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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]

#151

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…

[deleted]

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

#152

>The CVR was downloaded successfully; however, it was determined that the audio from the accident flight had been overwritten. The CVR circuit breaker had not been manually deactivated after the airplane landed following the accident in time to preserve the accident flight recording In addition to local storage, why isn't the audio(along with location, altitude and some sensor information) also streamed using somethi…

The current 2 hour limit (which is now 25 hours in Europe) is a legacy of privacy concerns. If pilots are concerned that their bosses would make a habit of yanking longer CVR units to micromanage what goes on in the cockpit (or using events several hours before an incident to somehow push blame onto the pilot for an it), they’d love the idea of it being beamed to a remote location. Yes, I’m sure there could be complicated byzantine cryptographic scheme that would theoretically solve it, but not sure they’d trust it.

There’s also bandwidth and satellite coverage not being magic of course.

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

#153
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.

Yep, biggest new thing here is discussion of witness marks showing no evidence of the bolts, and photo before the rivet repair showing that at least two of the bolts were present, and photo after the rivet repair during installation of the insulation showing at least 3 bolts missing.

So this all just serves to confirm that report, and what people suspected for a while; the bolts were just missing, removed for removing the door plug for the rivet rework and never reinstalled.

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

#154
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]

Where are you seeing a 100+ page report?

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

#155
post #126
post #117

Earlier quoted context omitted.

At a company I worked in, we had a joke about this: "Good thing we don't build nuclear reactors". In some software projects the level of rush, and the fact that bugs sometimes would leak into production was kinda horrifying. It would've been way more so, if it would've been the kind of project that could kill people in case of failure. Like it happened in Chernobyl with nuclear reactors, or at Boeing with planes. I c…

Quality is always a trade-off. If you're deeply into economics, you wonder about the trade-offs of cost to find defects before shipping, difference in cost of addressing defects before and after shipping including costs of mitigation from consequences of defects, % of defects that will never be found after shipping (and are therefore a real cost savings), and in the long game costs of having a reputation for shipping…

As the old saying goes: "Fast, cheap, or good. You can pick a maximum of two."

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

#156
post #126

Earlier quoted context omitted.

Quality is always a trade-off. If you're deeply into economics, you wonder about the trade-offs of cost to find defects before shipping, difference in cost of addressing defects before and after shipping including costs of mitigation from consequences of defects, % of defects that will never be found after shipping (and are therefore a real cost savings), and in the long game costs of having a reputation for shipping…

> Mitigation of many software defects is simple, but some aren't; hopefully you know which changes are expensive to fix if wrong, so you can more thoroughly vet those. This assumes you're fortunate enough to have a defect at the outer edge of the system. Most times, these problems are created in the initial rush of pushing something out and then tax every effort that depends on them, forever, and ever.

Amen.

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

#157
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]

Yeah, this is a preliminary report, they only report direct factual findings that they have collected so far, and as they mention in this report, they haven't yet examined the electronic manufacturing records that the insider was referring to.

The NTSB is not quick to jump to conclusions; they are very thorough, and they collect and sort through a lot of evidence. It's not surprising that there's information out sooner that says more for such a high profile incident; but once the NTSB final report comes out, it will be quite detailed and thorough, and cover all of this and more.

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

#159
post #124

Earlier quoted context omitted.

Rumor has it the controls are there, but subvert-able. Apparently, there are two ticketing systems (one for "history of plane," Boeing internal, and one for "day-to-day onsite work," visible by contractors and Boeing management). The work to fix the rivets was logged in the day-to-day, but management and the onsite staff managed to convince themselves that merely opening the plug to fix the vacuum-seal trim did not c…

You might want to cite your source on this, which I'm guessing is the purported insider speaking about same? From the portions of the report that hint at corroboration, > Documents and photos show that to perform the replacement of the damaged rivets, access to the rivets required opening the left MED plug (see figure 15). To open the MED plug, the two vertical movement arrestor bolts and two upper guide track bolts…

Yes what they said about two systems was from the insider account that was posted online.

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

#160
post #126
post #117

Earlier quoted context omitted.

At a company I worked in, we had a joke about this: "Good thing we don't build nuclear reactors". In some software projects the level of rush, and the fact that bugs sometimes would leak into production was kinda horrifying. It would've been way more so, if it would've been the kind of project that could kill people in case of failure. Like it happened in Chernobyl with nuclear reactors, or at Boeing with planes. I c…

Quality is always a trade-off. If you're deeply into economics, you wonder about the trade-offs of cost to find defects before shipping, difference in cost of addressing defects before and after shipping including costs of mitigation from consequences of defects, % of defects that will never be found after shipping (and are therefore a real cost savings), and in the long game costs of having a reputation for shipping…

>In a lot of software organizations with rapidly changing and undocumented requirements, there's a good chance defects will go unnoticed until they're no longer relevant, so spending a lot to find them before they're shipped is a waste.

It's really a shame that a good percentage of these applications full of bugs and "rapidly changing and undocumented requirements" don't get scrapped and stay many decades afloat until they get replaced by another application also full of bugs and "rapidly changing and undocumented requirements".

I think that that's a very sad way of seeing things honestly.

In the past the USA put the man on the moon, today repeating the same feat looks almost impossible. I bet that a lot of managers at Boeing also think that building planes like a few decades ago looks almost impossible now.

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