Bolts? We don't need no stinkin' bolts. It's only an airliner...

[Ace-Garageguy]

Anyone not living under a rock most likely has heard of the recent Alaska Airlines 737 door-plug blowout incident.

The FAA/NTSB findings are in on that particular oopsie...after inspections of subsequently grounded aircraft revealed missing or loose fasteners on several of them.

1) Spirit Aerospace, a Boeing subsidiary that builds 737 fuselages, buggered the installation of several structural rivets in the vicinity of the door.

2) The door was subsequently removed at the main Boeing plant to gain access to the rivets to correct the issue.

3) When the door was reinstalled, the retainer bolts were left out.

4) Nobody in the Boeing QC chain caught it.

5) This should be impossible if everyone in the chain had been doing his or her job.

I'm impressed.  

 

Edited February 10, 2024 by Ace-Garageguy

[ColonelKrypton]

2 hours ago, Ace-Garageguy said:

This should be impossible if everyone in the chain had been doing his or her job.

Indeed. The fuselages should never have gone past Spirit Aerospace if QA/QC was working how it should. 

Boggles the mind when I read stuff like this.

cheers, Graham

 

[stavanzer]

Trust Juan Browns to have the scoop.

I check his channel several times a week.

He is one of the best commentators on Flying out there.

[bobss396]

This is called an "inspection escape". Some repair activities have a checklist that go with them. Most of the time checklists happen after someone gets caught with their pants down. All of these repair shops fall under FAA scrutiny. So by now they know exactly who worked on the door, unless the shop is that far out of control, they dummy up everything and this time the results were tragic.

[Ace-Garageguy]

1 hour ago, bobss396 said:

This is called an "inspection escape". Some repair activities have a checklist that go with them. Most of the time checklists happen after someone gets caught with their pants down. All of these repair shops fall under FAA scrutiny. 

In this case, the "repair shop" was the main Boeing plant, where the door was removed for access to replace incorrectly installed rivets...that were installed incorrectly at the Boeing subsidiary Spirit Aerospace while building the fuselage. (Apparently poor QC/QA is an ongoing hallmark at Spirit Aerospace.)

The fuselages are built at Spirit, trucked to the Boeing plant for assembly to the wings and other major components, and final assembly.

Somebody at the main Boeing plant caught the poor work on the rivets, but somehow missed checking correct reinstallation of the door plug.

I've worked as an A&P in general aviation (smaller private aircraft), and EVERYTHING I did was supposed to be inspected and verified by the next guy up the line, the IA (Inspection Authorization Mechanic).

In some of the facilities where I've worked, some of the A&Ps and the IAs were grossly unqualified or just plain slackers. I was amazed at one shop where a licensed A&P (how this guy got a license I'll never know) put brake pads on a Cirrus in BACKWARDS, and nobody caught it until the aircraft owner was taxiing away from our tie-down area, and came back wondering what the "grinding" sound was on his just-100-houred half-million dollar airplane. Good thing he was a pilot who was sensitive to the feel and sound of his plane too, because a Cirrus cabin is not a quiet environment.

In another incident, an A&P with a fake license (who had previously been employed by the shop I was talking about above) failed to reinstall bolts in the aileron linkage on a big twin during a 100-hour inspection, resulting in a fatal crash shortly after the next takeoff by the owner.

One of the reasons I left working on GA aircraft was the (sometimes) slovenly approach to performing the extremely high quality work I'd assumed I'd be expected to provide. Some of the work I've seen on composite parts and structures in GA aircraft is so bad as to be truly beyond belief.

I have, on the other hand, worked with some very highly-qualified, competent, and conscientious people in GA (general aviation), but sadly, they are not in the majority (at least in my experience).

Edited February 11, 2024 by Ace-Garageguy

[NOBLNG]

Someone, or more than one person, should lose their job, their license, and be banned from working on aircraft. This could easily have been a catastrophic accident.

[redscampi]

1 hour ago, NOBLNG said:

Someone, or more than one person, should lose their job, their license, and be banned from working on aircraft. This could easily have been a catastrophic accident.

Not that I disagree, but humans happen. In any aircraft incident there is always a chain of failure points which almost always can be traced back to human mistakes at some point, and it's never just one point or one issue. It could be lack of education, lack of oversight, bad planning, bad engineering, a bad day, an unfortunate coincidence of lazy and complacent employees or any number of other factors. In our search for accountability we always want to pin it on one person and make them pay, no matter what the issue is, but there's always much more to the story.

 

Edited February 11, 2024 by redscampi
spelling

[Ace-Garageguy]

2 hours ago, redscampi said:

Not that I disagree, but humans happen. In any aircraft incident there is always a chain of failure points which almost always can be traced back to human mistakes at some point, and it's never just one point or one issue. It could be lack of education, lack of oversight, bad planning, bad engineering, a bad day, an unfortunate coincidence of lazy and complacent employees or any number of other factors. In our search for accountability we always want to pin it on one person and make them pay, no matter what the issue is, but there's always much more to the story.

 

All very true, but in aviation there's no room for oopsies, whatever the cause.

That's why there's redundancy in critical aircraft systems, sometimes even triple redundancy...and that's why there is supposed to be accountability for EVERYTHING ever done to something that flies, why the mechanic has to sign off on his work, and why his work is supposed to be double-checked and verified by the guy above him.

There is a very real reason for the old joke that "the airplane is ready to return to service when the paperwork weighs as much as the plane"...but chimps filling out forms doesn't guarantee things are done right in the first place, unless EVERY said chimp in the chain is competent and conscientious.

Boeing used to be the world-standard for safe, reliable aircraft.

After the last 737-Max MCAS software-engineering mess resulting in two major crashes and hundreds of deaths, and the apparent ongoing QC issues with assemblies coming from Spirit Aerospace, and the failure of the QA/QC chain at the main Boeing plant to catch SEVERAL instances of missing or loose door-plug hardware on SEVERAL aircraft...well, not so much.

And the top management is ultimately responsible for any oopsies committed by his underlings.

Edited February 11, 2024 by Ace-Garageguy

[redscampi]

5 minutes ago, Ace-Garageguy said:

All very true, but in aviation there's no room for oopsies, whatever the cause.

That's why there's redundancy in critical aircraft systems, sometimes even triple redundancy...and that's why there is supposed to be accountability for EVERYTHING ever done to something that flies, why the mechanic has to sign off on his work, and why his work is supposed to be double-checked and verified by the guy above him.

There is a very real reason for the old joke that "the airplane is ready to return to service when the paperwork weighs as much as the plane"...but chimps filling out forms doesn't guarantee things are done right in the first place, unless EVERY said chimp in the chain is competent and conscientious.

Boeing used to be the world-standard for safe, reliable aircraft.

After the last 737 software-engineering mess resulting in two major crashes and hundreds of deaths, and the apparent ongoing QC issues with assemblies coming from Spirit Aerospace, and the failure of the QA/QC chain at the main Boeing plant to catch SEVERAL instances of missing or loose door-plug hardware on SEVERAL aircraft...well, not so much.

And the top management is ultimately responsible for any oopsies committed by his underlings.

No argument from me at all. I suspect Mr. Calhoun's job is on the line. As it should be. The apparent systemic lack of care is appalling. 

[1972coronet]

I've been on my soapbox for more than 30 years about the "BLAH-BLAH-BLAH " 'quality' of 'workmanship' going into everything these days. 

Someone got a bonus for saving the company money - which is true for every bloated organisation in the U.S. ( I can't speak to other countries' standards).

Ostensibly, it's easier to pay a lawsuit than it is to toe-the-line - again, true of any bureaucracy.

It's like that ancient Greek philosopher said :

 

His relative , Apathese, is quite prevalent these days, too.

[bobthehobbyguy]

4 hours ago, redscampi said:

Not that I disagree, but humans happen. In any aircraft incident there is always a chain of failure points which almost always can be traced back to human mistakes at some point, and it's never just one point or one issue. It could be lack of education, lack of oversight, bad planning, bad engineering, a bad day, an unfortunate coincidence of lazy and complacent employees or any number of other factors. In our search for accountability we always want to pin it on one person and make them pay, no matter what the issue is, but there's always much more to the story.

 

The higher priority should be determining the root cause of this issue and taking steps to prevent it from happening again.

Second there does need to be accountability and actions need to be taken for those who contributed to this situation.

[stavanzer]

2 hours ago, bobthehobbyguy said:

The higher priority should be determining the root cause of this issue and taking steps to prevent it from happening again.

Second there does need to be accountability and actions need to be taken for those who contributed to this situation.

Not Gonna happen, Bob. Too much many to be saved for the CEO and Stockholders.

[bobss396]

"Root Cause Analysis". There... I said it. This should be performed after an event like this and should be quite revealing if implemented by the book. Yeah, it can be the long way home and a good QC manager can pull it off.