Phanatic posted:

The wheel fell off.

throwawayboeingN704AL posted:

January 16, 2024
Current Boeing employee here – I will save you waiting two years for the NTSB report to come out and give it to you for free: the reason the door blew off is stated in black and white in Boeings own records. It is also very, very stupid and speaks volumes about the quality culture at certain portions of the business.

A couple of things to cover before we begin:

Q1) Why should we believe you?
A) You shouldn’t, I’m some random throwaway account, do your own due diligence. Others who work at Boeing can verify what I say is true, but all I ask is you consider the following based on its own merits.

Q2) Why are you doing this?
A) Because there are many cultures at Boeing, and while the executive culture may be throughly compromised since we were bought by McD, there are many other people who still push for a quality product with cutting edge design. My hope is that this is the wake up call that finally forces the Board to take decisive action, and remove the executives that are resisting the necessary cultural changes to return to a company that values safety and quality above schedule.

With that out of the way… why did the left hand (LH) mid-exit door plug blow off of the 737-9 registered as N704AL? Simple- as has been covered in a number of articles and videos across aviation channels, there are 4 bolts that prevent the mid-exit door plug from sliding up off of the door stop fittings that take the actual pressurization loads in flight, and these 4 bolts were not installed when Boeing delivered the airplane, our own records reflect this.

The mid-exit doors on a 737-9 of both the regular and plug variety come from Spirit already installed in what is supposed to be the final configuration and in the Renton factory, there is a job for the doors team to verify this “final” install and rigging meets drawing requirements. In a healthy production system, this would be a “belt and suspenders” sort of check, but the 737 production system is quite far from healthy, its a rambling, shambling, disaster waiting to happen. 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. Obviously, this did not happen. Now, on the incident aircraft this check job was completed on 31 August 2023, and did turn up discrepancies, but on the RH side door, not the LH that actually failed. I could blame the team for missing certain details, but given the enormous volume of defects they were already finding and fixing, it was inevitable something would slip through- and on the incident aircraft something did. I know what you are thinking at this point, but grab some popcorn because there is a plot twist coming up.

The next day on 1 September 2023 a different team (remember 737s flow through the factory quite quickly, 24 hours completely changes who is working on the plane) wrote up a finding for damaged and improperly installed rivets on the LH mid-exit door of the incident aircraft.

A brief aside to explain two of the record systems Boeing uses in production. The first is a program called CMES which stands for something boring and unimportant but what is important is that CMES is the sole authoritative repository for airplane build records (except on 787 which uses a different program). If a build record in CMES says something was built, inspected, and stamped in accordance with the drawing, then the airplane drat well better be per drawing. The second is a program called SAT, which also stands for something boring and unimportant but what is important is that SAT is *not* an authoritative records system, its a bullentin board where various things affecting the airplane build get posted about and updated with resolutions. You can think of it sort of like a idiots version of Slack or something. Wise readers will already be shuddering and wondering how many consultants were involved, because, yes SAT is a *management visibilty tool*. Like any good management visibilty tool, SAT can generate metrics, lots of metrics, and oh God do Boeing managers love their metrics. As a result, SAT postings are the primary topic of discussion at most daily status meetings, and the whole system is perceived as being extremely important despite, I reiterate, it holding no actual authority at all.

We now return to our incident aircraft, which was written up for having defective rivets on the LH mid-exit door. Now as is standard practice kn Renton (but not to my knowledge in Everett on wide bodies) this write-up happened in two forms, one in CMES, which is the correct venue, and once in SAT to “coordinate the response” but really as a behind-covering measure so the manager of the team that wrote it can show his boss he’s shoved the problem onto someone else. Because there are so many problems with the Spirit build in the 737, Spirit has teams on site in Renton performing warranty work for all of their shoddy quality, and this SAT promptly gets shunted into their queue as a warranty item. Lots of bickering ensues in the SAT messages, and it takes a bit for Spirit to get to the work package. Once they have finished, they send it back to a Boeing QA for final acceptance, but then Malicious Stupid Happens! The Boeing QA writes another record in CMES (again, the correct venue) stating (with pictures) that Spirit has not actually reworked the discrepant rivets, they *just painted over the defects*. In Boeing production speak, this is a “process failure”. For an A&P mechanic at an airline, this would be called “federal crime”.

Presented with evidence of their malfeasance, Spirit reopens the package and admits that not only did they not rework the rivets properly, there is a damaged pressure seal they need to replace (who damaged it, and when it was damaged is not clear to me). The big deal with this seal, at least according to frantic SAT postings, is the part is not on hand, and will need to be ordered, which is going to impact schedule, and (reading between the lines here) Management is Not Happy. 1/2

throwawayboeingN704AL posted:

January 16, 2024
2/2

However, more critical for purposes of the accident investigation, the pressure seal is unsurprisingly sandwiched between the plug and the fuselage, and you cannot replace it without opening the door plug to gain access. All of this conversation is documented in increasingly aggressive posts in the SAT, but finally we get to the damning entry which reads something along the lines of “coordinating with the doors team to determine if the door will have to be removed entirely, or just opened. If it is removed then a Removal will have to be written.” Note: a Removal is a type of record in CMES that requires formal sign off from QA that the airplane been restored to drawing requirements.

If you have been paying attention to this situation closely, you may be able to spot the critical error: regardless of whether the door is simply opened or removed entirely, the 4 retaining bolts that keep it from sliding off of the door stops have to be pulled out. A removal should be written in either case for QA to verify install, but as it turns out, someone (exactly who will be a fun question for investigators) decides that the door only needs to be opened, and no formal Removal is generated in CMES (the reason for which is unclear, and a major process failure). Therefore, in the official build records of the airplane, a pressure seal that cannot be accessed without opening the door (and thereby removing retaining bolts) is documented as being replaced, but the door is never officially opened and thus no QA inspection is required.
This entire sequence is documented in the SAT, and the nonconformance records in CMES address the damaged rivets and pressure seal, but at no point is the verification job reopened, or is any record of removed retention bolts created, despite it this being a physical impossibility. Finally with Spirit completing their work to Boeing QAs satisfaction, the two rivet-related records in CMES are stamped complete, and the SAT closed on 19 September 2023. No record or comment regarding the retention bolts is made.

I told you it was stupid.

So, where are the bolts? Probably sitting forgotten and unlabeled (because there is no formal record number to label them with) on a work-in-progress bench, unless someone already tossed them in the scrap bin to tidy up.

There’s lots more to be said about the culture that enabled this to happened, but thats the basic details of what happened, the NTSB report will say it in more elegant terms in a few years.

quote:

So, where are the bolts? Probably sitting forgotten and unlabeled (because there is no formal record number to label them with) on a work-in-progress bench, unless someone already tossed them in the scrap bin to tidy up.

quote:

Not Your Lawyer
January 23, 2024

As an “original source” of this information under the False Claims Act, you could be entitled to recover somewhere between 15-25% of the total value of 737Max-9 sales as something called a qui tam relator. I am at a law school rather than in practice and so wouldn’t be the guy to help you, but I know a fair amount about qui tam and would happily connect you with a lawyer in practice. You’re probably going to need one anyhow if Boeing finds out who you are–and of course a nice thing about FCA whistleblower suits is that it’d protect you from retaliation against Boeing separate and apart from the eventual monetary award. I don’t particularly want to get involved other than sending you to someone qualified, but if you’re interested shoot me an email at [REDACTED]

AzureSkys posted:

As someone quite familiar with CMES, SAT, Removals, and all that it sounds very plausible. There is definitely a major compartmentalization problem at Boeing that leads to huge difficulty when something is out of routine to its specific group.

It gets very circular where you'll branch out with an issue only to be told by the next point of contact that it's not their responsibility/job/wheelhouse so they send you some where else only to get that same answer and eventually you end up with some later person telling you to talk to the first person you tried. Or you find a number under some focal contact list that turns out to be the disconnected line of someone who retired 3 years ago but no one knows who's even supposed be doing that job now.

Platystemon posted:

I don’t think that this can happen, but it would be incredibly satisfying if it did.

CarForumPoster posted:

I know a fair amount about the FCA for a non lawyer and this is likely a bad FCA case for multiple reasons. First, what payments did the government make to Boeing or what money did they lose due to fraud related to that specific payment? What payment would not have been made but for knowledge of this issue? In FCA cases frauds stem from payments made/discounts not received.

Second, even if this was a govt contract the government already has knowledge of this issue most likely, preempting the relator (whistleblower).

Third this is a rework issue on a commercially delivered plane. Even if the government was purchasing this model of plane, it’s not clear that it would be subject to the same issue.

There’s prob other reasons I could think of but that seems like a post by someone who knows literally nothing about the FCA/Qui Tam cases unless the govt is buying 737 Max whatever’s that are subject to this issue.

joat mon posted:

Or an attempt to phish the identity of throwawayboeingN704AL

joat mon posted:

Or an attempt to phish the identity of throwawayboeingN704AL

Murgos posted:

Why weren’t the CMES actions required to be closed out and signed off by by the CogE before delivery?

quote:

How was that plane delivered and how was it accepted when the missing bolts were documented?

Phanatic posted:

Per the account, they were. The issue was that the only CMES action pertained to the rivet repair and the seal repair, not removing the bolts to open the door. So the jobs in SAT and CMES were both closed out, but nobody wrote a Removal order for the bolts so there was no corresponding job to restore the bolts. Officially, the door was never opened, even though opening the door was a physical requirement to replace the damaged seal.

The missing bolts weren't documented, not directly.

GI Joe jobs posted:

If only the Digital Thread was finished, it would have caught those bolts!

hobbesmaster posted:

I wonder what sequence of events resulted in this being the best idea:

https://twitter.com/flyinghighryan/status/1751016662650736881?s=46

I guess they couldn’t do it VFR too for the full JANET experience.

hobbesmaster posted:

The inspection does involve taking out a few rows of seats and they’d probably need one of those big fancy tents if there isn’t an appropriate hangar in Cancun to use.

There has to be some story here ending in “gently caress it”

Cojawfee posted:

That's more of a slam and don't go.

Platystemon posted:

“Airplane performing touch and gos on reservoir ice in Utah took a dip through the ice. Both men walked away wet and cold.”

Humphreys posted:

It's quite clearly a slam dunk.

hobbesmaster posted:

There has to be some story here ending in “gently caress it”

Cojawfee posted:

That's more of a slam and don't go.

Wingnut Ninja posted:

Too much touch, not enough go.

Cactus Ghost posted:

those footprints tell a story. "oh gently caress oh gently caress oh gently caress"

DrBouvenstein posted:

hobbesmaster posted:

The inspection does involve taking out a few rows of seats and they’d probably need one of those big fancy tents if there isn’t an appropriate hangar in Cancun to use.

There has to be some story here ending in “gently caress it”