>[evidences] 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. Ok >Photos from the interior repair that show the lack of bolts Huh. Well that's conclusive.
Alaska Airlines flight 1282 NTSB preliminary report [pdf]
211–220 of 285 posts
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#212Earlier quoted context omitted.
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]
#213There was noticeable damage to the door plug's mechanical fittings from the violence of it being blown out of the plane. But the holes where the bolts belonged were pristine. That would not have been true if the holes had had bolts in them.
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#214Earlier quoted context omitted.
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…
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#215The 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.
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#216The 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.
Can someone explain to me why this door plug wasn't actually a plug that physically stays sealed from cabin pressure? That seems like a sensible failsafe?
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#217Earlier quoted context omitted.
> 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]
#218Earlier 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…
>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 unti…
TL;DR: we’re fine at engineering, we’re terrible at resource allocation. Or at least that’s the more relevant cause. I post this knowing full well that this is HN and I might well be disagreeing with a senior nasa employee…
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#219Earlier 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.
Re: Alaska Airlines flight 1282 NTSB preliminary report [pdf]
#220>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…
This is an old system that works well and reliably for pretty much every incident. I’m not aware of another case of this sort of thing (relevant flight recorder data being overwritten) happening in recent years anyway. If you spend time constantly upgrading systems like this you’re asking for a higher failure rate, for very little gain. That said, there’s a standard and reliable 25-hour flight voice recorder that sol…
And it also lists 17 more incidents where something happened in a flight and it took more than 2 hours to land so data from the incident was lost.