products on the internet from 2005-2018, I immediately discontinued EVERY supplier who had been acquired by merger or an investment firm. EVERY ONE OF THEM got taken over by accountants and quality went in the tank. We saw accountants get into the production line and reduce the number of threads of screws into particle board that caused doors to rip out from inertia during transit on container ships. It wasn’t until I had a drop-shipped item returned to me that was also one I owned pre-acquisition that I could tell what had happened. I removed a screw from my hinges and compared to the “new” screws… 3 threads shorter. Nearly every cabinet had its doors ripped off in transit. Terminated the company immediately and that’s when I started terminating others immediately upon their merger or acquisition. As long as the original owners were in charge, quality stayed the same. Once they were gone, the product lines in their entireties were destroyed. Hello Boeing-McDonnell merger… only the consequences are much, much larger. But accountants just don’t care.
Management runs Boeing, which is their job. IAM employees, mechanics, QA, do their jobs within the frame work of Boeing process and policies. Management does not “sign off any jobs that are done on the 737max. They are the invisible person, behind the curtain. They conjoul, threaten, persuade IAM employees to complete jobs whether done correctly or incorrectly. Their names are no where to be found. I bet if management had to stamp for their team’s work at the end of each day, that it was done correctly and free of coercion, and was available to the FAA and NTSB and anyone else, things would change at Boeing. Right now Boeing moves managers around frequently to mask any improprieties they might have committed.
Sam Sam your are 100% spot on. As are a lot of these comments. As s Boeing employee I myself refuse to fly on a new Boeing plane. The culture has degraded to the point that Boring isn’t Boring. It’s all about cost cutting. Making a safe plane falls to about 5th or 6th on their list. 3 more years and I can retire from this quagmire. Management has killed Boeing. It only survived in name only. Sad beyond belief.
This is the defining sentence, right here. By replacing federally licensed A&Ps with “mechanics”, Boeing traded safety for profits. A&Ps are bound by federal law and I have yet to meet one who is willing to go to prison over this kind of nonsense. The FAA needs to start doing their job and stop letting Boeing run the show.
“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”.”
Having worked for one of the leading airlines in the world (at the time) in Africa, we used to operate Boeings and Airbuses. I personally find them to both be magnificent machines regardless of shape and size and can only but admire the sheer engineering that has gone into them. If you are going to tell me that bolts just lie around and get thrown away without any reason against the inventory, we’ll umm okay!
I worked for McDonald Douglas for 20 years calibrating ovens and other process equipment and when Boeing took over the needs for calibration on a lot of the equipment , they said was not necessary. Seems as though the quality of the McDonald Douglas planes went down after the buy out.
Unless I’m missing something I don’t see this as a SAT problem. Yes they made the door plug but it wasn’t them that installed it to the fuselage and forgot to install the lock out bolts. And another thing. All these reports of ‘loose bolts’ are misleading. If you take the four lock bolts as an example, they don’t actually have to be tight to be installed correctly. The castellated nut doesn’t necessarily have to be torqued down, it may only be required to screw the nut down far enough for the the hole in the bolt to align with one of the cut outs of the nut for the split/cotter pin to be installed. In this scenario you may be able to rotate the bolt by hand but the nut and split pin is installed correctly.
I left Boeing – Everett plant in 2012, in 2013 Jan. thru March I worked as a contractor in Wichita/Spirit on the 737. I did many forward door Drill Outs for fasten and seal, can’t count the times my Forman (direct hire at Spirit) would tell me to go start working on the next plane and he would have QA come look at my completed job for Buy Off. I learned that QA never came physically to inspect/buy off my completed forward door drill outs/fasten & seal for pressure jobs. I also seen countless times that direct hire employees on the 737 would never Aldine a bare metallic part when original primer was removed . Not at all surprised by what I am seeing come to fruition in regard to quality issues on that program.
Here are some stats to help real people understand just how safe Boeing 737s are. Sure I, myself, understand how surprising and unnerving, and tragic and catastrophic these malfunctions are. Simply no way to say it with offending someone. But look at these stats, it is truly amazing how safe we are. Automobiles, cross walks, kill far more people, sorry.
of all commercial flights are operated by the 737s. More than 338 airlines in 112 countries fly the 737. On average, over 2,900 737’s are in the air with nearly 500,000 passengers at any given time. On average, one 737 takes off or lands every 1.5 seconds.
Thanks by the way, very very, doesn’t make very more intense, it actually makes is less believable.
My apologies, not able to final review my post before posting because it retracts to the last line before posting.
To correct, “without offending someone “
You worked for “McDonald Douglas” for 20 years and can’t even spell your employer correctly?
@Shonk: Autocorrect is a thing. Edit, unfortunately, is not.
I find this problem to be extremely shocking. I would like to start out by saying I’ve been working in the automotive manufacturing field.for 19 years. When there are critical bolts installed they are tightened by DC Tools. These tools not only tighten the fasteners but record the entire process to ensure there are no abnormalities. It also marries
the data to the VIN. When the unit reaches the end of the.line the VIN is scanned and if there are any problems with the process the unit is prevented from shipping. I am totally shocked that this method is not used everywhere especially on aircraft. How many other bolts are loose?
My husband and most of his crew on the flight line in Renton retired early a couple of years ago because the stress and stupidity of upper management was unbearable. The writing was on the wall before the two planes cashed less than 5 months apart in 2018 and 2019 killing 346 people.
With CEO Muilenburg Boeing went from safety and security to pushing out planes for profit.
Assembly lines were expected to build planes at an unreasonable rate. The flight line was receiving planes with unfinished or faulty tags and expected to do the jobs of the factory workers, which not only wasn’t their job but also wasn’t their expertise. When my husband and most of his crew left there was no one with the training and expertise needed to do the job. It saddens and sickens me what greed has done to a once great company.
Here here no true words have ever been spoken. as a Boeing IAM 751 employee, when I first came on it was all about quality everything safety and quality no questions asked. and since then we’ve digressed to where it’s all about profit. to hell with safety to hell with quality it is sad and we let our CEOs who have flown the company into the ground get 40 to 60 million dollar severance packages what we I am 751 folks carry a burden of the loss of 346 souls on two of our airplanes that we built
But I can assure you the members who work on the airplanes at the factory do an outstanding job under the circumstances which we have to work many many straight days without a break. management putting totally undue pressure to meet or exceed unreasonable deadlines just to ensure their bonuses and their bosses bonuses with no regard to quality or safety. It’s absolutely criminal what these McDonald’s Douglas and GE people have done to the Boeing company William bong is rolling over in his grave I’m sure as well as a lot of retired and no longer with this former employees who watched all their years of struggle and hard work and toilet to have it trashed solely for the chase of a dollar bill. William Calhoun step down for the good of the company which you claim is all you ever care about is what’s best for Boeing The board members all of you need to be slept away and an entire new start needs to be made The rot has gone too far to fix we have to burn this thing down to rebuild it again to restore it to what it once was and what always should be the Boeing company the world’s finest aerospace company
Think about this.
You can hire in as a janitor at Boeing, no aviation experience. Go to a Boeing job counselor. Sign up for a couple of the Boeing “classes”on the weekend. These are not a school classes. Just some “Boeing Certification” classes. Finish those in a couple weekends, apply for a flightline mechanic 97109 job, and there you are, on the flightline working on live airplanes. Having trouble do the jobs assigned? No worries they will make you QA. Are you pretty, no worries, you can become a QA manager, then an FAA coordinator. All in under 3 years.
One of the lessons from the late 1970s/early 1980s car manufacturers is that you can’t QC your way to better products. Quality Control is meant to address the shoddy manufacturing methods, not be a selection process for an irregularly built product.
The fact that QC was overwhelmed is a HUGE red flag for everyone to stand down and figure out what on earth is going on. You can blame unions or the lack thereof. You can blame subcontractor QC, you can blame management, you can blame society and even how educators teach kids. I don’t care. The goal is to find problems and address them, not throw blame every which way.
Yes, this goes back to Boeing “leadership.” This situation never should have been allowed to fester. Now they’re looking at massive damage to their reputation. Boeing is already in trouble on multiple projects. Much of this leadership gap seems to have started when Corporate offices moved from Renton, Washington to Chicago for whatever silly reasons. Get the damned leadership closer to the factory floor and start a conversation.
Or watch the company circle the drain and fail. With this level of incompetence, I’m having a hard time caring.
This is what happens when every part is built by different companies! I REFUSE to fly ANY Boeing aircraft made after the 777 program. BOTH the MAX and Dreamliners are a COMPLETE DISGRACE! Boeing cut corners to save a few bucks in order to give more and more money to it’s top management staff!! Yet NO ONE has gone to jail for all the people it’s MAX killed!
With all these problems, I find it incredible that more planes don’t fall out of the sky, it makes me not want to board any plane. The biggest problem is the individuals on the assembly line that don’t care and have zero work ethic, which is the fault of our society and our education system. They show up to work under the influence like they are a DEI worker at a fast food restaurant and they know they can’t get fired because we have created laws to coddle them without consequences, all while they are responsible for the lives of millions of people that travel. The leadership is a problem, sure, but a person on the assembly line that doesn’t have the mental prowess or care to install 4 bolts is the real problem here. No pride in their work, not a care in the world, I wonder if they have enough intelligence to avoid flying in anything they have touched.
You sir, are under the influence. You have no clue what goes on in that factory, you have no clue the amount of training and certification that takes place there. The young mechanics that I trained there recently are all excited to be building the best plants in the world. Boeing is a career for many. For you to just throw the mechanics under this bus is just asinine. READ: There us WAY more going on behind closed doors right now that have nothing to do with mechanics. Note: “Assembly Mechanic” is honest, hard work.
John, all I can say is you must have never worked at Boeing. Because observation sounds like something out of corporate handbook. The hard working IAM751 people give 100% all the time to making the best airplane possible. One point you do make is true. The new hires brought in for the most part don’t give a damn about work ethic or even care about quality. Boeing workers used to be the elite of the elite. Now we hire folks who’d rather smoke dope or play on their phones. Product of lagging way behind in wages and benefits. If you want the best you have to offer a top notch package. You want to pay like Walmart then you get Walmart quality people. Meanwhile elite managers get 40 to 60 million dollars for making decisions based on stock dividends. Resulting in planes that nose dive into the ground. Don’t every think that the vast majority of folks on the line don’t care. We have sacrificed our families our health for decades to build the safest planes in the world. The last 3 CEOs have decided that 100 plus years of Boeing is only worth what the board can give them. Huge bonuses and massive stock options. While innovation and safety are no longer considered. All the dog and pony shows that are currently being done at Boeing aren’t going to change a damn thing. Only a complete gutting of upper and middle management will.