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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]

#251

Post by fransje26 »

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…

According to the "insider source", 392 non-conforming defects in the fuselage door installation in the last 365 calendar days.

> As a result, this check job that should find minimal defects has in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations (so both actual doors for the high density configs, and plugs like the one that blew out). That is a hideously high and very alarming number, and if our quality system on 737 was healthy, it would have stopped the line and driven the issue back to supplier after the first few instances.

Source:

https://leehamnews.com/2024/01/15/unplanned-removal-installa...

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

#252

Post by projektfu »

p_l wrote: post #237
projektfu wrote: post #206

Earlier quoted context omitted.

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.

The original move to Chicago was for lobbying? I figured it was more of moving where the CEO wanted to live.

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

#253

Post by maxerickson »

sokoloff wrote: post #240
maxerickson wrote: post #189

Earlier quoted context omitted.

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.

It's not a quality trade off, which is at least implied to be what I am talking about in my comment.

Saying "Quality is always a trade-off" implies you can't actually make things better over time. I would accept something like "You can always trade off of the quality you are capable of producing to reduce costs", but the point is that capability can in fact change, and thus there are ways to improve quality that may not be a trade off (because they also improve the business/system along other dimensions). Even simple little things like aligning a process with the intended outcome can reduce costs while improving quality, you don't have to invent a revolutionary method of manufacturing.

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

#254

Post by p_l »

projektfu wrote: post #252
p_l wrote: post #237

Earlier quoted context omitted.

The original move was also related to lobbying potential. But the CEO who started the moves etc. was a Boeing lifer.

The original move to Chicago was for lobbying? I figured it was more of moving where the CEO wanted to live.

No, the reasoning officially was to move closer to acquired companies and better lobbying especially for defense involvement

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

#255

Post by zmgsabst »

mihaaly wrote: post #231
zmgsabst wrote: post #173

Earlier 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.

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…

I meant in the practical senses:

- learn to make your arguments in terms that appeal to the sensibilities of bean counters, not engineers

- learn to manipulate documentation so they’re forced to record overriding good engineering in a way that’s discoverable

- learn to identify key political players and address their desires, rather than appealing to “doing the right thing”

Etc.

All things that I’ve done poorly at various stages of my career — and seen other engineers struggle with as well. Much like being a manager requires training and education, so does being an effective advocate for engineering to the wider organization.

Or to borrow your analogy, if every engineer is afraid of boxing, then can we be surprised their views go unheard?

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

#256

Post by samstave »

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.)

Define. What EXACTLY does a pilot need privacy for?

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

#257

Post by sokoloff »

maxerickson wrote: post #253
sokoloff wrote: post #240

Earlier quoted context omitted.

> 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.

It's not a quality trade off, which is at least implied to be what I am talking about in my comment. Saying "Quality is always a trade-off" implies you can't actually make things better over time. I would accept something like "You can always trade off of the quality you are capable of producing to reduce costs", but the point is that capability can in fact change, and thus there are ways to improve quality that may…

Beyond a very early point in any engineering effort (where fruit might be not just low-hanging, but actually lying on the ground), nearly everything is a trade-off.

Those trade-offs (higher fixed costs in exchange for lower marginal costs and higher quality) can be wildly beneficial overall but finding large Pareto improvements against every dimension is rare in anything even remotely mature.

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

#258

Post by alberto180 »

j-a-a-p wrote: post #230
okdood64 wrote: post #215

Earlier quoted context omitted.

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?

Good point. Boeing (737) has the door open to the outside. The Airbus (320) the door opens to the inside. I can remember when I was small my Mom mentioned that doors of buildings in the US are mandatory to open to the outside, a rule that does not exist in Europe AFAIK. So there you have it, you have a significant higher chance of crashing in a Boeing, but when it happens, your can leave the plane 2 seconds faster.

Sorry that's both just wrong. The A320 Doors open to the outside (as can be seen here https://www.airplane-pictures.net/photo/1364569/d-ainb-lufth...), and also come with a mechanical opening aid that Boeing doesn't come with, because of the Grandfathering of the 737. And emergency exits in "Europe" obviously open to the outside. At least in West/North Europe

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

#259

Post by flaminHotSpeedo »

> 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 following the accident in time to preserve the accident flight recording

How the fuck is this still a problem on brand new aircraft?

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

#260

Post by flaminHotSpeedo »

ezfe wrote: post #211
guardiangod wrote: post #9

>[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.

Photos may not have been after conclusion of repair so technically not conclusive. However it certainly lines up.

The report makes it clear that the photo was taken after the rivet rework was complete, immediately before restoration of the interior
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