Boeing's Quality Management Failure Explained 737-Max-9 Door 24 Jan 2024

[@fabvee]

If the Board of Boeing can pay former CEO Dennis Muilenburg $62 million but can’t oversee 4 bolts being fitted to a removed door plug, they need to go.

[@stewartsmith1947]

Got to have money for those big bonuses ! After all, they earned them ! LOL

[@NesconProductions]

Just imagine how many additional workers could be brought on if you just cut that salary in half (ie $31 million) 🤔?

[@ret564]

Maybe we should come up some law that stipulate dividends should not be honoured outwith company profitability potentially putting the future saftey of operations at risk because they've spent the money for inspections on salaries. Might be worth thinking about for multiple industries. To many people would be out of pocket politicians included for that to ever happen.

[@falconeaterf15]

Nice to hear the deep insights from the “mom’s basement “ crowd.

[@lastdance2099]

I've been saying for years now that Boeing doesn't have a management problem, it has an ownership problem, and that's the Board.

[@peterkotara]

They aren't conducting a one day safety stand down, they are performing a public relations exercise.

[@C420sailor]

Yep. It was the same thing in the military. Safety stand downs were absolutely worthless. Nothing but lip service.

[@lairdcummings9092]

"Safety Theater."

[@peterkotara]

@@lairdcummings9092 there's a comedy sketch right there....I'm already imagining the costumes and makeup 😂

[@lairdcummings9092]

@@peterkotara No doubt! 😁

[@JR-jw3px]

exactly - PR eyewash

[@MrProach2]

The CEO of a major engineering company that I worked for (seventeen years for which I was a Quality Engineer) said to EVERY employee of the company: "The quality is remembered long after the price is forgotten". It was a mantra that made it a very profitable and safe business.

[@Jelli.889]

I am going to save this quote. Thanks for sharing!

[@HighlandScotsnGlens]

Allen - Bradley: A-B Quality Family Owned Business Built by Patriotic Hardworking Entrepreneurial Spirit Aspired to Free Enterprise vs Capitalism CEO/VPs Walked through Departments Knew their Operations Knew Employees by Name Valued Employee Suggestions Provided Medical Care on-site Privately Self Funded Health Plan Activities for all levels of Employees A Christmas Party Employees Children Dreamed of - Musical Performances, Circus Acts, Gift Bags Efficient Operations - Energy Savings Building Design Energy Recovery Heat Pump Systems: Capured Process, Lighting and Employee Heat - 50 years ahead of its time. Contributed to: Churches, Community, Hospitals, The Arts, Culture, Education & Schools MSOE - Milwaukee School of Engineering Many more things; too numerous to list! 2 Generations of Family Worked There! America... Capitalism will give you the lowest prices, but at what costs? Safety, Quality, Destruction of Main Street America, "Zombie" Tranq Drug Addicts & "Street Walkers" on every corner, No Investments in your local community (your's & your childrens future); the environment; replacement of local workers (your families and neighbors jobs & paychecks) by foreign slave labor; Endless convoys of Amazon delivery vans with more boxes circle your neighborhood to the point you can't even ride a bike or walk on your own streets, another cheap throw away plastic product that fill up the landfills & chokes the 7 seas, and Melamine in your pasta, is what you get! Do you really want it?

[@markschulze7841]

I do some quality management in industrial construction. May motto is “in 10 years nobody is gonna remember if we finished late, but they will see every day if we did a crappy job”

[@WOFFY-qc9te]

So True. @@markschulze7841

[@neeneko]

Sadly, ex-MD management have discovered quality doesn't matter, if you are contrite with enough confidence people will keep buying your junk.

[@lauriesue2244]

my Dad was a Boeing engineer 1967-1990. the CEOs/Board members, until the past few years, worked in offices close to manufacturing and engineering. Now they're clear across the country! Until the past 20-30 years, they were pilots, flight enthusiasts, etc. Not so in recent years. Now they just want to make a quick dollar. GLAD MY DAD ISN'T AROUND TO SEE THIS! He was so proud of his Boeing employment. Now the greedy execs are ruining the company.

[@markfryer9880]

Boeing is definitely not the same company that your father worked for! Ever since Boeing took over McDonald-Douglas and then the management of MDD took over Boeing from the inside, it has never been the same. Moving the Corporate Headquarters to Chicago was the first sign that they were no longer vested in building aircraft. The Headquarters have since 2023 been located in Arlington, W. Virginia. Does that look like the decision of a CEO interested in the quality of the products that they produce or someone more interested in easy access to Washington DC and the decision making going on there? Mark from Melbourne Australia 🇦🇺

[@Zerpentsa6598]

One sure way to destroy a good company - employ more MBAs.

[@richardhack9830]

You can definitely be proud of your Dad. Nowadays Boeing management and executives have no reason to be proud at all...

[@njjeff201]

Mmmm…. Sounds like my X employer Sony. Get rid of the guys who worked on the bench every day to use foreigners who never saw the machines. Reading off a computer screen isn’t the same as reading schematics or knowing the service menus by heart. We used to pick up the phone by 3 or 4 rings; now you might get a call back in 3 days.

[@njjeff201]

Mmmm…. Sounds like my X employer Sony. Get rid of the guys who worked on the bench every day to use foreigners who never saw the machines. Reading off a computer screen isn’t the same as reading schematics or knowing the service menus by heart. We used to pick up the phone by 3 or 4 rings; now you might get a call back in 3 days.

[@scowell]

For a real door, there is a difference. For a plug door, there is *no* difference... opening a plug is the same as removing it. Somebody skated on paperwork by using a door nomenclature instead of (what should be required) plug nomenclature. Thanks Juan, this shows the entire problem and why it happened.

[@misarthim6538]

Yeah, I think you're spot on. It doesn't even have to be someone skating on paperwork, it may be that someone who wrote the SOP didn't realize the 'plug door' isn't an actual door.

[@omgsrsly]

I agree. On a real door these 4 bolts don't exist anyway because their function of "locking" the door in place is provided by the door-handle or -lever mechanism instead.

[@stevenlesinski9882]

Exactly - this is not a door opening and closing, by calling it that - there is assumption it's one of the emergency doors. All plug types should have been documented as removal of door.

[@johnkingery403]

Exactly. The plug door isn't hinged so how can it be opened but not removed?

[@nickmaclachlan5178]

Yup, when is a door not a door?

[@CJB_B95L]

High paid executives won’t change until criminal charges start to follow criminal behavior

[@Cwra1smith]

This isn't a criminal matter, it's a poor training and quality management problem. Is Joe Biden responsible for the immigration problem?

[@jonclassical2024]

AMEN!

[@HeronPoint2021]

for several decades now these executives have been ALLOWED to play the New York cheap money influencer tik tok game like they were 14 year old peach bums whose behaviour has no consquence to their actions. Unfortunately, they made mistakes and when they do, people die. This is NOT a Snap/Chat reality show.

[@nancychace8619]

Lots of truth to that. Tell it to our current Supreme Court.

[@AndyFromBeaverton]

They have no idea how lucky they were not to lose hundreds of lives.

[@thoso1973]

The real problem isn't actually 'are there more Max airplanes out there with missing door bolts?' No, the real problem is 'how many OTHER bolts may be missing from other critical components in Max aircraft due to poor quality inspection, that we don't even know about?

[@emmanuels7723]

Yeah, doubt Spirit has been working on only the door plugs, and if they circumvent Boeing's bad quality control system, there certainly are other cases they did to cut corners. And not only on the max 9...

[@Enfield2A]

Always comes down to a Screw loose somewhere! Dam FOD!!

[@Martinit0]

@@emmanuels7723It doesn't appear Spirit circumvented the Boeing QMS, rather the Boeing QMS has a serious gap as it doesn't allow for that particular event to be recorded and hence properly tracked, checked and followed up.

[@raymondo737]

@@Martinit0 These being two different systems, I imagine there is an integration layer between them. Knowing absolutely nothing about them, I'll hazard a guess that there is information lost in the translation. There might also be a conscious intent to skip some of it to prevent clutter.

[@JamesTK]

Not to mention loose bolts after coming back from Boeing service that weren't loose before

[@mikekenney1947]

I was part of a replacement command team for a field maintenance squadron that failed an IG inspection decades ago. It was obvious that there were deficiencies at all levels of operation, not just what went on in the hangar. It was systematic command failure expressed simply as lack of “attention to detail” I never forgot that lesson. Lives were at stake.

[@higgydufrane]

I have worked at 2 fairly large manufacturing corporations in my life. 10 years at each. Never underestimate the ability of a corporation to make horrible decisions.

[@shawnpa]

Any organization. The steel industry pretty much collapsed because unions wouldn't take concessions. Companies needed them for real and went bankrupt. Now everything is made in China and debt to them plus supply/quality are issues.

[@BAD_CONSUMER]

It's because leadership positions attract a certain type of individual. True leaders don't seek it out.

[@tmayorca8770]

Well Boeing does not have a lot of A&P mechanics there. They're technicians so somebody would have had to oversee the removal and installation. Let's hope it was an A&P.

[@VanillaMacaron551]

Nor to completely fail to understand its own business and industry.

[@IndependenceIron]

@@VanillaMacaron551 As corporations move management away from their factories, and to these big hub cities it only gets worse. They lose track of whats important for their business and the customers. It becomes all about metrics and cutting costs!

[@TYRONE_SHOELACES]

This happens every day in every large production facility. . . it's just life. I work as a specialty pipe welder in a shipyard. I came in as a laborer on the weekend to make some extra cash. I was told that I was needed as a welder instead, and for me to get my gear and head down to the military ship that was getting ready for sea trials before being handed over to the Navy. When I get there, it is explained to me that the night before, as they were filling the fuel tanks with diesel, they noticed a smell and then a leak in a hallway. They had to remove the sheet metal wall, insulation, fire insulation to find a missed weld on 1" pipe for a sensor going directly into the tank, a tank that held thousands of gallons of diesel fuel. The tank somehow got to that stage without a complete weld being tested? ... how? ...tanks are pressure tested in the shipyard before being " cleared" for inside painting and then outside painting ...either the pressure test was not conducted or was conducted improperly. I am at the end of my career, almost 40 years of being a welder, combination welder, then high pressure pipe welder and then shipyard pipe welder. I have seen mistakes like this happen all the time. Here is one explanation that I know of first hand of what happens. The " White Hats" get together every morning, and it is discussed which white hat got the LEAST amount of work done the day before, and then they are told that the guy at the bottom will be fired for lack of production...which leads to Foremen, Managers and sometimes Directors falsifying inspection documents so that the work can be " signed off" and moved to the next level. When one Manager was caught red-handed, he explained that it was more important to him to " cover up" the mistake rather than expose it, and then be fired for missing a crucial inspection point. He said that so many people are involved that a missed weld could not be blamed on one person, so he assumed that he would not be held responsible personally. He said what stopped him from exposing the mistake was the fact that he had moved from one Province to another, bought a house a new SUV and could not afford to lose his job...so he took a chance. This is what happens all the time in production, but inspection levels HAVE to be much higher when dealing with aircraft as compared to Military ships...but so many of us don't want to lose their jobs, their homes, their wives over " doing the right thing". I personally have been fired from a good job because I brought to attention the defect in the welding that I was finishing up, but I was accused of doing ALL the welding, and so I was blamed for the failed weld, and fired. . . And I would do it again. These welders had burned through the RADAR cable going up the mast of a large offshore fishing boat, but they wrapped black electrical tape around the shielded cable to hide where they had burned it. As soon as the winter weather and salt spray got into that, the RADAR would have failed, and to me that means maybe, just maybe, those men on board that ship could have lost their " EYES" in a storm and could not go to sleep knowing I walked away from a possible disaster, and I would do the same thing tomorrow if it happened. I have a motto when I weld on important projects all throughout my life. . . I weld on things as if my SON is going to be the Captain, my WIFE is going to be the cook...so if I do a less than perfect job, I could be drowning my family ...so EVERY weld is the best I can do, every day.

[@arigelab]

Thank you ! 🙏

[@javaguru7141]

It's utterly absurd that you could be blamed for a massive defect that was covered up and you yourself called attention to. In today's job market, I think something like that happening to me would send me into despair.

[@TYRONE_SHOELACES]

@@javaguru7141 I had recently been hired there, so I was the "outsider" welder, and after they got the bill for the special cable that goes from the bridge to the top of the mast, which was $3,700.00 . . . That was enough of a "hit" for them to fire me.

[@RickTashma]

Beautiful perspective (re family) to keep you on point. Thx for the share.

[@TYRONE_SHOELACES]

@@arigelab You are very welcome. I was just typing ' out loud", typing as I thought to myself and quite honestly, did not expect to see 29 thumbs up below my comment in 14 minutes .. But again, you are very welcome. I love what I do, and every day, I still try to achieve a higher standard of quality compared to the day before...it keeps me " sharp".

[@jonsavelle1122]

As I remember it, Spirit initially was a Boeing plant that was spun off into a separate company - presumably as a cost cutting measure. How they can now have two incompatible QC systems is just incomprehensible.

[@blancolirio]

correct.

[@raygunsforronnie847]

Spirit was originally Boeing Commercial - Wichita. Boeing sold it to a private capital firm who later took it public under the Spirit name. My presumption at the time was that Boeing was looking for corporate degrees of separation from the fuselage, nacelle, and strut manufacturing. The cynical part of me says this was a legal strategy to protect Boeing when their fabrication QC went down due to cost cutting.

[@dave30076]

I wonder, too. Maybe the Spirit QC system has a lower subscription cost? They seem hell-bent on saving money even if it harms the process,.

[@xxwookey]

Doesn't seem very clever does it? The new system would need to be an awful lot cheaper to cover the extra cost of interfacing work.

[@christianbottger493]

But even if they both had used one system: there should never have been an option to just "open" a door plug instrad of removing. Boeing messed up writing that part of the quality control manual. But of course the Spirit workers messed up as well: they should never have picked that option to document their work. Looks like someone tried to save time by choosing this option in documentation because you can avoid some documentation work this way - on top of messing up when not fixing those bolts correctly in the first place of course.

[@robrobinette]

I was a flight safety officer in the US Air Force and blancolirio is by far the best aviation safety source on KZbin. Keep up the great work.

[@markgravatt5335]

His passion is clear and evident by seeing him at Reno this year in the STOL pits.

[@Embargoman]

Now Lockheed Martin is eating Boeing’s lunch.

[@rolandvachon9848]

This is what happens to a company when "bean counters'" take over and the experience of trained and qualified longtime employees is ignored and swept aside.

[@mmartin4978]

My exact thoughts

[@SB-cz9vo]

Sadly, this has happened in many places in the last decade(s). Aviation just has a harder response when the bean counters screw up big time.

[@hyperkoala1758]

And politics become priority

[@jonclassical2024]

DAMN STRAIGHT!!!!!!!!!!!!

[@SQLRYAN]

Not to mention some idiot with college degree who has no idea how things work is in management positions.

[@NigelsModellingBench]

I am a time served Rolls Royce Aero Engineer. (Retired). What the hell were those guys who refitted the door thinking was gonna hold that door in place? Was there no SOP? No work instruction? Was there no sign off on the completed job? Did no one even check the seal was correctly replaced, or the correct seal was used? This is crazy!!!

[@naturalverities]

Not to mention what happened to the fasteners that were removed and that apparently went unnoticed thereafter. Ouch!

[@entropyroshan9846]

There should be work instructions as well as a quality checkpoint noted in the instructions to remove and replace that door (I’m sure this isn’t the first time they did that work from the sounds of the crappy workmanship of Spirit). Those instructions should be certified thorough a proper engineering review when they would have been written (probably by Spirit engineers since it sounds like they took the ownership of the repair and it was their crew working on it from what was said). And that Spirit crew would have been responsible for the quality check if they were owning the work. Having a Boeing quality check would have been redundant at that point. That’s a lot of assumptions on my part of course. If Boeing were to have taken the lead on the seal repair then they should have to do the same with instructions, reviews and quality checks. Not clear yet who owned the repair.

[@dermick]

@@entropyroshan9846 I agree - honestly the whole Spirit spinoff seems like it needs a closer look.

[@camf7522]

It would appear that Boeing treated opening a door plug the same as opening a door….it is outrageous hey! One is a maintenance procedure (or should be) and the other a normal procedure. One has bolts, nuts, fixtures etc and the other has an emergency slide! WTF are Boeing thinking?

[@skayt35]

@@entropyroshan9846 Boeing _knows_ that work quality and quality checks of Spirit Aerosystems are abysmal, so Boeing _must_ double-check any safety-critical installations. Not performing those checks is gross negligence on Boeing's side!

[@joehelland1635]

Having been an Apache mechanic for 7 years it blows my mind that any level of work that requires removal of hardware can be performed without being written up and verified when completed by QC.

[@GWNorth-db8vn]

My first thought on seeing those bolts was, is some guy re-using the cotter pins? My company does a lot of what we call "CNN jobs" because if you mess it up, you might find out from the news. I've had to fix or replace things made by much more educated and supposedly competent people than an apprentice mechanic or a line worker. Not documenting something like this is insane.

[@neeneko]

Apache is kinda a golden child at Boeing, they get the resources to really do things.

[@StarkRG]

Ahh, but you see, they didn't _remove_ the door plug, they only _opened_ it, and, while the procedures are almost identical, only removing it triggers the re-install and inspect procedures. They didn't want to do that because inspections take time, so they just opened it instead.

[@GWNorth-db8vn]

@@StarkRG - That's called gaming the system. It's the same process with the same risks, and it should follow the same protocols.

[@NikoMoraKamu]

@@GWNorth-db8vn those boing fellas are veery good in changing names

[@russellamaru5175]

Having worked as a process chemist that included quality control in the metal working industry, I am well aware of quality control issues. And, it is well known that Boeing has been plagued with QC issues for the past 15 years or so. Unfortunately, management has yet to resolve these problems. And, as a fellow commenter recently stated: "If the Board of Boeing can pay former CEO Dennis Muilenburg $62 million but can’t oversee 4 bolts being fitted to a removed door plug, they need to go." So very RIGHT ON!!

[@jamesmedina2062]

you can build in clauses and consequences in any endeavor but it is so easy for many systems to be created which oppose that and creates fat cats. Humans seem predisposed to look for methods to reduce work and this means consolidating power and eliminating consequences for lapses in quality. For example: UNIONS

[@HsquaredH2]

I agree that the Board and imo, upper, middle and lower management need all be removed in order to fix this however, what does any of that have to do with how much he gets paid? It’s completely irrelevant!

[@bobolulu7615]

Since when was the CEO supposed to oversee every bolt and rivet installed in every plane? You're just jumping on the, let's blame someone, bandwagon. You're an idiot if you think it's the CEOs fault.

[@fredharvey2720]

Dennis was fired years ago

[@cascadesouthernmodeltrains7547]

I was an Avionics Tech in the Navy. Whenever I opened a radar component, even if I only removed the lid for a visual inspection I had to have a CDI (basically a quality control inspection) done on the piece of gear before I could check it off as complete and put the lid back on, then again to check that all the fasteners were torqued to spec and then and only then I could wrap it up and the part could be returned to the aircraft. The Navy did this for ANY maintenance action on any aircraft. I’m shocked that this isn’t an industry standard.

[@joshuawalker7054]

Naval Avionics Tech here as well. Yea, That blew me away. Not only opening part of the fuselage, but also REMOVING FASTENERS didn't immediately trigger a QA check after maintenance. Just... WOW!

[@richardtjan4757]

Apparently military lives are important, but not those of civilians.😢😂

[@Part_121]

I was an aircraft mechanic at the now long defunct Eastern Airlines and that's the way our Aircraft Service Center in Miami was run too. They called it double-buy-back on everything. However, once the plane was no longer in an overhaul situation, say out on the line, only items on the Required Inspection Items list (RII list) required 2 sets of eyes. I suspect a pressurized door might have been an important enough item to be on the RII list though. It's really not rocket science..

[@jonanderson5137]

​@@richardtjan4757wrong perspective. Many of these aircraft are difficult or impossible to replace.

[@wadepatton2433]

. Thanks for your service and insight. Industry is not the military. The military doesn't have bean counters scrutinizing every process and applying production pressure on every person in the manufacturing division in order to squeeze a few more dollars into stock values. As I understand it, the military isn't focused on profits, but on the success of the mission. 737's would cost a LOT more if the military was building them, but they'd likely be built properly.

[@jamesnasium4035]

The Seattle Times article is a real eye opener. The problems with the Max 9 go far beyond the door plugs.

[@hardyfamily396]

How do we know that it’s limited to the Max 9?

[@markphillips2076]

@@hardyfamily396 There have been reports of foreign objects left in tanker aircraft delivered to the USAF, so I doubt very much is "just" a Max 9 issue.

[@hardyfamily396]

@@markphillips2076 that’s what I’m getting at. Plus the 787 production lines being shut down for a year over quality issues, 737 rudder checks, etc. I don’t feel that I can reasonably and rationally have any confidence in taking my young family on modern Boeing aircraft anymore. Which is sad, frankly.

[@lisaa8795]

@@hardyfamily396 I felt that way too until reading that Spirit Aerosystems Europe is an important supplier for Airbus as well. It's not 100% certain that blame for this problem is solely attributable to Boeing until the investigation is done.

[@hardyfamily396]

@@lisaa8795Sprit supply 70% of the 737 to Boeing, including the whole main fuselage. They supply "leading and trailing" parts of the wing to Airbus for the A320s, which are fitted by Airbus. That's an entirely different scale (Ref: Spirit Aerosystems). And, although we can be sure their aircraft are not perfect, I can see no evidence that Airbus have the same sort of deep rooted quality system failures that Boeing plainly have. They haven't had their production lines shut down due to quality problems. They haven't had the major in service incidents. They haven't had the whistleblowers.

[@happyhome41]

Wow - my acquisition training over 20 years in the Air Force, it was axiomatic that is far easier, less expensive etc etc to do things right the first time - to build quality in, than to cut corners in a misguided attempt to improve schedule and reduce costs and fix it later. So difficult, and costly, to attempt to fix quality after the fact.

[@grayrabbit2211]

It is...but shareholders (and customers) don't like paying more up-front.

[@peterfox2565]

Like the old time Slogan from I think Zenith "the Quality goes in before the name goes on"

[@nancychace8619]

Respectfully, I'd beg to differ with you. Shareholders are in to make money. They can't do that if the company declines for lack of good quality management. No investor wants to lose money. Don't blame the shareholders - they're getting screwed, too, pardon my brusqueness.

[@HeronPoint2021]

Start by being as careful as you can with who you hire. I'd start by asking the new hire to use "axiomatic" in a sentence. That will wash out half the applicants!!

[@alglen9208]

​@@grayrabbit2211Then you have a product that is substandard

[@stephenphillips6245]

Funny how history repeats itself...the DC10s had a similar problem...two, great pilots landed them with little losses. The problem was ignored further and a crash killing all the passengers happened. Shout out to the book: There are no accidents by Jessie Singer...a good and enlightened read.

[@alastairbarkley6572]

"...great pilots landed them with little losses..." No, they didn't. American 96 was lucky. The damage to the control surfaces was limited. Turkish 981 3/3/1974 Paris, Everybody (345 souls) killed. Still Europe's deadliest by a country mile. Or, do suggest that a real Murican pilot can fly a DC-10 with pretty much all control surfaces disabled by explosive decompression damage whilst those pesky Europeans really shouldn't get more than a VFR licence on a Cessna'?

[@peterguirguess853]

​@@alastairbarkley6572 American pilots are better. Yes! I'm not afraid to say the obvious truth

[@carlrasmussen2778]

New construction submarines in the 60’s , while still on sea trials phase, new-con, would randomly pick yard workers, who actually did the construction, ride to sea and submerge the boat to find construction faults. Quite the motivator if you would like to return to your family, and stay alive.

[@lairdcummings9092]

The "SUBSAFE" program after the loss of the Thresher is the heart of it. I'm stunned and amazed that there isn't an aerospace equivalent spanning all players.

[@ernestbecker5213]

This practice is still performed today.

[@stevenslater2669]

A good way to make those workers take ownership of the quality of their work. Remember the Robert Conrad TV series, Black Sheep Squadron? The pilots were forever crossing swords with the crew chief who was responsible for maintaining the aircraft. Well, a mentor and close friend of mine was a crew chief for a U.S. Marine squadron in the South Pacific during WWII. Unlike the TV show, the crew chiefs actually had to take repaired planes up for a test flight, including aerobatics, while the pilot WATCHED FROM THE GROUND! You bet the ground crews did meticulous work on those Corsairs! Maybe Boeing board members and corporate officers should be required to fly shakedown flights in new airplanes. There would probably be a lot fewer cost reduction campaigns…

[@TimothyLipinski]

Great Comment ! Management at NASA killed two Crews of the Space Shuttle ! ! ! tjl@@lairdcummings9092

[@KayAteChef]

​@@stevenslater2669Cost reduction is vital to competition and there is nothing wrong with it. Safety and quality is more to the point.

[@richardbudd5334]

A&P for 45 years. Any time a safety was removed and redone we always had a second set of eyes look before any further work was done. This is just plain insane that it wasn't caught.

[@motorTranz]

Same in welding/sheetmetal fabrication. You generally had to have a coworker double check your fit up. Some government contracts you have to log checks.

[@cv990a4]

The fact that Boeing QC and Spirit Aerosystems QC systems don't talk to each other is crazy. Spirit is Boeing Commercial Aircraft's single biggest subcontractor, no? In any event, it's a massively important sub. Part of the original sin here is that Spirit was spun out of Boeing. Perhaps part of the solution is that they should be reintegrated.

[@ReflectedMiles]

@@cv990a4 Whenever they're ready to go on strike, the union takes credit for the quality of what they produce. Strange we're not hearing them take responsibility for this at either company, eh?

[@cv990a4]

@@ReflectedMiles I'm not a big union guy, but this is 100% a management issue.

[@ReflectedMiles]

@@cv990a4 Yeah, no. It's an everybody-who-was-involved issue. The buck stops at the C-suite, but that's not the only place it goes. When any individual or group within an organization wants to lay claim to being the cause for the great quality they produce, that is a two-way street. This is McDonnell Douglas at its finest.

[@groovykevin2059]

After 20 years in the automotive industry as a Quality Engineer, I moved to the aerospace industry about 10 years ago supplying both Airbus and Boeing pipelines. I was shocked to discover that the quality management systems in aerospace are nowhere near the robustness and maturity of the auto industry. Makes me think twice about flying.

[@Editsjidanger]

Dude, I am the same as you.

[@RK-kn1ud]

Given how poorly cars are manufactured today, that makes your statement even scarier. They're all profit engineered junk. Lol

[@cjswa6473]

Flying ⚰️ coffins

[@RyTrapp0]

That is just wild

[@jordanhenshaw]

At what company?

[@TheKevo7777]

My grandfather was a master Machinist for Lockheed Martin back in the 50s 60s 70s and early 80s. Their attention to detail was of utmost importance. If anybody dropped the ball they will let go rather swiftly. And it makes sense as lives are on the line.

[@Curt_Sampson]

That sounds like a safety systems failure, to me. Individual can and do "drop the ball" on things like this, and that's not going to change because humans will never be perfect. If you want better safety, you need _systems_ that can deal with this, catching and fixing human error. The person who should be fired is not the one who dropped the ball, but the managers who let systems get set up that let the errors through when an individual drops the ball.

[@glenyst5216]

So many fine engineering industries have been utterly destroyed by Wall St and the greed-driven US business model .

[@sturek]

I think the CEO's along with directors of quality control at all companies involved should spend the next month or three flying on 737-8/9 Max flights sitting in the window seat next to those doors....show us all their faith in the work their employees are doing.

[@JimMacintosh]

Wrong. They should just be fired. **from a Max 8 FO**

[@greybeard5774]

@@JimMacintosh- Yup .. fired, but AFTER they've been sitting next to those "doors" for a few years on a daily basis, and if they're still alive then :)))

[@benjaminway5699]

Yeah and the flying expenses should be out of their pockets😂

[@JoshuaTootell]

Doesn't work, the math checks out that they would be safe, and then they could say "All clear!". See also: John Gummer

[@beaconterraoneonline]

Another problem created with this type of issue is how many other components, systems and processes are suspect, and on other models? Trust is everything. Boeing has a big problem. Juan, appreciate your channel and the work you do.

[@johnstreet797]

In God we trust, everything else we check

[@garybulwinkle82]

Once you lose the public's trust, it maybe impossible to regain it!!

[@NicolaW72]

@@garybulwinkle82 Yes.

[@dave30076]

That is my fear. What else could be loose or missing on these aircraft, something that may turn up in high time aircraft (in a few years)?

[@sbdreamin]

"how many other components, systems and processes are suspect, and on other models" .... all of them. Every aircraft, every system, every f'ing bolt.

[@Flakfire]

My father worked for Boeing/McDonnell Douglas for something like 30 years as an engineer in quality (last worked at GKN). The amount of wild stories he has about QC are troubling. Poor training of assemblers, policies ignored, and management more concerned with their promotions and paychecks than getting a job done properly. He used to love his job, but the last years definitely saw a change in workplace culture and he wasn't happy with the lackadaisical attitude. Needless to say he's not surprised with the current turn. Boeing simply cut too deep and became too lazy. Now they're paying for it. I hope this turns the company around, but they're a few incidents away from completely losing the confidence of travelers.

[@whitedragondojo]

I won't fly Boeing Max ..... NO way.

[@davidryder3374]

So many places in American business actually reward and incentivize stupid management decisions. If you want change, you have to completely revamp the incentive structure. This goes for education, business and government. Any time human beings can get more by doing the wrong thing, that's inevitably the direction the majority will choose.

[@Roybwatchin]

I worked for Boeing for 19 yrs and now at another large aerospace company for another 18 years, so total of 37 yrs in aerospace. I agree that the cuts Boeing and others made over the last decade or so have caused huge problems in the industry. They were literally paying senior employees 40 - 80K cash to retire early and make room for newer, younger, more motivated and cheaper employees. The big problem with that logic was that the younger guys have NO experience. I don't blame the young guys, I was once one of them. They went down this path for several years of offering golden parachutes to get guys to retire and in doing this, they lost an untold amount of knowledge along the way. Now you have a bunch of new managers and workers that came from places like Burger King and Tire Shops, etc. and very few have any experience in the complexities of aerospace. This is a different world in aerospace and we are starting to see the damage that Boeing and others in the industry have caused. The sad part is that the newer generation of managers and shop workers, including QA, they don't know what they don't know. They don't even realize when they're in trouble and this perpetuates all the way up the food chain. We have a whole industry that is oblivious to all the problems brewing within in their companies. This will only get fixed with time and lots of trial and error, just like we did before, you know, the same timeframe of when we got all those senior employees trained and on top of their game. This is a hard lesson of what not to do.

[@mrbmp09]

TIL "lackadaisical" is a word.

[@hb1338]

The really difficult part of the situation is that if Boeing's customers go elsewhere (i.e Airbus), Boeing loses income, its profits drop and the temptation to cut staff and reduce quality checks becomes even stronger.

[@ecase727]

Great report, thanks. There has been much in the news about finding “lose” bolts, but I always felt this would be irrelevant. Since the bolts are loaded in shear, as long as the nut is installed preventing them from simply falling out, there is no way the door can open. Simply they were never installed, your breakdown in their quality process things are starting to make more sense.

[@unoriginalname4321]

Nuts can vibrate off if not torqued properly or if the cotter pin is left off.

[@perwestermark8920]

Just note that while inspecting these specific bolts, they have found *other* bolts that have been lose. Bolts that actually must be torqued with force and that are not relying on any cotter pin. So it has been a bit hard for the news to keep track of all issues.

[@mylifeisdope916]

i dont think its just a few bolts good buddy. its a mindset, viewpoint, way of business, and life. these fellas are driving what was a great engineering company directly into the ground. i wonder if they higher ups at boeing tell their family to fly on airbus?

[@KasimirGabert]

The higher ups at Boeing fly on Gulfstream and other corporate jets.

[@mylifeisdope916]

I also noticed this at school. a lot of the new "efficient" business practices work great on paper, increase efficiency, profits, everything. until something happens. the "just in time" thing, where you dont have a backlog of orders stacked up in the back room waiting to go out the door, bit us pretty hard when a single boat got stuck in some sand halfway around the world. this thing where a company passes off the quality control aspect onto its suppliers and just assumes everythings proper when it shows up at the door with seemingly zero inspections. its no bueno. yes its costs an extra half a cent to test the metal a supplier sent to make sure its what was ordered. but it could save lives. yes going thru a new fuselage and doing an incoming, heck maybe even an outgoing, inspection to make sure stuffs torqued properly or even there in the first place *bolts*, maybe little johnny left his wrench in the wing flaps, who knows. it could cost $5 or it could cost your best friends life. grow a brain people.

[@joshwatson7303]

The main problem here isn't the quality control issue. It's that the people who make up corporations are not criminally charged for decisions that result in criminal outcomes.

[@pmccoy8924]

Boeing just had a tire fly off just today on a Delta 757. DEI ABCD is destroying industry in each and every major industry worldwide.

[@dermick]

Indeed, there seems to be very little accountability in cases like this. Fines on a corporation don't seem to make any difference as these are just "costs of doing business".

[@wolf-dietergrabner9762]

Sounds like external consultants streamlining the process without responsibility or in depth understanding. Nobody gets fired for hiring them but instead companies should do their work properly. What a mess.

[@MegaSunspark]

It's not going to happen. Remember the 2 space shuttle INCIDENTS? No one at NASA or the contractors were ever charged or went prison, fired or even fined, while there was plenty of evidence of obhorent, criminal behavior.

[@Wayoutthere]

Bingo. ACCOUNTABILITY has been gone for a while now, including in politics. Many signs of end-stage western civilization.

[@robinmyman]

What else hasn’t been fitted properly in Boeings?

[@kellypaws]

A quality first culture.

[@MiteshDamania]

We will find out soon enough

[@bobwilson758]

And air bus - Same shit - different place ! Really ! Think about it .

[@BobRossRightHand]

@@bobwilson758 I'm thinking really hard but cant recall a single time the 320neo became a bomb drone nor had it's door/plug blown off in-air due to missing bolts

[@nate4745]

Also missing, various screws, nuts, washers, pins, etc. around the aircraft. The name of the company really does sound like a part falling off. Boing!

[@michaellastname4922]

Thanks for a lucid discussion. (BTW, the air worthiness system in Russia is tanked: no spare parts, no software updates.)

[@tigersfan14]

Have to give props to the Seattle Times. They’ve had the best reporting on Boeing news for a long time. Given their locale, they really know their beat. Invaluable reporting.

[@MrRugbylane]

100% agree. The reporting by the Seattle Times is an excellent example of what journalism should be....and not just on this topic. Imagine if the mainstream media applied the same standards to many other topics.

[@plebius]

​@@MrRugbylaneThey are mainstream media mate. The term means traditional broadcasting or publishing outlets. Seattle times have been around since 1891.

[@alt572]

For many people, mainstream media nowadays means clickbait tabloids. Sadly they have left legacy outlets in the dust, because people are more likely to click on clickbait, instead of thoroughly researched articles @@plebius

[@paulwheeless1080]

Too bad private equity vampires destroyed the Chicago Tribune starting in 2007...could have been watching Boeing's HQ's move there from Seattle from 2001 to 2022 (when they moved again to DC after the 737 MAX crashes).

[@JoshuaTootell]

​People don't even know what they are talking about. They are just spewing out the same crap they hear from some influencer. Seattle Times is definitely "MSM" ​@@plebius

[@NorCalTRACON]

If these bolts were missing, what else could be missing or loose? That’s the scary part

[@volvo09]

Yeah, like linkages for control surfaces and whatnot tucked away in the wings! Scary stuff!

[@Tonbeefcak]

Exactly my thought. They already have an issue with rudder assembly bolts loose or missing.

[@majboomer1285]

Having working in and around aviation for 20+ years on the defense side of the industry, I can say without a doubt that the Quality Control / Quality Assurance departments are one of the most important, yet most chastised departments even within the companies themselves. Many people don't want to "say something" when they "see something" because it is treated as an inconvenience on so many levels. They are too afraid they will make someone look bad or hurt their feelings by challenging these things. When I was in Air Force Basic Training I was told there are two things that know NO stripes, and that is safety and security. It does not matter who you are or who they are, if you see an issue with either of those two things, say something. The biggest problem I have seen with that philosophy is getting leadership to back people up when it gets called out. Building that kind of supportive culture MUST start with, and be maintained with support from the top down.

[@DR_1_1]

You need a lot of diplomacy when you notice something wrong, even dangerous, talking about it honestly, and worse, publicly, is the best way to get fired.

[@latetotheparty184]

When I worked in a large state psychiatric hospital I was told by a buddy if you see a problem don't report it, because if you report a problem then YOU are the problem. Kind of like shooting the messenger kind of reaction.

[@TheGecko213]

No one likes a tattle taler or a whistle blower . Better to keep your head down and nose clean 😂

[@eddietrujillo7914]

I was in QM/QA in food manufacturing and indeed quality is often seen as a hindrance rather than a benefit, very frustrating for a QM/QA employee.

[@brockwaymt]

As an engineer who worked in quality I can say that nobody gets praise or a promotion for expending time and money to fix a problem. You get praise for meeting target dates, shipping product, and getting your paperwork in on time. If you as a qc stop production you get hate from above and below. Management hates you for blowing their numbers. The line workers hate you because they get no OT if the line is stopped. And you just killed their production based incentive pay.

[@mackydog99]

I worked at Spirit Aero in Wichita last year as a contractor. A particular term used to describe certain managers was "bean counter." Saw this with my own eyes.

[@fredharvey2720]

What did you see besides that?

[@mackydog99]

@@fredharvey2720 Mostly just section 41

[@mackydog99]

@@fredharvey2720 I saw the ISS fly over early in the morning on several occasions!

[@fredharvey2720]

@@mackydog99 Dude I mean at Spirit Aero.

[@mackydog99]

@fredharvey2720 I know..........I was being facetious. Basically there were too many chiefs and not enough indians. Management was out of control and many of the workers took advantage of it. I saw several inspectors leave. The usual backstabbing and backbiting. Irresponsibility and unaccountability will bring you to your knees! But seriously......I did go out between the buildings in the early morning and watch the space station fly over. I get the feeling that you may have worked there.

[@thomasrosenbloom8566]

I have been in manufacturing in a variety of roles for almost 30 years. Regardless of the business, but particularly in manufacturing, understanding and constantly tending to your core competencies is ALWAYS job #1. When Boeing decided to build airplanes by committee and outsource their core competencies, it was not IF things like this would happen, but WHEN. An entirely foreseeable consequence for those who truly focus on the business rather than the profit. But Boeing got rid of most of those folks. The only question now is whether they are willing to do the hard work to fix this or whether they are doomed.

[@MrSiciro]

And you can rest assured that there was someone that warned them that this would happen and that person or persons were ignored

[@Mantarr1]

@@MrSiciro or fired

[@AndyHullMcPenguin]

@@Mantarr1 More likely, both. One of the key takeaways here is that there were essentially two identical processes. One to remove, and one open the door. Why, when it is essentially the same job? I suggest the answer is probably for one of the following scenarios. No inspection for opening, since it speeds up operations. Speed first, Safety last. Alternatively, this is a cut and paste error. In other words, the process was lifted from a similar airframe or variant's process, where the two processes, opening, and removing, were entirely different. Blame will be dished out, no doubt, but will lessens be genuinely learned?

[@digitaurus]

The issue is that opening a door doesn’t involve removing things like bolts, whose replacement would need inspection. Of course, opening a door plug does but CMES appears not to register the distinction between a door and a door plug in this respect. Obviously management will have recognised that opening a door plug was a removal but they wanted to cut corners. I shudder to think what else has been going on.

[@HeronPoint2021]

these doors and the work are concealed. I've been taking "job progress" photos for three decades now. |I leave them on the hard drive for each project as finished, put in the corpl safe (or in the Cloud). if you want to PROVE the bolts are in the plug they you go.

[@danielgregory3295]

If there is no documentation, then it never really "happened" anyway, they must think..😮

[@digitaurus]

@@arrdubu Thanks for the clarification.

[@postersm7141]

Fun fact, Boeing manufacturers less than 40% of the airplane. This is in sharp comparison to the merger with McDonnell Douglas prior. Prior to McDonnell Douglas they pretty much manufactured the entire aircraft. They were an engineering company back then and now they’re just an assembly company using the old McDonald Douglas mantra of cutting cost and corners wherever possible. Even at the expense of safety and lives.

[@OneAdam12Adam]

For the love of money is the root of all evil. MBA bean counters just ignore the crucial engineer adults in the room and this is what you get.

[@drgLACity]

Hence why the DC-10 had problems…

[@patrickrankin4476]

Exactly!

[@AndreySloan_is_a_cnut]

Yep. McD was a garbage company, and unfortunately they essentially bought Boeing using Boeing's money. It was advertised as Boeing buying them, but in reality, McDog installed their craptastic management which only knew how to cut corners and costs, moved the headquarters to Shitcago, and here we are. Many heads need to roll to save what was once a company that was the pride of the United States.

[@fyrman9092]

Amazing after 25 years, that budget mindset still remains. It seems like the pattern will continue. Lessons have not been learned after the 787, MCAS and now this debacle.

[@contrebombarde6950]

Small note about CMES vs. SAT--according to the leehamnews source, SAT is *Boeing's* second, not-authoritative records system--not Spirit's. Spirit has access to SAT, but "can't be allowed" access to CMES (even though it has apparently demanded in the past by Boeing Senior Managers). Thank you for another great video! Love your channel!

[@rachelLadyD]

cant be trusted?

[@contrebombarde6950]

​@@rachelLadyD I would read the leehamnews link for more details--tons of interesting info there (though unsubstantiated). From what I understand, the reason Spirit employees are onsite at Renton is because the defect rate is so high (some egregious examples listed, including documented examples for this plane); otherwise, Boeing would be doing the fixes and documenting them in CMES (the authoritative record system). But since Spirit is onsite because they're rushing shoddy product out the door, and they do not have direct access CMES but do have access to SAT, the fixes are getting coordinated in a non-authoritative system. Boeing is ultimately at fault, but there are many things going on that made something like this inevitable. I can see why there are Boeing employees that refuse to board a MAX (even after they were no longer grounded after the crashes).

[@svr5423]

I totally understand those people. I always had parts left when I finished building my Lego airplanes as a kid.

[@kevinmartin7760]

That's really a double failure: 1-technician's failure to replace the bolts as part of closing the door 2-procedural failure in having no inspection requirement after closing the door. I might add 3-No one asking "Hey! What are these nuts and bolts doing here on the floor?" Really... where *did* the bolts go? Did the tech who opened the door stick them in his pocket? Don't those split pins (Cotter pins) need to be replaced and not re-used so there should be a parts BOM for the procedure? I suppose that's part of number 3, no accounting for parts in & out.

[@RyTrapp0]

Don't forget the initial failure, the reason they had to open that plug in the first place - to fix the seal

[@awuma]

Perhaps they were never there.

[@JohnnyMotel99]

It simply beggars belief that whoever put the door back in it's place did not spot FOUR holes where the bolts were, unless they were in a hurry or maybe they assumed it was the job of the next shift, or maybe it was at the end of their shift and they were urged to clock off. Far too many questions. But Boeing has to know who it was who refitted the door. But this reminds me of my last place of work, a TV post production house. I cam in early one morning and dropped a tape in the machine to edit. Did the edit, the edit was QC'd but what no-one noticed was that I had edited the wrong episode but named it what was on the paperwork. We worked to 100% accuracy and that one error cost me my job. But I know why it happened, all of us were bored out of our heads doing repetitive edits.

[@vwecco1]

The its “not my job” attitude prevents people for going one inch past minimum requirement to keep the job. Even if they see the bolts loose on the floor, they don’t care. Then there so many others that haven’t got any clue about anything, lack curiosity, or ability to even think.

[@JanRademan]

The CMES does not take into account if a mid cabin door was fitted with a plug door or a deactivated door. So it gave operators the option of selecting an option which only makes sense if a door is fitted. And operators selected it because it gave them a loophole to close the ticket faster. Nice.

[@georgiannacook8874]

Call me old fashioned but did this happen before computers came into being? I was a general aviation pilot and they used to laugh at me because I spent so much time pre-flighting my plane before I went up. I said I was the one going to be up there and I want to make sure everything was in working order I don't mind taking a few extra minutes. This is a terrible thing when you go flying how do you know that your plane is put together properly? Certainly hope this problem can be solved.

[@SFDukie]

Appreciate your takes Juan. Your no nonsense, just the facts style is helpful

[@MasterNinja57]

After hearing about Boeing eliminating 400ish QC positions back in 2019, I wondered how long it would take for an incident to occur.

[@Boris-Jx]

Source?

[@mcculfja]

@@Boris-Jx I probably shouldn't have said anything

[@treborg777]

Boeing has been trying to eliminate QA for many years, seeing it as an un-necessary expense. Just have the mechanics sign off on their own work, that's just fine.

[@oxpack]

We have people in my group managing projects while working from home. It is such a joke. Hoping they aren't allowing QC via zoom calls or some other nonsense.

[@evo-labs]

@@treborg777 Yet people tell me that there is "nothing wrong with making a profit"...

[@aaronlopez492]

This incident with Boeing reminds me of the short sided penny pinching QC at Firestone back in the 90's that damaged an iconic name brand, still struggling to put it behind them. Business Schools should be using this cases as examples of what not to do when trying maximize profits. Thank you Juan.

[@russcudney1469]

The 721 debacle or the issue with explorers? Both were just as bad

[@doug112244]

That Ford/Firestone tire fiasco should be in every business textbook as an example of how not to do it.

[@sd906238]

Too busy tripping of $100 bill to pickup pennies.

[@frontagulus]

My experience of business school is that what is more important than learning lessons like that is networking with financiers to create the next killer app. I don't place much value on business schools, and they most certainly shouldn't be part of universities - they should be vocational training oriented

[@Alanstrainworld]

Oh my gosh…. I forgot about that, yes Ford n Firestone are still trying to get over that…

[@smakusdod]

Treating the door removal as some kind of temporary event .... just wow! Any removal of 'fixed' accoutrements should be logged and re-inspected!

[@johnaclark1]

Watch again. Door "removal" was logged and tracked. Door "opening" was not. On most doors they are obviously two different things. In the case of these doors they are virtually the same thing.

[@dave30076]

@@johnaclark1 Yep, on a normal cabin door, there would not be any process to check a door after it is opened and closed. Normal operation. But this "door" isn't meant to be opened and closed, and to do so requires removal of the bolts.

[@LeverPhile]

Doors can be 'removed' or 'opened' while plugs are always 'removed. Everyone (Juan included) seems to be calling the plug a door however.

[@the_real_ch3]

It’s not even when a fixed item is removed. Anytime a bolt is unpinned and unthreaded there needs to be accountability for that bolt until it is reinstalled, pinned, and inspected.

[@major__kong]

Are we at a point where we're finally stupid enough where safety depends on whether something got logged or not? On safety critical items, even in my garage, I never walk away with something half installed. It's either fully installed or fully removed. It's never in between. And does the line supervisor need the computer to tell him to do a walk around and look for obvious things before they button up the aircraft?

[@johnbrown6189]

Back in the day building DC9's each part of the planes assembly was subjected to inspection. The inspection was documented by what was referred to as a snag sheet. Any manufacturing or assembly non conformances was recorded on these sheets then given back to production for repair. The plane was not considered fit until all items on the snag sheet were addressed. Each DC 9 came with a complete record of all SNAGS that where found. Missing bolts or rivets is an example of gross negligence for manufacturing, inspection and engineering.

[@williamcandee5267]

That employee who whistleblew says that actually there is nothing recorded in CMES about either the door being opened or removed, hence no QA inspection requirement. That's why Boeing said initially that they never opened the door. What they apparently do have in CMES is that a seal was replaced but nothing about how. Of course, you can't replace the seal without opening or removing the door, but that's what CMES shows. SAT, on the other hand, explains what actually happened. As a classic example of software not supporting safety: apparently because the plug door is a panel, not a door, it can't be "opened", only "removed". So there's no place in CMES to show the door having been "opened", only "removed". So since they didn't "remove" it (but of course they did), they didn't record the opening in CMES. Of course, it SHOULD have been shown as a "removal", for all the reasons discussed -- like that a QA inspection would then take place.

[@BenJaminLongTime]

This is not entirely accurate, because it is a panel and not a door it 100% would be a removal. any time previous work/acceptance is disturbed (aka these bolts) paperwork stating a removal was performed is in fact required and would be generated in the CMES system. It can even state that "the door/panel was not removed but torque was disturbed and door/panel was opened" or this statement wouldnt have to be stated at all and the removal paperwork would stand on its own and it would drive all of the right instruction to reinstall everting per engineering with all required QA buyoffs. The gap here is more of 1. 2 different systems which dont directly talk and 2. mechanic error for not making the removal paperwork described. ... I dont want to state details about why I know this but I can tell you that I am not speculating, these are facts of boeing system and process... very unfortunate this happened but very fortunate no one was hurt.

[@MartyGarrison]

There is only 1 installation (or re-installation) process so there should be only 1 process for removal. I don’t care if you call it “open” or “remove”. If those bolts are removed then they should assume the door needs to go through the installation process again with all associated inspections.

[@scofab]

From a documentary on the B-787, a worker said: "They're building 'em to sell, not to fly". Not too far off IMO, and really sad to watch Icarus fall. Thanks Juan.

[@yl0000]

The scary part is how many other such “QA system gaps” exist between the two companies?

[@philip4193]

What an excellent video! Thank you so much for explaining (in laymans terms) not only what actually happened concerning the work on the plug-door seal but also why problems occurred due to a disconnect between Boeing's & Spirit's different internal reporting procedures. Makes the whole thing now crystal clear to me in my understanding as to how this huge and potentially fatal oversight in the inspection regime could have occurred.

[@festerofest4374]

Juan has done such a good job of explaining the role and function of the door and the bolts in the previous episodes that I completely understood the mechanics, BUT those animations at the end are fantastic!

[@TSRGarage]

I retired from Boeing a few years ago. In the last few years of work, they were moving rapidly away from actual QA inspections. Instead, they decided on using a system of production workers signing off each other's work and even eliminated some inspection steps. A few of us thought it was a "not one of their best" ideas. Upper management loved it. It would save time and money, not having to call a QA over to check work , and fewer QA to hire. (But management did push the stock value over 📈$400 for a while). Speed and profit over quality or, in some cases, ??safety??. Is this ??? Just one of the results ??? 🤔😮

[@JR-jw3px]

prior to MAX/MCAS forecasts indicated $525. Its been in free fall since. re: Alaska - The Standard Airworthiness Certificate is dated 25 Oct 2023. Was the "issue" in place then or did it occur at some point after?

[@jamesmedina2062]

Sounds like the beginning of the end of ROBUST quality assurance checks. Corporate culture in America is a sure way to lose money and a great way to sabotage democracy. But along with eliminating your competition through hostile takeovers and other hijinks, it makes for what appears to be a great place for the "investor's money".

[@SmittySmithsonite]

Money - the root of all evil!

[@Motivation-qf5gg]

@@SmittySmithsoniteyeah financial engineering so much easier than actual product engineering

[@KITLEVEY]

"It would save time and money, not having to call a QA over to check..." That's it in a nut shell. Now all you have to do is add that money they saved and subtract the money they just lost and the check the sign in front of the answer for a + or a - . My money is on Air Bus.

[@sundance2005]

I am a retired airline mechanic and at the airline I worked for no matter how big or small the job was if you open something there is a close out procedure before you close it and once you have it closed a final. Absurd that a panel (of any type) can be opened and no inspection(s) on closing. I am sure this is the result of unskilled management and mechanics(???) doing the work which to the downfall of the industry is common practice these days for vendors supplying the aviation industry.

[@russellhltn1396]

I suspect the issue is up at some higher level, it was decided that "opening a door" was no big deal and didn't require much follow up. That's understandable if we're talking about a normal door. But "opening a plug door" is different and it appears the rules/regs/software didn't take that into account.

[@ropersonline]

Your introductory line to this video is pure poetry.

[@sb859]

USAF maintenance had personnel at different levels; a 3-Level was an apprentice, basically learning on the job after tech school. The 5-Level did the job along with the 3-Level who was learning. Then a 7-Level would inspect the work and sign off on it. 9-Levels were overall Supervisors. The key ingredient was that expert 7-Level who was tasked with inspecting and signing off the work.

[@danharold3087]

Which would fall apart if the level 9 was told he had to reduce cost. Leaned on the 7 who responded by letting a few things slide. In a few years when the 3s become 7s you have Boeing. Yeah not that simple but it is part of it.

[@malcolm20091000]

Hmm, Levels 3, 5, 7 and 9. That's odd.

[@rianduplooy8453]

Sir, thank you for putting this content out. I am a GA pilot up in Canada. I have been aware of the poor quality control at Boeing, for the past 3-4 years. This is due to some whistle blowers that came forward a few years back, that spoke up about the lack of good quality control, due to out sourcing some sections of manufacturing of the fuselage. So it was just a matter of time before something pops up. I do think that the management at Boeing is accountable.

[@lordgarion514]

Things must be getting worse, because this is directly boeings fault, not the people they get parts from. Not only should the company be given serious fines, but there's at least one person in management that deserves prison time, and at least one lazy employee, that needs to be fired, who can't be bothered to put bolts back in after they take them out.

[@sethtenrec]

@@lordgarion514 it’s not the same employee putting them back that took them out, that’s part of the problem …communication (lack there of)

[@daveb2280]

Boeing started doing heavy out-sourcing work about ten years ago. Penny wise. Pound foolish.

[@lordgarion514]

@@daveb2280 The door, which was made by an outsourced company, was perfectly fine. In fact, it was so fine, that with no bolts holding it in, it made more successful flights than Boeing's capsule. 🤷‍♂️ It was the Boeing employees that put the plug in the hole, and was too stupid to understand that it needed bolts...... And I'm sure that idiot is an overpaid union member. Probably won't even get fired. Just a write up.

[@user-qr8ki8ue4i]

My dad 'early retired" from Boeing as a systems engineer back when MD and Boeing merged. As one of Boeing's 'top ten engineers' (a designation he was honored with) , he saw the writing on the wall when Boeing chose to put bean counters in charge. Edit to add: Mullaly tried to get my dad to go into management. He respected Mullaly, but told him politely to pound it.

[@WheepyUwU]

Bean counters 🤣 You're totally not wrong though

[@markfryer9880]

Your Dad called it right! Boeing today is nothing like his Boeing and it is definitely not for the better. 😢

[@saabpoppa]

That's a great in-depth analysis Juan. The lack of coordination between the two record keeping systems is the most enlightening part, and likely to be the real reason for this incredible failure to check something as simple as the installation of four bolts. The one-day safety stand down is eyewash, obviously, and the two companies need to work full speed to integrate their assembly and inspection tracking.

[@toddbroeker187]

Been a Boeing guy my whole life. Love the history of Boeing. Went to Las Vegas this weekend on a Airbus 321 Neo and flew home on a 737-900. Needless to say, I was more relaxed and at ease on the 321 than the 737. What a shame!

[@z31beck]

Did you like the part of the history when all their contracts for air mail were cancelled for fraud?

[@sawyersdad5292]

So as a Boeing guy why are people not doing the job? Not just in this instance, but in general. It has to be the guy on the line that didn't replace that bolt.

[@cherryjuice9946]

@@sawyersdad5292 The issue seems to be more complicated than that. They have a "process error". According to this video, they use a quality software system that didn't understand that the bolts needed to be checked or possibly even installed. It was no "single person" because the Boeing process dictates the work that needs to be done. What Spirit knew needed to be done was not recorded in the Boeing system because there is no coding for that. This type of error will be more and more common in the future. Management for the past 20 years thinks they can manage better or smarter, if they just come up with a "process". Software driven processes are a favorite of theirs, because they can tie that to performance measurements to know where the problems are, and make their little graphs for their morning meetings. Management loves to talk about things, and measure things, and come up with processes, but this simply removes from further from the real world. Rather than discussing man-hours, and planing processes, they should be out on the floor verifying that their processes really work correctly. I worked in tech for nearly 40 years, and am glad to be retired. It started getting silly, and more and more detached from reality. I know some folks will be upset with my next remark, but there are too many business majors on earth, and too many spread sheets that use numbers that were "gamed" to be the numbers they want to see rather than meaningful, but unpleasant, truthful numbers.

[@Airpaycheck]

I think Boeing stopped being Boeing when MD took over. The name was changed to protect the guilty. Kinda like what what USAir did to AA. Same colors, different airline.

[@COIcultist]

It's the guy on the line that doesn't do something, but it's a management function to prevent what would happen through normal human actions. Not knowing better but through tiredness or being distracted I've built things incorrectly. Generally no one dies though from a faulty turbocharger build. Over time things such as build boards are adopted to show you have used all the parts. Torque guns can have a use counter or steps can be interlocked, so you can't do process d in a series till you have done process c. Other than the release of dioxin in Italy in the 1970s and Flixborough (UK) nearly all big accidents occur on night shifts. If the big accidents happen on night shifts what do you think happens to the rate of small accidents? You want processes to catch prospective errors and well rested staff with adequate breaks and changes of task to stay alert. Anything less is a recipe for........

[@Crediblesport]

When I worked at Lockheed, every change to an airframe was photographed and documented '. We had photo books in every modification done to every airframe and the paperwork.

[@shaymcquaid]

I'm a 35+ year aviation mechanic. Last 15 years in manufacturing. The workforce gets exponentially less qualified every year. It's scary.

[@cgriebel1]

Right on. New hire shows up, goes thru a bullshit training process, gets a few things done during the day without too many questions, befriends his peers and the quality control guy, then grabs that paycheck on Friday...and shoots right to his dealer. Drug tests don't mean a thing these days, as there's a dozen ways to defeat these systems. Seen it too many times.

[@ohsweetmystery]

👍 It is happening everywhere, in every field.

[@marsthedude1]

@@cgriebel1 you've lost your mind. Drugs didn't do this and it's incredibly insulting to those blue collar workers to say it was. If you watched the video, you'd know this was a *management* decision to have asynchronous QA.

[@stewartsmith1947]

x10@@ohsweetmystery

[@ppsarrakis]

people dont have opportunies+time+money to get overqualified.

[@rl7487]

Wow sir. A&P mechanic and pilot. That’s commendable.

[@svm2020]

My concern is what else is out there that we don't know. It can't be just these four bolts making the entire aircraft fly safely at 35,000 feet!

[@Mantarr1]

It is frightening to think of the potential outcome if that door had of blown at 35,000 feet

[@AndyHullMcPenguin]

In reality, if there is more than one plug door, then its four bolts per door. This mess, is why safety processes need to be externally audited. As has been pointed out by smarter people than me, you can't have safety critical companies marking their own homework.

[@jonathanbott87]

Like the issues with the tiller linkage bolts or the mcas issues?

[@karmatraining]

Just a symptom of the disease. If they could get something so basic so wrong across so many planes, it's not just somebody having a bad day. It's systemic.

[@lisaa8795]

@svm2020 I'm with you. The NTSB spokesperson at the press conference I watched said in response to a similar concern, that they would broaden the scope of their investigation if they need to. I hope that's true!

[@Retr0racin]

I retired from that place after 35 years working there four years ago. Started on the wings then had some good connection and got a job as a tool room guy setting up power feed drills . I went to the 2nd shift and rode out my last few years there. I turned 62 today SS starts next month and they could not pay me enough to go back.

[@natural1952]

Also smart starting SS at 62. I did the same. I'm 71 now and no regrets.

[@snorttroll4379]

why start early?@@natural1952

[@mrkc10]

This is why I’m always anticipating Juan’s next video. His brutal honesty and telling it like it is in pilot speak is where the rubber meets the road. Best aviation accident/incident channel.

[@NicolaW72]

Yes, absolutely.

[@Rasscasse]

Good comment 👌

[@Graham_Wideman]

"where the rubber meets the road" -- perhaps you meant "where the angle of attack meets the atmosphere"?

[@SeekingTheLoveThatGodMeans7648]

What's a pilot going to say about a goof up like this, except that that stupid thing in the middle of my airplane that formed part of the passenger enclosure in the fuselage and was meant to help it keep the breathable pushy air in and people and things from fallling out wasn't installed right because idiots were in charge of it? This isn't even a case of flight control characteristics becoming abnormal. This is a sudden stupid hole in the airplane.

[@pademo57]

Great info. Wanted to get your opinion on what another captain said: 1) Rudder assemblies having missing bolts 2) according to a FAA bulletin if the engine auto de-ice remains on in clear air for more than 5 minutes the cowling assembly could break away from the airplane and possibly harming passengers. How in the world isn't the FAA complicit as well as Boeing?

[@MikeDudley-b4b]

Those final graphics deserve a replay in slo mo; they were ace as to explaining the door plug function. Thankyou Juan for the inclusion. Mike.

[@CharlesinGA]

Just stop the video about the point his Patreon logo appears and go tot the settings "gear" and click playback speed and pick 0.25 and then restart the video.

[@dtkincaid]

You do such a great job of explaining all of this, Juan. Thank you for keeping us all up to date.

[@pigdroppings]

Very nice animation by the big dollar NY times.

[@ktydeck]

Thanks for this Juan! My grandfather was employee number 9 at Stearman and retired as the assistant to the general manager of Boeing ICT. I am sure he is spinning many revolutions in his grave. What a pity... Sigh....

[@Ratlins9]

Thank you for your input and for making this video. This information isn’t readily available to the public. Your erudite knowledge in the field of aviation as well as your explanation of this incident is appreciated.

[@BamaRailfan]

As a trained A&P AND as someone who works in quality for a non aviation manufacturing company, it is ridiculous that this got overlooked.

[@RootedHat]

Ridiculous and reckless. The documentary on this whole shebang is going to be really interesting!

[@BigDukeX]

Late last year, end November if my recall is correct, there was a Southwest flight departing from SAN, San Diego International - for Hawaii. An Alaska flight was second for departure and reported to the Tower that... “a Door was Open” on the Southwest. Tower ATC reported this issue to the Southwest crew..., expecting them to pull off. However, the Southwest was already cleared, on the roll - and rotated. The pilot on the Alaska commented... “I’ve never seen that before”. The Alaska crew advised the Tower that they would contact the Southwest on the guard frequency after their take off. I found that the Southwest climbed to FL16, and maintained that level in a racetrack pattern just north of Camp Pendleton to sort things out. I also found that they diverted to LAX... 45 minutes later. Not certain just what door was open, but those guys on Alaska certainly were totally surprised at what they had just witnessed. Boeing airframes are making it into the news in a overwhelming bad way far too often these days.

[@DR_1_1]

Must have been a lower desk door, not for passengers...

[@DR_1_1]

BTW, a Delta plane lost a nose wheel at Atlanta airport 2 days ago...

[@richardgraham1167]

Boeing and Spirit need to operate within the same QA system ASAP. Thanks for this timely, clear and interesting plug door update.

[@vmpgsc]

It was just dumb in retrospect for Boeing to spin off their Wichita division as an independent sub. I guess being vertically integrated is only for crazy companies like SpaceX that don't bow down to Wall Street.

[@goratgo1970]

Immediately.

[@stevenf1678]

And sprit should never ship anything to boeing with known quality defects.

[@gordonmorrow]

I worked as a new hire engineer at Boeing in early 1980’s. Back then, company philosophy was to make everything possible in house. This meant optimum quality control but more expense. Soon, this changed and major components were outsourced to other companies, even overseas. I remember horror stories about entire wing sections arriving from a country shaped like a boot which in no way possible fit the fuselage hole pattern. My mentor once told me what MIL-TFD-1111 stood for: “make it like the f****ing drawing for once”. Another told me “Whenever humans build something, always over-design it for the inevitable screwups, because people don’t like it when airplanes fall out of the sky especially when they are in it.” Let’s not forget that the plane did land safely and no one died. So that’s impressive in itself. And lucky.

[@paulsherman51]

In the 1980's and 1990's "vertical integration" used to be the Holy Grail of pride, quality, loyalty, safety, and innovation. Looks like now we've gone limp.

[@TheKevo7777]

Definitely different times

[@alanburke9370]

our mil spec was MIL-TFP-41C

[@fireteamomega2343]

That was back when you had engineers passionate about making quality things. I remember a kid fresh out of a university master's in chemical I believe... cocky but didn't know $hit about applying anything to the real world. He got set up with a massive and new project which hadn't been done before. The team was having trouble with getting things to a production stage. So I was asked to help. I looked at his drawings and noticed that his tolerances added up over exceeded the overall. So I mentioned it and he got all butthurt and essentially told me to f off I know better. Ok so I went back to my own work. A month later the company I worked for hired a crew to assemble the project and put on a barbeque. I remember telling the senior machinist that it won't fit. Sure enough the last piece didn't fit 😂 After that he must've gotten it bad from management head down no more cocky $hit asking me questions all the time.

[@markhull5776]

This is tragic. When I was at TWA, we would bring them in on an OP-16/17 (basically a "D" Check), strip them bare and reassemble. We had strict QC with everything! We even did the aging aircraft 41 section mods on the 747 where the entire flight deck was stripped. Never had any kind of these issues. Something really bad happened to Boeing after the McDonnell acquisition. Sure not like back in the 727 days.

[@sanitman1488]

Yes the same here with Pan American 747 “D” checks. Never had issues like this but again we didn’t have this DEI nonsense. The Boeing of our day sure as heck isn’t what it is today. Greed destroyed this once great company.

[@michael931]

Harry Stonecipher happened.

[@AndreySloan_is_a_cnut]

@@michael931 - BINGO!!! At the end (not in the Douglas years, but certainly after they merged with McDonnell) MD became a garbage company that produced garbage. To install their management at Boeing and expect anything else was pure insanity. The entire C-suite and board all need to be replaced with actual aviation people (no bean counters) to try to right this floundering ship.

[@charleshaggard4341]

The problems seemed to have started when Boeing's Board of Directors decided to let the bean counters run the company instead of engineers. Their Headquarters is now outside of DC so that ought to tell something.

[@pamelah2152]

Same thing is happening in Healthcare...the bean counter mentality. Private Equity is destroying quality and driving up costs.

[@treimers95]

You forget that the Boards of all these Fortune 5000 companies ARE beancounters themselves..... ....we are headed into an increasingly incredibly dangerous world because of these beancounters and Wall Street calling the shots on everything from aviation to Big Pharma to maritime to transportation... All across the world, the focus is on "how do we get our stock dividend to go up this week" largely by devaluing human experience and knowledge as being "too expensive to pay for, surely we can do it with half the people and all of them just starting out, costing us less salary, and them (understandably) knowing less in their 20s for low(er) salaries than the experienced guys that got laid off for costing too much and complaining too much about quality and shortcuts. The beancounters are FAR more of a collective threat to humanity than any politicians are....

[@JDHitchman]

IMO, Boeing has been in decline since the 1997 merger with McDonnel-Douglas. Far too many MD executives were retained diluting Boeing management and the move of the Boeing HQ from Seattle to Chicago was a major mistake.

[@dwaynemcallister7231]

That's the truth!

[@daveautrey5858]

BS. McDonnel Douglas was a much better company quality wise. Boeing was a cheaper alternative. @@dwaynemcallister7231

[@WOFFY-qc9te]

Absolutely correct, Boeing started its decent before the ink was dry. The US allowed it to happen but continued the funding from the Fed for half baked projects with NASA. Such a shame.

[@LongIslandMopars]

​@@dwaynemcallister7231 I agree

[@lewisaveryfiler7087]

@JDHitchman At the time of the 1997 merger, only two members of the MDC Board of Directors were retained as members of the post merge Boeing Board of Directors. (John McDonnell and Harry Stonecipher) Those two were the two highest shareholders in the merged Boeing stock. Two former MDC Board members were also added to the post merge board. These were but four of thirteen total members of the post merge Board. Just a quick side note about Stonecipher. He was only at MDC for three years prior to the merge and right from the get go he was disliked among the MDC rank and file. Also, after the merge he only remained the head of Boeing for another three years and then retired. Although he did come out of retirement when Phill Condit was booted out. My point here is Jack Welch GE business model that he brought to MDC was as shocking to MDC as it was to the heritage Boeing folks post merge. His Jack Welch infected way of doing things was not the heritage MDC way of doing things. At the time of the merger, I am not aware of a single executive level manager (below Board of Director level), that had management authority over Boeing"s Seattle and Long Beach.commercial operatons. At the time, of the merger, and for quite some time thereafter, Phil Condit (a 35+ year Boeing engineering veteran had direct executive level management authority for all of Boeing's commercial operations in both Seattle and Long Beach. So I ask a serious and sincere question as I truly would like to understand if I am wrong. Just who other than Stonecipher were the "far too many MDC executives retained" that are responsible for the "decline"? Please name those other MDC executives. Again, I a not trolling you. Everyday is see comments that MDC executives are responsible, but nobody can ever name those executives. Besides Stoncipher, who are they? I truly would like to know the answer. LIST OF BOEING POST MERGE BOARD MEMBERS John H. Biggs, Chairman and Chief Executive, Teachers Insurance and Annuity Association-College Retirement Equities Fund John E. Bryson, Chairman and Chief Executive, Edison International and Southern California Edison Company Philip M. Condit, Chairman of the Board and Chief Executive Officer, The Boeing Company Kenneth M. Duberstein, Chairman and Chief Executive, The Duberstein Group John B. Fery, Retired Chairman and Chief Executive, Boise Cascade Corp. Paul E. Gray, Chairman of the Corporation, Massachusetts Institute of Technology John F. McDonnell, Retired Chairman, McDonnell Douglas Corp. Donald E. Petersen, Retired Chairman and Chief Executive, Ford Motor Company Charles M. Pigott, Chairman Emeritus, PACCAR Inc. Rozanne L. Ridgway, Former Assistant Secretary of State for Europe and Canada Harry C. Stonecipher, President and Chief Operating Officer, The Boeing Company George H. Weyerhaeuser, Chairman, Weyerhaeuser Company ****** Biggs, Duberstein, McDonnell and Stonecipher previously served on the McDonnell Douglas board of directors

[@peterjackson3646]

As usual very objective assessment…no headline drama! Thx for this

[@Chris11249]

"...gonna take a lot longer to un-screw than originally thought." You made me laugh out loud. Thanks for the great reporting.

[@Dhakajdnrnxndjdnr]

The Boeing story will be taught in business schools to show why short term profits are not always shareholder value.

[@NicolaW72]

Yes, indeed.

[@dave30076]

Big chart: Money saved by shortcuts in the QC process, versus money lost in total stock value. The second one will be MUCH larger than the first.

[@VanillaMacaron551]

Funny that Boeing is so into its own history and legend. The company produced a documentary in recent decades that runs for something like eight hours. Imagine how they'll try and airbrush the events of the past four years.

[@darkiee69]

Now for the big question: How many of those bolt assemblies could they have bought with the latest round of bonuses for the higher ups? And the most important thing now is to remove the "open" option for plug doors and always have them registered as removed since that is what you're doing. The Open option is for regular doors where you can either open them, or remove them.

[@xxwookey]

There is a difference in the procedures for 'open' and 'removed' even on the plug door. In the first one the straps remain in place and the plug door is not raised off the hinged bottom mounts. If removed there are some extra checks (re-install/check-already-installed the springs, reattach the straps). Maybe you can write it the same for both in terms of 'check this is present/attached. I'm not sure. But they are different procedures.

[@TrainDriver186]

There's a lot to be said for making processes consistent. A few more "if/then" options may be required, but it appears from outside that the process up to "open door plug" is identical whether opening or removing, and only a few extra steps required to make it "remove door plug". Likewise on re-installing and securing. One checklist, with some steps that can be deleted if door plug is not being removed from the aircraft. How many other "different only in semantics" processes could also be simplified to reduce the potential confusion and missed steps?

[@eduardodaquiljr9637]

Can you show the bolt larger?its difficult to digest what you are specifying if objects is too small.

[@pm1104]

This is the first clear explanation that I have seen regarding this issue…….THANK YOU JUAN FOR YOUR EXCELLENT REPORT!❤

[@2760ade]

Thanks for including the animation at the end. It shows clearly how the plug doors are secured and why this one failed to remain in place!

[@goratgo1970]

Talk about "THE GOLDEN BOLT" (those who did FOD walks in the USAF know that saying) yes a giant loophole in the Boeing inspection system, but as a mech. I still can't think of one item that doesn't require a QA inspection upon installation to get signed off. Especially one that gets covered up by a panel after. Thank you for the thorough update Juan!

[@-werksmith2078]

In my time on an Air Force flightline, any time a mechanic removes a panel it triggers a work inspection AND a panel inspection. Something not mentioned, where did the bolts go once removed? Didn't the seal repair order at the least specify replacing the cotter pins if not the bolts and nuts to complete the repair/modification? I suspect the order from engineering was not thorough. Then no one questioned it after.

[@jjsmallpiece9234]

When I was an aircraft engineer, for every job your recorded every task done on a maintenance job card. As a job progressed you left an 'open entry' if work was still required to be done. Until there was a new entry saying the job was complete, the maintenance controller would not close the job maintenance card to release the aircraft for flight.

[@ericdean4397]

As a former ICBM Miniute Man Missile Tech, in this career we were constantly taking pictures of everything we did to verify all works was completed in accordance of Air Forse Space Command AND all other partners technical data related to the Rocket. Lockwire used on just about every single bolt and fastener, even on cannon plugs for electrical connections. Perhaps Boeing needs to implement these practices into ALL avenues of the assembly of the Airplane.

[@rafaelcastillo2636]

Hello! In your experienced. Is it a fact, some launch or service codes are on "Floppy Disk" Wondering minds want to know. Thank You for your service.

[@HeronPoint2021]

With the advent of cell phones, I've been taking "job progress" photos on job sites for three decades now. Once we were sued three years after completion: contractor thought he did 300 grand worth of work (he had done this before) and sued Head Office for non-payment. The hard drive off of each site is secured in a safe: (or in the Cloud) When a job is covered/difficult to access photos of work completed are a no brainer. Even had several shots of a tree on site we were gtrying to save along the shot crete: it started leaning into the neighbours new garage; weekly photos showed the movement, and I caught it in time.

[@omgsrsly]

ICBM Minute Man Missile Tech has to be the coolest job title ever!

[@michaelkhoo5846]

It's beyond belief that they appear to have had incompatible data architectures behind their QA processes. Edit: How can they track the history, maintenance, status, dependencies, etc, of any component, and its relationships to any other component, if they are described differently in each system? - as you go on to explain.

[@misarthim6538]

I can understand that, but in that case they should never have allowed two different teams working on same airframe.

[@ColinWatters]

It's crazy that the QA inspections are different for door opening and door removal. It might be OK on a regular door but not a plug door.

[@bubba99009]

Not sure that the different software or teams was as much of a problem as Boeing just not setting up the correct inspection process in their software. Why is there even a separate "open" operation for a door plug when the only way you can take out a plug is to "remove' it? Why does the inspection not check the bolts when you have to remove the bolts to perform the work? It's bad QA processes at Boeing (which Spirit is following in Washington). Makes you wonder how much of a mess the rest of their inspections are. I would bet good money that the creation and setup of these procedures was offshored, just like the development of flight control software that killed hundreds of people.

[@misarthim6538]

@@bubba99009 My guess is that for standard door, there actually is a difference. Opening normal door is literally a different operation than fully removing a normal door. Whoever wrote / approved the SOP on this either didn't realize that plug door isn't actual door or they tried to cut corners by abusing the nomenclature. Must be investigated.

[@ColinWatters]

@@bubba99009 I think there are hinges at the bottom that allow the plug door to be opened without actually detaching completly from the airframe... but all the bolts have to be removed just the same.

[@jonahansen]

This is an error in the safety CMES system. It's like a bug in a computer program. Whenever the bolts are removed, there should be a quality check that they have been re-installed. The CMES does not ensure this - if the door is only "opened", the bolts are removed, but there is no requirement that they be inspected to ensure that they have been re-installed as there is when the door is "removed". So ultimately this should be laid at the feet of the safety engineers who write the CMES procedures and their managers at Boeing.

[@MontanaMedic13]

If after the original 737 Max 2 years of grounding they couldn't turn things around then why would it be any different now. The other "safety escapes" won't show up for years until there are more incidents. If there are loose rudder bolts and door plug bolts then you can guarantee that there are countless other issues that simply haven't presented themselves yet. You can't just have an inspection and call it good, now you have to doubt all aspects of assembly and many of those things can only be truly visualized and quality checked as it is being assembled, not after delivery. So frustrating to watch a great American company like Boeing focus so much on stock holders that profit overrides quality and safety.

[@ron9381]

Boeing’s plan on selling production to private contractors is so they can get out of the existing union contracts that did not allow them to fire people with seniority. What they were in fact able to do is piss the union labor off which is causing this poor quality. The management was not looking after stock holder equity. management plan was to get a big bonus and run with the cash and leave the stockholders holding the bag and that’s in fact what has happened since 2017.

[@MRFLAPPYTREE]

I work for Collins Aerospace, admittedly i dont work on planes but i work on computer equipment that goes in the cockpits. But i work to the same standards that are needed for aviation and I honestly can't believe something like this wouldn't have been caught by someone. Guarantee some builder mentioned that issue and it got lost in the BS of corporate offices.

[@istudios225]

Remember what the Oceangate CEO (no less) said about his own Titan sub?? "You know, at some point, safety just is pure waste. I mean, if you just want to be safe, don't get out of bed....." ~ the late Stockton Rush

[@JoshuaTootell]

I'm also a Collins guy (wait, are we Collins? Raytheon? UTC? I'm confused). While there is a lot I don't like about working here, the quality of the parts we send out isn't one of them. From what I can tell working here, our stuff is 100% high quality American manufacturing.

[@snorttroll4379]

a question. I want to acquire businesses and build something like utc. Any tips for getting to buy some of the rtx assets? also What are a few words of wisdom you have in regard to manufacturing.1. life in general.2. and thirdly about acquisitions and performance in business. getting the stuff done? also would you please check out the researcher aubrey de grey? working on worlds most important problem these days.@@JoshuaTootell

[@cremebrulee4759]

Thanks for the information, Juan. It doesn't matter that they just "opened" the door plug and didn't "remove" it. If the bolts that secure the door to the fuselage have to be removed to open the door, there has to be a verification that the bolts were replaced properly. To not do so is absolutely unacceptable. It is illogical and indicates a lack of concern about ensuring passenger safety. Disgusting. Boeing and Spirit bith need a thorough and honest quality audit. This can't be the only hole in their quality systems. It's only a matter of time until something else fails.

[@carlosoruna7174]

Seems to me Spirit is being set up by Boeing to take the fall..

[@markeaton6435]

As a retired tech with Lockheed Martin, I have seen the pressure to remove QA steps in the manufacturing\delivery process. At least we were also under the watchful eye of DCMA (at least on the flight line), since our product was strictly military.

[@fireteamomega2343]

As a machinist it used to be you bug off your own work then it routes to inspection. Inspection pretty much followed every process of the work order. Redundancy redundancy because we're dealing with aircraft.

[@ashkebora7262]

The "quality escapement" actually happened over the last twenty years with Boeing getting rid of their quality engineers.

[@samuelfielder]

Blancolirio suggests this is a communication problem between Spirit's SAT system and Boeing's CMES system, but I wonder if it is more a semantic problem. Opening a door didn't require reporting; removing a door did. This distinction seems pretty sensible in nearly all cases: you can open a door using its hinges without undoing anything, whereas removing a door requires undoing something. However, in this particular case of a plug door, you can't open it without undoing something. So the problem could be a failure to realise that the standard open/remove distinction does not apply in this special case.

[@ericdage]

Or, there is a cost to Spirit when a supplier discrepency triggers an inspection by Boeing.

[@Tarektheinhaler]

It’s just greed that led to this.

[@jeffburrell7648]

I disagree that this is just greed. The OP has a good point and until I saw the Times animation I was confused about what caused the issue. It is obvious to me that coding for opening this door on a 737 MAX 9 should be the same as for removing it. Then engineers and quality people who set up the quality system for this aircraft either did not know or forgot this should be done. Had they compared the quality system against the work instructions and an FMEA for the door, it should have been evident there was a problem.

[@shadowopsairman1583]

This door plug should have been a writeup regardless, its not a door at all but a panel and should be counted under ATA Code 53

[@davidtuer5825]

From what I read, opening the door plug and removing it is the same operation.

[@robertphillips2983]

Great job Juan, yes this really is a quality system problem. The Q.A. planners were asleep at the wheel, to not have an inspect op. red-inked into the planning documents (physical or electronic) to check for proper re-installation of the door. But more than that, from a Quality Assurance / Continuous Improvement perspective if you allow chronic escapes from your sub-tier supplier, allowing them to be constantly fixed at your plant, not only are you accepting inefficiency as the norm (what I call an embedded rework), you are also inviting the laws of probability to come and bite you in the ****!! The Quality Assurance group at Boeing, all the way up to the senior level, are looking pretty shabby over this incident. Such a shame.

[@kenbrown2808]

I worked for a company where nearly every project involved me following other workers and fixing their shortcuts. there was finally a conversation with my wife regarding whether we would go with a Harley Davidson and antidepressants, or a plan to fire that company. I don't have a Harley, but I'm okay with that.

[@Flakfire]

nailed it.

[@blahblahblah23424]

Absolutely this. Routine rework being necessary or accepted in the first place is *always* a sign of an insufficient quality culture.

[@mbvoelker8448]

Right. You can't enable shoddy work and expect anything to ever change. You have to refuse detective products at the door at the suppliers expense. A sewing factory I worked in did that. It took a month of brutal 60 hour weeks to make up the shortfall, but subsequent shipments had a negligible failure rate.

[@kpetro1675]

What you don't understand is Boeing has no problem they're meeting their DEI quota, which is what's important to their investors.