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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]

#201

Post by Rapzid »

peteradio wrote: post #180
Rapzid wrote: post #168

Earlier quoted context omitted.

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…

Spirit has no competition. How do you threaten the supplier who owns your production when you have no other options?

That you Dave Calhoun? I guess your replacement will figure it out and let us know.

Seriously though, that's a problem people getting paid sh* tons of money are supposed to be on top of.

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

#202

Post by javawizard »

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…

This sort of thing always reminds me of this Dilbert comic: https://twitter.com/k8em0/status/1078824013843984384

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

#203

Post by adamsb6 »

imoverclocked wrote: post #66
cjbprime wrote: post #17

Earlier quoted context omitted.

The largest US pilots union opposes it on pilot privacy grounds. (To be clear, I think having an expectation of vocal privacy while you are in charge of an airliner is absurd.)

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 the plane landed safely is not an indication that every part of the post-incident process went well.

There could be steps that weren't followed, there could have been training gaps. There could have been secondary impacts of sudden depressurization that could have spiraled out of control, but the pilots thought on their feet to save the plane. We'd want to know exactly what they did so we could add it to the recovery process.

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

#204

Post by rationalfaith »

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…

[dead]

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

#205

Post by lazide »

zmgsabst wrote: post #173
mihaaly wrote: post #128

Earlier quoted context omitted.

I have tendency to hope for unrealistic things too. Not a reliable trait of mine, no. But in my clear moments I am afraid that much sooner will come the world peace and union of all nations and religions than unimaginative but determined bean counters learn from millions of catastrophes of the past and future to come giving up pushing their core value and first rule of 'take more, give less' into the infinity and bey…

I think the hope is people of good conscience stop being political cowards. If you believe in quality engineering, but refuse to engage in the political and business dimensions of an enterprise to fight for that view, then you are just virtue signaling — since you’re refusing to engage with the tools needed to make it happen.

First, being cowards this way would need to stop being the wise choice to make.

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

#206

Post by projektfu »

userbinator wrote: post #198

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…

Potentially the result when you rob workers of the right to pride in workmanship. The most common complaint from old Boeing people who have left is that after the merger the McDonnell-Douglas people took over and the company switched from pride in engineering and quality of workmanship to cost cutting and bean counting. Also, shortly after the merger the corporate HQ moved, reflecting the priorities of the CEO. It has since moved again, apparently to be better for lobbying.

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

#207

Post by mlindner »

peteradio wrote: post #180
Rapzid wrote: post #168

Earlier quoted context omitted.

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…

Spirit has no competition. How do you threaten the supplier who owns your production when you have no other options?

These sorts of what I like to call "reverse monopolies" are all over the place in US industry now. So many companies dumped out pieces of themselves to a single company that then supplies for all of them, removing the ability of those companies to actually compete with each other by differentiation.

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

#208

Post by mlindner »

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.

If they cause a rapid decompression they incapacitate themselves and won't be able to use the cockpit.

Also how do you cause a rapid decompression without a gun of some kind?

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

#209

Post by gary_0 »

matheweis wrote: post #193
renewiltord wrote: post #146

Earlier quoted context omitted.

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.

https://xkcd.com/2030/

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

#210

Post by renewiltord »

matheweis wrote: post #193
renewiltord wrote: post #146

Earlier quoted context omitted.

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.

Indeed. And yet immediately outmatched by the number of lives destroyed by motor vehicles (probably per day).
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