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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]

#231

Post by mihaaly »

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.

It is always refreshing to meet fellow naives like yourself, I like the company of the likely minded!

Engaging in today's political theatre and culture (that is the keen slave of forceful bean counters/collectors btw.) with the prediction of constructive advancement for the quality of life, that is some very hardcore stuff! Even for me.

(what I can do beyond raising voice is to show example rather than piss into the headwind hurricane. and hope others will follow, or I can follow. but definitelly not replacing my inner Gandhi with Rocky in a blink and getting into a fistfight with scores of agressive pro boxers simultaneously who are itching to run over anyone in their way. also I can avoid the products of those bean people, not feeding them with my purchases or assistance any way, encouraging others doing the same. vermins should starve, not bloom!)

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

#232

Post by l33tman »

whythre wrote: post #217
outworlder wrote: post #194

Earlier quoted context omitted.

> 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.

Sounds like a lot of steps and paperwork… steps and paperwork that might easily and regularly get fudged.

The idea is that the system as a whole should be resilient to a certain degree of this, as it will be caught in other places or at least reported at a (hopefully non-fatal) aviation incident that leads to a report and analysis, at which point you backtrack and issue recommendations that actually have clout (like, you can't fly with your plane anywhere in the world if you don't fix this).

Of course if the entire industry is corrupt it doesn't work, but to a certain degree I guess it is robust. This time it led to a potential disaster but it will become safer as a result..

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

#233

Post by mihaaly »

addaon wrote: post #171
mihaaly wrote: post #122

What is the analogy of leaving out all bolts from that door? 'Forgetting' to put in any of the screws holding a gas tank in place in a car? 'Missing' all welds in one of a skyscraper's lower columns? An 'oversight' of providing rendundant instruments in an airplane with natural tendency to stall? What a hopeless shitshow is going on there behind the company gates that these kind of things can happen in succession? A…

> 'Missing' all welds in one of a skyscraper's lower columns? Or just throwing the rebar in at random maybe? [0] [0] https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D...

Oh Jesus! I seriously thought my hypothetical example is extreme, but apparently not!

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

#234

Post by sofixa »

SoftTalker wrote: post #110
rootusrootus wrote: post #80

Earlier quoted context omitted.

A minute is a long time when you're sitting at your computer. But after the sudden depressurization, I imagine the pilot is focused first on making sure he has complete control of the airplane, assessing the situation, running checklists. Besides, 10K is just barely above the normal pressurization altitude anyway, it doesn't pose an immediate risk to the passengers that justifies just nosediving towards the ground. E…

First and most importantly the pilots have to get their own oxygen masks on, if they delay this at all they will become hypoxic, unable to think clearly, then pass out, and then it's over for all on board.

See Helios Flight 522 for how that ends when the pilots don't realise what's going on and don't put on their oxygen masks.

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

#235

Post by chx »

luxuryballs wrote: post #195
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.

The checklist for that is very different from what the manufacturer would do. It would take a lot of time and therefore be very costly to verify every single bolt, rivet and weld was done correctly.

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

#236

Post by sofixa »

addaon wrote: post #171
mihaaly wrote: post #122

What is the analogy of leaving out all bolts from that door? 'Forgetting' to put in any of the screws holding a gas tank in place in a car? 'Missing' all welds in one of a skyscraper's lower columns? An 'oversight' of providing rendundant instruments in an airplane with natural tendency to stall? What a hopeless shitshow is going on there behind the company gates that these kind of things can happen in succession? A…

> 'Missing' all welds in one of a skyscraper's lower columns? Or just throwing the rebar in at random maybe? [0] [0] https://www.gr-us.com/%E2%80%9Chorror-at-the-harmon%E2%80%9D...

> According to an article in the Las Vegas Sun, “Some of the steel, known as rebar, was so badly positioned that it stuck out of the concrete floor and was sawed off to conceal the mistake.” In addition, “Harmon workers reportedly moved rebar without first getting an OK from the structural engineer . . . .which is a major no-no in the construction chain of command.

WTF! How was there no punishment for everyone involved in this?

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

#237

Post by p_l »

projektfu wrote: post #206
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 ha…

The original move was also related to lobbying potential.

But the CEO who started the moves etc. was a Boeing lifer.

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

#238

Post by p_l »

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…

Nope.

The process was there so that the people would know there was work being done on the doors despite not being there for it. If you see an unfinished work from a previous shift, it does not mean you can start messing with it - there might be context you do not know.

Which is why such things are supposed to be noted in appropriate ways. Similarly why aviation has so many procedures everywhere - because we know and understand that sometimes you miss things. For any human reason, not just mismanagement. The process is a way to have reliable place to double check with.

This is different from over reliance on automation, which is arguably less of an issue of automation itself (it's just more visible in such areas) as much as getting out of training because you do not encounter certain things so often. 96 people died because in a stream of many deviations, among other things, the crew never trained how to do IFR landing without ILS, autopilot or no autopilot.

The process is the part that says "yeah, I haven't done this in a long time, I need to train, here is documentation that provides we need to do it and can't delay".

Similarly CMES is supposed to track "work was done on this part of the ticket, now different work needs to be done, do not assume it will be done by other teams"

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

#239

Post by p_l »

cjbprime wrote: post #17
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…

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.)

Make it so they don't have reasonable suspicion CVR data won't be abused by the company, and you might get somewhere. For example criminal consequences for misuse that hit C-level and possible leakers.

Sincerely, someone who had death threats partially thanks to manipulated audio record that was done in good faith during investigation, which was leaked and edited later by third party who gained access to it 5 years later.

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

#240

Post by sokoloff »

maxerickson wrote: post #189
toast0 wrote: 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…

Quality is always a trade-off. That's a pretty huge assumption. For instance, compare firearms prior to replaceable parts to firearms after. Better, cheaper, easier to make (because craft was replaced with process). Some up front cost, but absolutely not a trade off, it was a huge advancement. Of course modern process control does more or less let you relax conformance rules to reduce cost, but it's farcical to call…

> Some up front cost, but absolutely not a trade off, it was a huge advancement.

Any exchange of higher fixed costs for lower marginal costs (or other benefit) is a tradeoff.

This is a tradeoff that was/is massively beneficial, but it’s still a tradeoff.

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