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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]

#191

Post by WalterBright »

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…

They should also have a video recorder on a 2 hour loop. Many difficult investigations would have been easy if the investigators could see what the instruments were showing and what the crew was doing. And even, who exactly was in the pilot's seat!

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

#192

Post by trompetenaccoun »

lp4vn wrote: post #97
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 [...] whether management is actually allowing the quality department sufficient independence to investigate these issues and fully resolve them If management in the aerospace industry works like management in the software industry, then I guess they are pushing for results as agressively as possible without much concern about safety or anything else.

That's not how it traditionally worked in aerospace. Commercial airliners are such a safe mode of transportation because from start to finish there are (or used to be?) very high safety standards all around. I can't speak for what's going on with Boeing currently though. Things certainly seem to have deteriorated.

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

#193

Post by matheweis »

renewiltord wrote: post #146
belter wrote: post #46

Earlier quoted context omitted.

Instead of Software Development becoming more like Aeronautical Engineering, every day, Aeronautical Engineering becomes more like Software Development...

Well, to be clear, I don't usually put people in danger. There's a lot these engineers could learn from software engineers: who are really the highest performance at engineering as a craft. One base rule: Above all, kill no one.

I think that software engineers put people in danger more often than they would like to believe; have a look at the UK Postal Service scandal for a great example of a seemingly innocuous bit of software absolutely destroying numerous lives.

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

#194

Post by outworlder »

onetimeuse92304 wrote: post #115
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 (...) Very likely that number is meaningless. I suspect this is the kind of environment that incentivises hiding non-conformances whenever possible. For example, better quality control usually results in an increase of number of defects, at least temporarily. But that just because large portion of these defects were undet…

> Very likely that number is meaningless. I suspect this is the kind of environment that incentivises hiding non-conformances whenever possible.

That, by itself, should be the kind of thing that should shutdown a company permanently. Remember, this is the aviation industry, where they track the mine where the ore from the bolt was mined, and who tightened the bolt up and with which torque wrench.

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

#195

Post by luxuryballs »

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…

Also I’m kinda surprised an airline wouldn’t inspect a newly acquired plane before putting customers in it.

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

#196

Post by Cacti »

resolutebat wrote: post #190
zmgsabst wrote: post #176

Earlier quoted context omitted.

I don’t think there were two approved procedures. I think there was an approved procedure (“removing the plug”) and a deviance from process, justified with ad hoc semantic games.

I doubt this was intentional? It sounds more like mistakenly applying the procedure for opening a normal door, which requires no followup, to opening a door plug , which does.

lol of course it was intentional.

what the Spirit mechanics had to do was a RMV, they knew this, because the Boeing eng rep told them so, but they didn’t like this, so they marked it in the system as an OPEN but performed the work of a RMV, to avoid the additional quality checks a RMV would require. And then they fucked up the RMV but didn’t know and no one else did because it was marked as an OPEN so no one checked the bolts.

this was very intentional. the Spirit mechanics thought they were hot shit and didn’t need to follow the stupid, slow process. and they abused the system to allow them to file the work as more innocuous than it was. because they didn’t need anyone checking their work, or whatever they were thinking.

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

#197

Post by outworlder »

belltaco wrote: post #29

>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…

Starlink is a consumer system. Won't happen without a specialized product. Inmarsat is expensive. And we are talking about streaming audio from all planes currently in flight.

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

#198

Post by userbinator »

A lot of comments here are going on about process, as if humans are mindless and otherwise perfectly controllable robots...

I'm going to be contrarian and say that this is exactly the sort of thing that happens when you train humans to be robots: They lose all signs of common sense and critical thinking, and what's worse is that on top of that, they'll still have their inherent imperfection. Normally the former would counteract the latter, but not if you only make them rigidly follow some process all the time. They stop thinking about what they're doing. They stop paying attention to all the other things in their environment they would've noticed, and even if they do, they won't question it because they'll just assume someone else also following a rigid process will take care of it. They won't think "this door plug should've been bolted in place now that the work that needed it opened is done, but where are the bolts?"

I'm not saying to throw out all the process and make them figure everything out, but I think there has to be a balance, similar to how overautomation and reliance on that has also lead to avoidable incidents in aviation.

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

#199

Post by fipar »

bigiain wrote: post #147
zer00eyz wrote: post #100

Earlier quoted context omitted.

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.

> if someone recored my whole work day every day I would not be happy I'd be perfectly fine with not voice recording people who's daily work may or may not impact the global delivery of cat pictures. I think if you choose a job where there are several hundred people's lives on the line relying on you doing your job professionally and correctly, the expectation of privacy argument is somewhat less convincing. > I don'…

I don’t disagree with you but we can’t ignore the fact that it’s much easier to find delivery drivers and call center workers than airline pilots.

As everything, it’s all about the leverage each side has.

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

#200

Post by belltaco »

outworlder wrote: post #197
belltaco wrote: post #29

>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…

Starlink is a consumer system. Won't happen without a specialized product. Inmarsat is expensive. And we are talking about streaming audio from all planes currently in flight.

> Starlink is a consumer system

Not true.

https://arstechnica.com/information-technology/2022/10/starl...

https://cleantechnica.com/2022/07/06/fcc-approves-starlink-f...

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