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Alaska Airlines flight 1282 NTSB preliminary report [pdf]

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

#161

Post by krisoft »

zer00eyz wrote: post #100
hencq wrote: post #76

Earlier quoted context omitted.

I think there's some validity to the privacy concerns, but it seems those could be addressed with proper access controls and rules. The recordings should only really be listened to in the aftermath of an accident, in which case, as you say, the expectation of privacy should (in my opinion) take a backseat.

On one hand I agree with you. On the other hand, if someone recored my whole work day every day I would not be happy. I don't think you would stay at your job of that was a condition of it. There has to be a better solution to this issue.. extended recordings in an emergency, triggers based on conditions, private keys for pilots... IDFK, cause I try not to get involved in engineering that might KILL someone.

> I don't think you would stay at your job of that was a condition of it.

I don't think I would care. Especially if it is only read out very infrequently (when we have an accident.)

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

#162

Post by runarb »

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.

> were the bolts missing because the Spirit team did not know they had to be put back

It would be interesting to know what ultimately happened to the bolts if they indeed were removed.

When I disassemble something, I do as I was taught in my mechanical class in high school, and always keep all parts I take of in the same box. If I am left with some extra bolts when finished, that would be a worrisome sign.

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

#163

Post by yborg »

spdustin wrote: post #53

Looks like the anonymous whistleblower on Airline Pilot Central Forums [0] was legit. [0]: https://www.airlinepilotforums.com/safety/146074-boeing-inte...

I'm guessing twice as much corporate effort is currently being deployed to find this guy than is being applied to fixing Boeing's quality system.

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

#164

Post by randerson »

dmitrygr wrote: post #22
aftbit wrote: post #13

> The accident airplane was required to be equipped with a CVR that retained, at minimum, the last 2 hours of audio information, including flight crew communications and other sounds inside the cockpit. >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 follow…

> Given how cheap flash is these days How cheap is flash that will survive a sudden stop from 400mph to 0 mph in no seconds flat, will survive a post-crash fire, and/or submersion for years in salt water? Flash data retention at high temps is TERRIBLE (and gets worse for MLC/TLC/etc), see any flash datasheet. It is NOT nearly as simple a problem as you might think. Yes, it is a solvable problem, but please do not dis…

I often wonder why we still rely so heavily on local storage when in-flight Internet exists. Flight data could be streamed in real time to the cloud for redundancy.

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

#165

Post by toomuchtodo »

crznp wrote: post #118
imoverclocked wrote: post #66

Earlier quoted context omitted.

Well, there is the theory and then there is the reality. Theory: having less privacy makes things easier for accident investigators, post-mortem. Reality: In this case, the pilots did their job and got the plane down safely despite rapid depressurization and literally having their headsets sucked off of their heads. It is extremely unlikely to be pilot-error that a door-plug ripped off the airframe at 16,000' or that…

That is a non-sequitur. Investigators should have access to accident data regardless of whether the pilots did their job. Root cause analysis isn't the only reason: it would be good for pilots to have this case study, as well as analysis on how systems responded to the abrupt change. Having this data is strictly better than not having it.

Middle ground would be to have full media access for investigators, but a union rep managing a review and redaction process to have anything immaterial to the investigation redacted. This preserves both valuable data and privacy. Checks and balances.

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

#166

Post by malfist »

aniftythrifrty wrote: post #129
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…

[flagged]

That's not what a union does

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

#167

Post by ledauphin »

WatchDog wrote: post #119

> The flight crew reported that the cockpit door had opened during the depressurization event. In a revision to the Flight Crew Operations Manual, issued on January 15, 2024, Boeing confirmed that the door functioned as designed. Interesting for terrorists. Cause a rapid decompression, and get easy access to the cockpit.

yeah, this is a significant hole in the locked cockpit door plan.

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

#168

Post by Rapzid »

krona wrote: post #14
nostromo wrote: post #11

> Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads. Ooofff. No bo…

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

It's crazy their supplier is delivering so many must-fix defects they have to have a warranty team on site to help fix them. Crazier that Boeing just let that get more and more out of hand instead of making Spirit get their shit together on their end.

https://www.youtube.com/watch?v=xIAfCupuZ3w

Edit: Also that entire culture and dynamic between Boeing and Spirit on the production floor seems very toxic and driven by misaligned incentives. There should be zero place for bickering, aggressiveness, and finger pointing in that SAT channel. If something needs to be fixed Spirit needs to fix it with a smile. If Boeing and Spirit need to review who is responsible for what, and what needs fixing and doesn't, that should happen in review in a different setting. The production crews need to be able to execute on their processes and focus on the quality of the product without having timeline and budget concerns seeping into their day-to-day.

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

#169

Post by albert_e »

lambda wrote: post #153
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.

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 removin…

> removed for removing the door plug

there was apparently two (identical) procedures -- one for "removing" the door plug and one for "opening" the door plug -- but only one of them actually called for paper-work and quality inspection after it is done.

It seems they decided to "open" the door plug instead of "remove" it to work on the sealing issue? -- and thereefore documentary record of the work performed and inspection thereafter is lacking.

It would be useful IMO to explore what led the team to prefer "opening" versus "removing" -- and if the subtle difference in documentation requirement was a consideration in preferring one over the other -- and if that points to deeper pervasive culture issues that leans towards less work rather than give safety and quality the primary importance.

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

#170

Post by wolpoli »

wmidwestranger wrote: post #138
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 a…

Once upon a time, QAs and developers also had a bit of cooperatively adversarial relationship as well. It's no more now as teams are restructured by business, so they cooperate.
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