The Boeing 737 MAX 9 was temporarily grounded – and tremendous faith was lost in Boeing – after a the left mid exit door plug detached from Alaska Airlines aircraft N704AL while performing flight 1282 from Portland, Oregon to Ontario, California.
The NTSB has now issued a report on what happened, and it tracks what readers of View From The Wing already know: the plane left the factory missing bolts to hold the door plug on, and tracking of defects at Boeing seems to be a problem.
When the wall of the plane just breaks off mid flight @AlaskaAir pic.twitter.com/pMWhpiHmFY
— Kyle Rinker (@Kyrinker) January 6, 2024
We first learned from a whistleblower (that View From The Wing was first to cover) that the bolts on the door plug were missing when the plane left the factory.
- A defect in the plane was found
- It was addressed as warranty work by Spirit AeroSystems on-site
- But the door was never sealed properly.
The NTSB’s preliminary report on the incident confirms this version of events. You might think that Boeing is stonewalling investigators, but it seems like they just have shoddy records (and they are not allowed to have shoddy records).
A month after the blowout, though, Boeing has not provided the NTSB with documentation about who opened and re-closed the door plug, how exactly it was done and with what authorization.
“The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left mid exit door plug during the rivet rework,” the NTSB report states.
Credit: NTSB
It may be shoddy recordkeeping, and a high volume of production problems, that caused these bolts to get missed.
According to the whistleblower, it appears that Boeing uses two different systems to log defects, which creates tracking problems – and that there’s no paperwork on the door removal because it was determined that “the door only needs to be opened” (not removed) to do the work and therefore no removal order was placed into the formal system.
However the bolts would have been taken out whether the door was removed or merely opened. And since this didn’t get tracked, no quality inspection was done, and the bolts are now “[p]robably 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.”
Boeing spun off Spirit AeroSystems and now it’s an outsourced supplier to the plane manufacturer, to keep costs down. Then-CEO Harry Stonecipher, who had been CEO of McDonnell Douglas, separately noted “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.”
Now it turns out that only 20% of Spirit’s top executives’ compensation was based on the quality of their product? I guess you get what you measure (and pay for).
Yet while Airbus has problems of its own, they don’t seem to have the same production faults as Boeing even though they work with Spirit AeroSystems, too. It seems likely that, while defects fall at the feet of Spirit, it’s Boeing’s quality assurance program that seems to let problems like this one out the door.
We know that the downfall of Boeing was caused by the McDonnell Douglas executives being put in charge. So, why don’t the stockholders jump down the board of director’s throats and DEMAND that headquarters be returned to Seattle/Everett and that Boeing go back to being an engineering firm? Think of what Boeing accomplished after the Apollo 1 fire. They pulled together a menagerie of companies and ideas, whipped them into shape with a no nonsense attitude towards OK is not good enough.
Boeing seems to have dropped Lean Six Sigma from their build program just to get planes out thee door.
So now we know what led to the plug failure. But what I’m still not understanding and wish I could understand better is what sort of mistake is this? Is this workers simply not giving a shit who can’t be bothered to do a simple job correctly and quality control totally out to lunch – what it sounds like – or is there some technical problem that makes doing this job correctly, and QC catching it when it is not done correctly, more complicated than it seems?
@Win Whitmire I agree with you except relocation Boeings HQ back to Seattle has nothing to do with anything.
@ Mak All of the above, take out the or and replace with and.
After Sully landed in the Hudson, and I subsequently learned how superior Airbus’s flight control software was, I chose to prioritize Airbus for my travel when I could. I don’t see a reason to change that.
AA pushes me onto geriatric 777s, but at least, by now, I trust after 20 years anything that is going to fall off, will have done so.
I see no reason to fly relatively new Boeing ‘planes unless one has no choice.
That is quite an extrapolation to Airbus. Does Spirit build complete assembled fuselage and ship them to Airbus?
Unlike Boeing, Spirit does not manufacture complete fuselages for Airbus, but only some parts
Allowing shoddy records is part of the rot from the top. The CEO should be pushed out,
It could also be due to overworked and understaffed groups.
Sadly due to wanting ever increasing stock price, profit margins, etc. management frequently cut costs by either cutting corners, outsourcing, etc. and you lose quality.
I was pleased that Boeing manufactured their 737 MAX 9 with such precise tolerances and superior aeronautical engineering that their aircraft could fly 150 times while missing multiple critical door bolts before their jet experienced a catastrophic left mid-exit door plug blowout. I am confident that the Wright Brothers would be incredibly proud of The Boeing Company and their engineering excellence.
Jim: I respectfully disagree. When Boeing management was in Seattle/Everett/Renton, those who assembled the aircraft had a “direct line” to upper management. “Hey, Mr. Boeing president, we gotta problem. Come here and let me show you.” Now, upper management and engineering is no where near the folks that actually build the aircraft. As numerous documentaries have pointed out, McDonnell Douglas’ Stonecypher said that he was going to transform the company. Well by golly, he did that alright. I reiterate what I’ve said before, “If it ain’t Boeing, I ain’t going!” has been replaced with, “If it’s a MAX, I ain’t a pax!” And to Jack: I forgot all about lean Six Sigma. EXACTLY!
Having two tracking systems is a failure from the top. Raising production rates while training hundreds of new employees after experience people left during Covid is a failure from the top.
It’s not just Boeing. There’s a widespread competency crisis; industrial accidents, train derailments, day-to-day failures in less dangerous industries.
Baby boomers are retiring. Younger employees are getting promoted to fill the boomer positions. Unqualified people are getting hired to fill the entry level vacancies. The “great rotation” ended with a lot of workers in over their heads.
Attrition always happens, but covid put it into overdrive right as the largest generation hit retirement age.
This is a union failure. The union employee on the floor that is suppose to inspect if the bolts and other parts are installed and are correct did not do their job because they don’t care, this is due to it not having any effect on their job security since they are union and it doesn’t matter if you do a good job or bad job the union will stand behind them.
@Pat – That is a hot boomer take to imply that competency is being lost because boomers are retiring. More like boomers have been implementing these failed policies and practices in the first place, and then leaving younger people to pick up the pieces. It was a bunch of boomer MBAs that moved Boeing out of Renton.
“We first learned from a whistleblower (that View From The Wing was first to cover)…”
The whistleblower wrote the comment on the Leeham News website available to countless readers, which you credit properly in the earlier post.
So, you were the first to cover a story unfolding on another website? Congrats!
Boeing doesn’t have a quality control crisis -stop- Boeing has a management crisis -full stop-
Serious question, Why aren’t aerospace companies required to post hot lines for the FAA, DOT, DOD?
Workers sure in the hell can’t go to H.R.!