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3 month old 737-9 Max depressurisation incident

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najaB

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Thanks.

Simply Flying has reported that N704AL is being returned to Boeing. Alaska Airlines is going to take a 737-Max 10 in compensation. Covered in this video:

It will be interesting to see what Boeing does with the airframe - they could try to sell it to another operator, use it as a test frame, or scrap it. If they go down the latter route it'll be one of the shortest-lived 737s in terms of flight hours.
 
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YorkRailFan

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The NTSB has been holding a hearing regarding the door blowout on AS 1282.
Testifying on 7 August, Boeing senior vice-president of quality Elizabeth Lund told investigators that following the 5 January accident Boeing transferred “two employees who were likely involved in the opening of the plug” off the production floor. Those workers have since, at their request, been placed on administrative leave.

However, Lund clarifies Boeing has not fully confirmed which employees were responsible for opening the plug, or exactly when they opened it.
Embarrassing that Boeing still has not confirmed which employees were responsible, it's over 6 months since the incident.
The National Transportation Safety Board’s (NTSB) ongoing hearing into the January in-flight failure of a Boeing 737 Max 9’s door plug has highlighted problems at Boeing’s Renton site, including concerns about employee training and pressure to complete work.

But testimony also reveals that many workers still view the culture at Renton as positive, citing a work environment characterised by teamwork, collaboration and dedication to safety.

That mixed picture came into view during a 7-8 August NTSB hearing in Washington, DC, part of the agency’s investigation into how and why Boeing in October 2023 delivered to Alaska Airlines a Max 9 with an unsecured left-side mid-cabin door plug. During the two-day hearing, NTSB investigators questioned executives from Boeing and its top supplier Spirit AeroSystems, seeking information about what went wrong.

As the hearing opened, the NTSB released transcriptions of interviews held with numerous Boeing factory workers in Renton. Some workers painted a positive picture of the site’s culture.

“Everybody makes it feel comfortable here,” one line worker said. “Everybody helps out each other, and gives pointers to each other.” “We all take pride,” said another. “These planes carry people… I fly. My family flies.”

Others expressed concerns, citing perceived pressure to complete work quickly, training deficiencies and the inexperience of many new employees hired by Boeing in recent years.

Boeing has insisted it has significantly strengthened its training regiment, including by beefing up both on-the-job instruction and the “foundational” training it provides to all new employees. “It’s just push-push-push, push-push-push, push-push-push,” one worker told investigators.

“I just feel like the levels of knowledge and experience that we have differs, and I think that’s the hugest factor when it comes to how everyone operates,” said another.

Boeing has already taken responsibility for the 5 January door-plug failure, saying that during the jet’s assembly workers in Renton failed to install four bolts intended to secure the plug. But the oversight is more complicated. Boeing rarely needs to remove door plugs during assembly, as the plugs arrive already installed in fuselages supplied by Spirit.

After the Alaska jet’s fuselage arrived at Renton on 31 August last year, Boeing discovered it contained five defective rivets. Spirit needed to fix the rivets, but to complete the work Boeing needed to remove the plug, which it did on 19 September. Critically, Boeing’s workers failed to document the removal.

With the rivet rework complete, a Boeing “move crew” on 19 September closed the jet’s doors – including the plug – and moved the aircraft outside the factory in preparation for delivery.
Even if training was inadequate, it raises the question why QC still didn't catch errors made. It doesn't matter whether workers were adequately trained or not, QC has no excuse to hide behind after failing to catch errors.
The head of the National Transportation Safety Board said on Wednesday the Alaska Airlines (ALK.N), opens new tab Boeing (BA.N), opens new tab 737 MAX 9 mid-air emergency, opens new tab was entirely avoidable because the planemaker should have addressed unauthorized production work long ago.
"This accident should have never happened. This should have been caught years before," NTSB Chair Jennifer Homendy told reporters on the second day of a hearing into the Jan. 5 incidentin which a panel blew off an Alaska Airlines flight after takeoff from Portland, Oregon."There have been numerous, numerous Boeing audits, FAA audits, compliance reviews, compliance actions plans, noting a history of an unauthorized work, unauthorized removals," she added.
Federal Aviation Administration official Brian Knaup said at the hearing the agency has found additional issues with unauthorized removals by Boeing. "We have an open enforcement action around removals," Knaup said, adding the FAA has increased investigations of hotline and whistleblower reports.He defended the FAA's oversight of Boeing before the accident. "We believe we conducted effective oversight," Knaup said, but conceded it was better since the accident. "Safety culture isn't a compliance thing."
He said the FAA has increased unannounced audits and acquired dedicated space for personnel at Boeing's 737 factory and at supplier Spirit AeroSystems (SPR.N), opens new tab, which Boeing is in the process of acquiring.The NTSB's Homendy added there was no guarantee the door panel issue would not occur again.
Boeing created no paperwork for the removal of the 737 MAX 9 door plug - a piece of metal shaped like a door covering an unused emergency exit - or its re-installation during production, and still does not know what employees were involved. The plug was missing four key bolts when it was delivered to Alaska Airlines, NTSB has said.Boeing did not immediately comment.
If Boeing had learned from prior unauthorized work, "then this would have been caught and this would have been prevented," Homendy said, adding the board was also scrutinizing FAA oversight of Boeing.
"We have a lot of questions -- there was information known," Homendy said about FAA oversight of Boeing, citing defects, missing and incorrect documents, as well as incorrect policies that "have been issues for years. This is not new."

This is the NTSB not just having a dig at Boeing, but also the FAA for not stopping incorrect work practices at Boeing, despite the crashes of 2 737-8 aircraft a few years ago.

Boeing Co. is redesigning the fuselage component that blew out of a nearly new 737 Max 9 aircraft mid-flight in January, as the planemaker seeks to draw lessons from the accident that has thrown it into crisis.

The company revealed the plan during a day-long hearing with the US National Transportation Safety Board, which grilled executives from Boeing and supplier Spirit AeroSystems Inc. about their safety and manufacturing culture. Boeing said engineers are working on design changes that would prevent the so-called door plug from being closed until it’s firmly secured, after the NTSB found the element hadn’t been properly reinserted and was missing bolts to hold it down.

Now this intrigues and confuses me, as discussed near the beginning of this thread, the design of the door plug was not the reason for the blowout, it was the fact that the 4 bolts needed to keep the door plug fastened to the aircraft were never installed. The 737-900ER has used the same door plug design for years and never had any problems. Also, why is Boeing doing this work? The door plug in question was designed and built by Honeywell Grimes, not Boeing.
 
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YorkRailFan

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Designed and built by Honeywell, but installed by either Spirit or Boeing, no?
By Spirit. As I said, nothing wrong with Honeywell's design of the plug.

The NTSB has released details of an interview held with 4 Flight Attendants onboard AS 1282:
As Alaska Flight 1282 landed in Portland, flight attendants were finally able to ask passengers the question that had been wracking them since they first heard a loud boom aboard the Boeing 737 MAX: Had anyone been seated next to what was now a gaping hole in the side of the plane?

The passengers didn’t understand the question, so a flight attendant asked again, more pointedly — had anyone been ejected from the airplane?

“At the point where I first saw the hole, I saw five empty seats,” a flight attendant told National Transportation Safety Board investigators a few days after the Jan. 5 incident. “So I was absolutely certain that we had lost people out of the hole and that we had casualties.”Fresh details of the terrifying ordeal were outlined in NTSB documents released this week before the agency’s hearings looking at what occurred on the Jan. 5 Alaska Air flight, when a wrongly installed panel blew out of the Boeing plane as it climbed out of Portland.Among the cache of thousands of pages are interview transcripts with the four Alaska flight attendants. In hourslong interviews, the attendants detailed the chaos after the explosive decompression, their interactions with passengers —including a screaming mother and an unaccompanied 5-year-old on his first flight — and the horrifying uncertainty of not knowing whether any passengers had been lost or if the pilots were even alive.The start of the flight to Ontario, Calif., had been uneventful, they recalled. Passengers seemed to be in good moods as they found their seats; the 5-year-old boy was the very last to board and was seated with two brothers who were also unaccompanied minors. A flight attendant noted passengers paid attention to the safety briefing.

As the plane climbed through 16,000 feet, two flight attendants in the back chatted idly while one enjoyed the M&Ms a passenger had gifted to the crew. Then an explosion, described first as a hiss then like a cannon. The overhead masks fell and the lights came on.

“It was like an eternity of just disbelief,” one flight attendant said.

A flight attendant got up and looked down the aisle, not realizing there was a hole – until they saw a woman’s hair flapping in the wind. Her colleague became emotional, saying “we lost passengers, we lost passengers out the window.”The scenario had happened before: In 1989, nine passengers on United Airlines Flight 811 were killed when they thrown out of a hole caused by a cargo door bursting at 23,000 feet. The Boeing 747 was about 20 minutes into the flight from Honolulu en route to New Zealand.

“I remember just telling him, ‘We can’t think about that right now, we have all these passengers we have to take care of,’” the flight attendant recalled. They were especially concerned about the unaccompanied minors and lap babies, whose faces were too small for the oxygen masks.The front flight attendants were also assisting passengers and trying unsuccessfully to communicate with the pilots. The wind was so loud that they couldn’t hear anything. It was incredibly hot – one attendant said it felt like her makeup was melting, another in the back compared it to boarding an old aircraft in Mexico with no air conditioning. They were told later the heat may have been caused by exhaust coming in through the hole.

All four moved throughout the plane, even when they weren’t sure it was safe for them to be out of their seats. Without a portable mask, one flight attendant tried to “monkey bar” from mask to mask like they had been taught in training to get to the 5-year-old, but the masks were so tangled they opted to go without a mask.

“We had to just use our own intuition and that involved taking a risk, it involved us saying ‘is it safe for us to get up?’ We don’t know,” one said.“What we know is there’s a tiny little boy who might need oxygen and so we were motivated to just, I guess, put that individual’s safety above ours in the moment because we just didn’t know what else to do.”

Right before they arrived back at the Portland airport gate, a flight attendant ran toward the row where the hole was and yelled: “Is everybody here, Do we have everybody here?” As they went through the different sections, each passenger said yes. The flight attendant gave a thumbs up to their colleagues in the front.Flight attendants later learned the two closest seats hadn’t been occupied — a rarity since passengers often moved to sit in window seats.“Those two seats were empty even though I’m sure there would’ve been somebody who would have preferred not to be in a center seat and would have happily taken a window seat,” the flight attendant said. “Thank God they didn’t.”One flight attendant noted the scenarios that could have led to a far worse outcome in the plane: The passenger in the aisle seat didn’t unbuckle their seat belt and lay down, like a lot of people do. There wasn’t a child sitting on someone’s lap next to the window. A flight attendant hadn’t yet started walking to the back of the cabin to begin beverage service.

“We got so lucky,” the flight attendant said.

Toward the end of their interview, a flight attendant said they didn’t feel safe getting on a Boeing MAX again, and had a question of their own:

“When this is all said and done, investigations are over … how can we know this is not going to happen again and this is safe?” they said. “Because that should not have happened.”

A harrowing experience.
 
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edwin_m

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Designed and built by Honeywell, but installed by either Spirit or Boeing, no?
Possibly the re-design will make it so it's obvious if the bolts aren't fitted, for example the door might not stay in position unless they are.
 

jon0844

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Thanks.

Simply Flying has reported that N704AL is being returned to Boeing. Alaska Airlines is going to take a 737-Max 10 in compensation. Covered in this video:

It will be interesting to see what Boeing does with the airframe - they could try to sell it to another operator, use it as a test frame, or scrap it. If they go down the latter route it'll be one of the shortest-lived 737s in terms of flight hours.

Do like Amazon and just sell it again as 'nearly new'? :smile:
 

YorkRailFan

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One of the pilots onboard AS1282 has spoken about her experience of being in the cockpit on that flight.
Emily Wiprud didn’t know exactly what had happened, but the Alaska Airlines pilot was certain something was going very wrong as flight 1282 made its way out of Portland on January 5.

"The first indication was an explosion in my ears and then a whoosh of air," Wiprud, an Alaska Airles pilot, told CBS News of the flight.
All the pilots knew was that an explosive decompression must have taken place onboard.
In the chaos, during which the Boeing 737 Max 9 jet lost a large panel called a door plug, her headset went flying out of the aircraft, as did some passengers’ mobile phones. She looked around and saw “empty seats and injuries” and feared some of the passengers had been thrown out of the plane too.
It is a miracle that the two seats closest to the door plug were unoccupied on that flight.
Wiprud said she recalls looking down the aisle of the plane and seeing rows of passengers stare back at her, some of them injured.

"I didn’t know that there was a hole in the airplane until we landed," she added. "I knew something was catastrophically wrong."
All the crew onboard acted extremely professionally, their actions will not be forgotten.
 

YorkRailFan

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Some key points from the Head of the FAA's Testimony to the Senate Subcommittee:
"Given the depth and history of Boeing’s safety deficiencies, its lack of candor with the FAA, and the agency’s reactive regulatory posture, the newly released information raises questions about the effectiveness of the FAA’s oversight of the company," the committee said.

The FAA did not comment but Whitaker said at a House hearing Tuesday that Boeing needed to undertake significant safety culture improvements that might not be completed for years.

This all goes back to when the FAA allowed Boeing to effectively self-certify aircraft, which lead to the two MAX crashes. A string on acting administrators at the FAA didn't help matters following this, which lead to decreased scrutiny prior to the blowout on AS 1282.

The Department of Transportation has published a report that was commissioned following AS 1282, about how the FAA has dealt with production issues Boeing has had with the 737 MAX and 787:
The report overall concludes that the FAA has not adequately assessed a production system as vast and intricate as Boeing's. The Inspector General found that "FAA's approach to overseeing Boeing manufacturing and production does not use data-driven assessments to target audits."The report found that 15 of 34 allegations of undue pressure the review team checked remained unresolved by the FAA for more than a year. Further, two of these cases have been open for more than two years.

The document also revealed that the FAA has not adequately ensured that the American plane maker and its suppliers can produce parts that conform to the approved design. It stated:

"FAA does not require its inspectors to review First Article Inspections that are intended to ensure a manufacturer's processes can, at the outset, produce parts that meet engineering and design requirements."In addition, the report stated that the FAA's compliance system cannot track milestones or identify if there have been repeated compliance issues. Additionally, the FAA has not evaluated the effectiveness of Boeing's Safety Management System.

In response to the 40-page document, a Boeing spokesperson told The Seattle Times:"We continue to engage transparently with regulators and other stakeholders to improve quality and safety and regain the trust of the flying public. Our plan emphasizes workforce training, simplifying manufacturing plans, eliminating defects, strengthening our safety and quality culture, and monitoring the health of our entire production system, including with suppliers."
The Report has also published several recommendations:
The document included 16 recommendations for the FAA to improve its oversight of Boeing aircraft production. The recommendations included developing and implementing guidance for inspectors on assessing risks in Boeing manufacturing facilities and creating a structured oversight approach for planning and conducting audits to ensure a comprehensive evaluation of Boeing's production.Additionally, the review recommended evaluating the Aircraft Certification Audit Information System to ensure it meets inspectors' needs, clarify FAA Order 8120.23A for defining findings, and update guidance to require inspectors to assess Boeing’s risk evaluations of suppliers, integrating these assessments into FAA audit planning.

It has long been known that the FAA has a staff shortage and has its resources stretched, meaning this news doesn't come as a surprise.

The FAA is starting another three month review into Boeing:
The Federal Aviation Administration (FAA) said on Friday it will open a three-month review of Boeing’s compliance with safety regulations, continuing the agency’s closer oversight of the company since a panel blew off a Boeing jetliner during an Alaska Airlines flight in January.

The FAA said its review will examine key areas of safety processes at Boeing to make sure that they “result in timely, accurate safety-related information for FAA use”.

An FAA spokesperson said the review was not triggered by any particular event or concern but rather is part of the FAA’s oversight of safety culture at the huge aircraft maker.

Boeing did not comment immediately on the new review.

The FAA administrator, Mike Whitaker, has ordered special audits of Boeing and other steps to examine the safety culture at the company since a panel called a door plug blew off a 737 Max during the Alaska Airlines flight.

A good, sensible move. It will be very interesting to see what they find, probably concerning too.
 
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