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Alaska Airlines flight 1282 NTSB preliminary report [pdf]

ntsb.gov

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Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#131

Post by zerocrates »

imoverclocked wrote: post #85
cjbprime wrote: post #60

Earlier quoted context omitted.

That document is an in-progress proposal to amend a rule, no? I think there was strong opposition to this rule before this accident flight, and the blowback from the missing data here might be strong enough to be able to get it passed anyway.

> the blowback from the missing data here might be strong enough to be able to get it passed anyway Nice pun. What do you think would have been gained from the CVR data in this case? Do you think pilot error had anything to do with the door-plug failure? Do you think the CVR was left running on purpose/accident? If I were one of those pilots, the first words out of my mouth probably would have been, "what the $&#*?!"…

You don't need to necessarily be looking for pilot error to want the recording. Maybe it picked up the sound of the plug separating and that could be useful. Maybe it records an alarm, a call from the cabin, whatever. Maybe the way they work the checklist for decompression reveals some problem that should lead to a change in the checklist. Maybe it corroborates or disagrees with the FDR.

Of course I think it's most likely that it wouldn't be that relevant in this particular case.

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#132

Post by michaelt »

gtmitchell wrote: post #55

A very thorough preliminary report. I've worked for a long time in quality systems, and this is a perfect example of a systemic failure. They've got work being handed off between Boeing employees and 3rd party contractors with insufficient controls in place to verify that very basic tasks are being performed. I'd be curious to know how many non-conformances they typically see during assembly of a plane and whether ma…

> I'd be curious to know how many non-conformances they typically see during assembly of a plane

Well, the report says "During the build process, one quality notification (QN NW0002407062) was noted indicating the seal flushness was out of tolerance by 0.01 inches.

So I'd say they've had about 2,407,062 quality issues :)

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#133

Post by stefan_ »

dzdt wrote: post #25

The report seems to mesh with and confirm many details of the anonymous insider account at https://leehamnews.com/2024/01/15/unplanned-removal-installa... . The bolts were not reinstalled following work on the plug rivets/seal. The official system doesn't record that work was done requiring the bolts to be removed.

[flagged]

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#134

Post by Arrath »

michaelt wrote: post #132
gtmitchell wrote: post #55

A very thorough preliminary report. I've worked for a long time in quality systems, and this is a perfect example of a systemic failure. They've got work being handed off between Boeing employees and 3rd party contractors with insufficient controls in place to verify that very basic tasks are being performed. I'd be curious to know how many non-conformances they typically see during assembly of a plane and whether ma…

> I'd be curious to know how many non-conformances they typically see during assembly of a plane Well, the report says "During the build process, one quality notification (QN NW0002407062) was noted indicating the seal flushness was out of tolerance by 0.01 inches. So I'd say they've had about 2,407,062 quality issues :)

Then its revealed "Well the numbering schema started at QN AXX... and we looped through the alphabet a few times.."

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#135

Post by ethbr1 »

michael1999 wrote: post #69
ipython wrote: post #24

Earlier quoted context omitted.

This is a puzzling attitude to me. Every time we technologists see a crappy proprietary solution being used for a problem, the first exclamation is, "why not use ? That's so dumb, they spent $10k on that tool when they could have spent $100 on X!" There must be a middle ground here- the paradox is that Google, Apple, etc have this ability to generate user friendly software and hardware at scale. But they aren't consi…

The issue here isn't using google chat, the accusation is that this was Spirit and Boeing conspiring to not record these in the proper work order system under the pretence that this work was being done by Spirit as-if-it-were pre-delivery. Read https://www.airlinepilotforums.com/safety/146074-boeing-inte... And then this from the doc: "The investigation continues to determine what manufacturing documents were used to…

A key point I read somewhere in the accusations is that non-Boeing contractors (e.g. Spirit) by policy cannot have access to CMES.

Consequently, you have a system of record that a major party to work doesn't have access to.

As we've all seen, this leads to "actual coordination" being instead done in a system all involved parties do have access to (SAT).

Which inevitably leads to a desync between CMES (SOR by fiat) and SAT (SOR in practice).

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#136

Post by 188320356 »

stefan_ wrote: post #133
dzdt wrote: post #25

The report seems to mesh with and confirm many details of the anonymous insider account at https://leehamnews.com/2024/01/15/unplanned-removal-installa... . The bolts were not reinstalled following work on the plug rivets/seal. The official system doesn't record that work was done requiring the bolts to be removed.

[flagged]

The report is 19 pages.

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#137

Post by treflop »

koyote wrote: post #108
krona wrote: post #14

Earlier quoted context omitted.

> How did this pass Boeing QA? https://www.airlinepilotforums.com/safety/146074-boeing-inte...

So were the bolts missing because the Spirit team did not know they had to be put back (i.e. it was not recorded as a task that needed to be done) or was that simply just another mistake in the long line of mistakes they've made? Reading through that post gave me nightmares of dealing with outsourcing software teams where you send them a small issue to fix and their fix breaks 3 existing items.

I took it to mean that someone forgot but the mistake would have been caught if the removal was documented in the authoritative record system, since that kicks off an automatic workflow where QA is notified and must sign off.

But they didn’t for whatever reason so two mistakes stacked.

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#138

Post by wmidwestranger »

gtmitchell wrote: post #55

A very thorough preliminary report. I've worked for a long time in quality systems, and this is a perfect example of a systemic failure. They've got work being handed off between Boeing employees and 3rd party contractors with insufficient controls in place to verify that very basic tasks are being performed. I'd be curious to know how many non-conformances they typically see during assembly of a plane and whether ma…

> Also, I think a lot of middle and upper level management needs to lose their jobs over this.

Given that if a worker doing the work raised this problem or took initiative to resolve it, they'ld probably be punished; I completely agree.

Reminds me so much of how, once-upon-a-time, there seemed to be actual engineering management in a cooperatively adversarial relationship with business managers but not anymore. Now any sort of engineering in business seems to be completely business managed and business minded. I'm sure it's great for profits while it lasts but I haven't observed engineering becoming better and I suspect business is suffering by overextending itself too, I just don't have any solid observations.

(Well, maybe one, my brother does warehouse / logistics management and says, despite there being every reason in the world, he has never seen the accounting software and the inventory software successfully and productively linked. So, big opportunity there for a serious player but maybe not the profitable compared to the issue?)

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#139

Post by [deleted] »

koyote wrote: post #127
fcsp wrote: post #121

Earlier quoted context omitted.

As things stand, it seems the anon insider report from 3 weeks back was legitimate and accurate, and holds answers to your question: https://leehamnews.com/2024/01/15/unplanned-removal-installa...

I read that but could not work out which of my two statements are true. Might just be bad reading comprehension on my side...

[deleted]

Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]

#140

Post by fcsp »

koyote wrote: post #127
fcsp wrote: post #121

Earlier quoted context omitted.

As things stand, it seems the anon insider report from 3 weeks back was legitimate and accurate, and holds answers to your question: https://leehamnews.com/2024/01/15/unplanned-removal-installa...

I read that but could not work out which of my two statements are true. Might just be bad reading comprehension on my side...

From my understanding, both Boeing and Spirit have been employing very shoddy practices, but at that point in the production line it's Boeing who is responsible for QA
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