Alaska 1282 isn’t a “737 MAX” story; it’s about quality assurance at Boeing or Spirit

Update: The Federal Aviation Administration today notified Boeing it is under investigation for potentially failing to ensure the door plug was properly installed.

By Scott Hamilton

Jan. 11, 2024, © Leeham News: Alaska Airlines Flight 1282’s (AS 1282) decompression last Friday on a Boeing 737-9 MAX understandably brought new focus and doubts about the MAX program.

The MAX was grounded by the Federal Aviation Administration for 21 months after the March 2019 crash of an Ethiopian Airlines 737-8 MAX. This followed an October 2018 crash of a Lion Air MAX 8 under similar flight conditions. The two accidents were traced to the root cause of a mis-designed Maneuvering Characteristics Augmentation System, or MCAS.

Note: This data is based on October 2023 information. Full year 2023 data is not available at this writing.

When a door plug for an inactive emergency exit blew out of AS 1282 at 16,000 ft minutes after departure from Portland (OR), it meant trouble for Boeing and confidence in the MAX. Fortunately, no fatalities and only a few minor injuries resulted from the decompression. The flight returned to Portland and landed safely.

Alaska grounded its fleet of 65 MAX 9s within hours. United Airlines followed the next day. It has more MAX 9s—79—than any other airline. Shortly after United’s action, the FAA made it mandatory: the MAX 9s would remain grounded until inspections and fixes, if required, could be completed. A few other international airlines followed suit.

But as information emerged through Tuesday of this week, it became clear that this story is not a “MAX” story. It’s a story about quality assurance at Boeing or Spirit AeroSystems, the maker of the 737 fuselages and the plug door.

Series of quality assurance issues

There have been a series of quality assurance issues in recent months at Boeing and Spirit. Quality assurance is also known as quality control and, in Boeing-speak, “quality escapes” or “quality escapage.” In shorthand, these terms are “defects” in manufacturing or final assembly. A missing bolt on the 737 rudder was discovered last month. Mis-drilled holes by Spirit on the after pressure bulkhead on the 737 was discovered before that. And now, loose or missing bolts on the door plug appear to be responsible for its separation from AS 1282.

The National Transportation Safety Board (NTSB) hasn’t mentioned it, but an additional element of its investigation likely will include checking the bolt manufacturer to see if there were any defects in the manufacture of the bolts. The bolts on the Alaska door are missing. The NTSB doesn’t know, yet, if these were installed—or were loose and fell out, allowing the door plug to shift in its mountings and separate from the plane.

News reports indicate that Spirit ships the fuselages with the bolts loose in the door plug so Boeing can open the plug during final assembly. If this is standard procedure, which has not been confirmed as far as LNA can determine, then Boeing’s process was flawed because personnel didn’t properly secure the bolts during final assembly. Boeing CEO David Calhoun said in an employee meeting that Boeing must own its mistake—but he wasn’t specific in the short video publicly released just what this mistake was.

Boeing has a detailed inspection process. LNA outlined this process Monday in the Related Article below.

Related Article

Aircraft remain grounded

Meantime, the Alaska and United aircraft remain grounded. Alaska announced cancellations at least through Saturday. United announced cancellations at least through today. These are likely to be extended. FAA approval of Boeing’s recommended inspection-and-repair process has been slow coming.

New MAX 9 deliveries are halted. According to data from Cirium, there were six scheduled for delivery this month—three to Alaska and one each to Copa, Greater Bay Airlines (Hong Kong), and Corendon Dutch Airlines. Two are scheduled for delivery to Greater Bay and Alaska in February.

There are 30 MAX 9s scheduled for delivery this year, according to Cirium data from October. Alaska is due to receive 19 of these.

Air Wars details the launch of the MAX

Some Boeing critics and the uninformed suggest that the door plug is a remnant of the 1997 merger with McDonnell Douglas Corp. and that MDC-inspired cost-cutting led to the door plug design. Some others suggest the same cost-cutting culture is responsible for launching the MAX.

Both of these theses are wrong, fundamentally because this is a quality control issue and not an airplane issue like the MCAS design. But on the facts, the origination of the MAX was a parallel design study against a new airplane design during the years leading up to the July 2011 launch of the MAX.

The full, inside story of the MAX development is told in Air Wars, The Global Combat Between Airbus and Boeing. Interviews with key Airbus and Boeing people explain how Airbus maneuvered Boeing into launching a re-engined 737 model (the MAX) instead of proceeding with an all-new airplane design. The Boeing side also explains that airlines wanted a quicker solution than afforded by a new design. Finally, Boeing couldn’t figure out how to quickly ramp up production to the high rates needed to replace the 737.

122 Comments on “Alaska 1282 isn’t a “737 MAX” story; it’s about quality assurance at Boeing or Spirit

  1. It’s been widely reported that both UA and AS have found numerous “loose bolts” during their inspections of the grounded 737-9s. It’s not clear which bolts they’re referring to.

    The FAA has asked Boeing to re-do their inspection instructions and procedure after ‘feedback’ from both UA and AS.

    It’s looking like these planes could be grounded for a while yet. While possibly not related to the AS plug separation, the “loose bolts” and Boeing’s admission of “quality escapes” may yet see further inspections required by all MAX customers.

    • are these still endemic quality assurance failures
      or is it a pandemic decimating Boeing’s shareholder value?

      “quality escape” is NewSpeak vocabulary.

    • The problem with widely reported is its often wrong.

      It probably is not true in this case but I have long learned we need to stand by for real information.

      Logic says they would not use different process on a MAX with a Exit Block vs non as it disrupts the process to do different things on different hulls including -9 hulls that do not have that feature, though that can be wrong as well.

      Stay tuned for real information

      • Probably not true? Both United and Alaska made statements to the press.

        Ha ha, you can deny as much as you want, but United now up to 15 737-9s with loose bolts.

        There’s a reason the FAA is now investigating Boeing.

    • Let’s not forget the emphasis at Boeing (ie. SEC submission for 2022) on the cancer called DEI. No more hiring of the “best and brightest).

  2. On the face of it, manufacturing planes (while complex machines) is a simple 3-step process.

    1 – Build the plane to specifications.
    2 – Check and confirm that 1) was completed satisfactorily.
    3 – Document steps 1) & 2)

    Boeing seems to be failing at all three steps. Sadly, this isn’t a one-off issue for Boeing, just the latest in a long line of “quality escapes”.

  3. I suggest more attention be paid to number 3 of Deming principles

    W. Edwards Deming’s 14 Points

    Create constancy of purpose for improving products and services.
    Adopt the new philosophy.
    —->>> Cease dependence on inspection to achieve quality. <<<—
    End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier.
    Improve constantly and forever every process for planning, production and service.
    Institute training on the job.
    Adopt and institute leadership.
    Drive out fear.
    Break down barriers between staff areas.
    Eliminate slogans, exhortations and targets for the workforce.
    Eliminate numerical quotas for the workforce and numerical goals for management.
    Remove barriers that rob people of pride of workmanship, and eliminate the annual rating or merit system.
    Institute a vigorous program of education and self-improvement for everyone.
    Put everybody in the company to work accomplishing the transformation.

    These total quality management principles can be put into place by any organization to more effectively implement total quality management. As a total quality management philosophy, Dr. Deming’s work is foundational to TQM and its successor, quality management systems.

    decades ago Boeing invited Deming- seminars to supervisors were given with viewfoils
    A year or so later- Deming came back- dog and pony show by Boeing as to ' how well' we did.

    Deming finally commented to the effect ' didn't understand what I taught '-
    Never invited back

    BTW if japan had saints- Deming would be at the top tier

    Thats how Toyota became a world leader.

    • Deming’s principles were the foundation of the “quality” culture that made Japanese manufacturing so formidable in the 80’s and 90’s. As I read the principles now, they are exactly the opposite of Boeing’s culture.

      Scott says the Alaska door plug is not a culture problem. Perhaps not.

      But given the Alaska door plug, and the loose bolts on other airplanes, and the documented complaints of manufacturing problems in the months leading up to the plug emergency, we have a systemic quality issue in the context of a cost-cutting leadership message.

      Isn’t that exactly what a culture problem is?

      Certainly, Calhoun’s speech to workers left me with the impression that he doesn’t understand manufacturing, doesn’t understand how his leadership message is heard in the workplace, and he certainly doesn’t understand what Boeing needs to do, to regain the trust of airline customers and the public.

      • Yea Stan- I know him fairly well A few years Before and after I retired we’ve had several conversations about Boeing and SPEEA issues.

        He knoweth of what he speaks re BA kulture before the sellout
        and some after. Dan Hartley was also a good friend :))

    • Boeing has acquired all 7 of the following diseases on the courtesy of
      Jack Welch-GE- interns still in charge
      Per Deming

      The “Seven Deadly Diseases” include:

      Lack of constancy of purpose
      Emphasis on short-term profits
      Evaluation by performance, merit rating, or annual review of performance
      Mobility of management
      Running a company on visible figures alone
      Excessive medical costs
      Excessive costs of warranty, fueled by lawyers who work for contingency fees

      And no vaccine in sight

      • I think GE Aerospace was pretty well balanced, the rest of GE not so as buying/selling/closing businesses a bit of random both during and after Jack. Investors told GE back then just to focus on GE Capital and sell off all industrial business. Had they listened would GE be history now. Still danger to have GE HQ messing with GE Engines instead of leaving it to Evendale and just collect the money afterwards.

  4. What’s the warranty on these planes? Can Alaska and United collect lost revenue from Boeing?

    • Boeing will compensate them, but it is usually paid in cheap future services & discounts on new aircraft

    • Yes the same door is currently in operation on 737-900ER planes and has been since I believe 2006. I am not sure how many are in operation but as far as I am aware its the exact same design.

      • It is a systemic issue.

        Those 737-900ER where produced under a less deteriorated environment. probably.

        900ER :: last deliveries in 2019 and inside a multi year continuous production environment.

        • One would think that all 737-900 / -900ER’s in operation (lots of them at Alaska, United and Delta) would have gone through one if not more “C” checks by now which usually involves removal of the interior and inspection of the airframe. Seems to me chances are very small that the same issue could still happen on aircraft that are 4+ years old and have undergone 1 or more “C” checks. However, who knows what the FAA will do, they may go way overboard trying to exercise CYA mentality and seek to include -900 / -900ER’s in the mix.

          • Many are less than 2 years old- this one was only a few months old.

          • would the info of finding loose bolts on regular airframe inspections under airline control
            have been pushed back upstream into manufacturing?

            I know of this happening in the automobile domain.

  5. If I’m not mistaken, the door type plug on the MAX-9 is the same design as the 739ER and FAA haven’t grounded those, so as Scott says, it’s not a “737 MAX” story, it IS a quality issue that is related to BOEING not seeming to be able to get back to making quality airplanes.

    Is it going to take another hull loss with all PAX before things change.

    It’s simple, make quality airplanes and you make money, at this point another hull loss very likely will lead to the break up of BA, that won’t please the shareholders now will it?

    The door plug fell out (aided by the springs that push it up) and much is being made of PAX potentially being sucked out of the aircraft … think about what might have happened if the door plug had hit the horizontal stabilizer … the door plug isn’t very aerodynamic, it was pure luck that the airflow didn’t flip it right into the stabilizer.

    1981 Dan-Air 240

    Time for something bolder, BA just can’t afford any more loose or missing bolts, no more holes drilled in the wrong places, no more debris, metal shavings, ladders, strings of lights in tails of Dreamliners …

    I can’t believe I’ve written that “ladders & strings of lights in the tail” … time to wake up, smell the coffee & get a grip.

    It’s a numbers thing, if you keep pushing your luck you can get away with it only for so long, at some point your luck runs out.

    How is Starliner doing anyway, will Dream Chaser fly before Starliner, if it does, perhaps Starliner isn’t needed anymore? Dream Chaser is potentially much more versatile anyway.

  6. Your explanation is not absolutely clear, nor are any of the others that I can find on line. Plug escape doors a largely standard these days and the Boeing door in question given the photos that are available is no different. Nor to the photographs appear to show damaged structure. (again?) If this was a normal escape door that blew out the situation would be very serious, and that does not appear to be the case. This door was a (permanently)sealed door, and correct me if I am wrong there are 2 such doors on this variant.
    Your comments as to the way they are shipped and the failure of Boeing manufacturing seem conclusive. Seems the door release mechanisms (handle etc) is removed, some kind of bolting locking devise is installed as a replacement and secured. It seems (again?)internal cabin fittings are then installed and plug is invisible from the cabin???)
    The extent that both airline maintenance and crew would be aware of this or even “need to know” is questionable. (Remind you of other issues?)

    It is my understanding (?) that upon completion of test flight the aircraft is opened completely for C of A
    inspection and company inspection/acceptance.

    If so, the airlines are also somewhat complicit and it is the airlines who are responsible for their training of crews and maintenance, …..or not.

    The pressurization light indicated failure 3 times as reported. (Remind you of other issues?). Can you advise what triggered that light. Was there in fact an operational vestigial micro switch on the vestigial door in question ?
    It would seen from the reporting that other such vestigial door “plugs” were also not secure(d), in which case Boeing is very lucky indeed as is the FAA.

    Wonder if that is why they are so quiet ???;-)

    • Gxrooaaan- the door-window in question is NOT repeat NOT a ‘ plug’ type door with a tapered frame such that pressure holds it in place and must be near zero delta to pull and twist it open.

      It is doubtful that airlines remove interior panels to check on that door before or after delivery absent a related issue.

      Most of the answers you seek can be found with little effort on internet.

      it IS a quality control- inspection- issue mostly the responsibility of Boeing.

      • The NTSB calls it a “door plug,” so that’s the term we and others use. But Bubba is correct, it is not an actual “plug” door.

        • domain specific language

          “door plug” ( domain: use )
          ~= Thingie that replaces an actual door in case of nonuse to achieve integrity of the pressure vessel.

          “plugtype door” (domain: design )
          ~= door design that is pressed into its seat by pressure differential and cannot exit to the outside ( except you move it back, turn … )

      • I am sure someone with more detailed knowledge than this old geezer about the ” plugged” exit-door-window could do a better job than my attempt at explaining the ‘ missing-broken- bolt ” confusion. But following is my .000003 worth.

        A_ The design of the ” J” hooks AND the multiple Pads is such that the pads take the pressure load to keep the door in place.

        B- the 4 ” j ” hooks are simply to control and stop the door from being raised enough ( by the spring assist ) to clear the stop pads and open outwards.

        C_ the now famous 4 bolts seem to be sized not for load but to fill the ” j” hooks such that complete removal of the bolt is needed to allow the door to ‘spring up ‘ and open outward. After all – the real door latches ( similar to bolt )are ‘inserted-removed ‘ by a simple solenoid
        D_ the nut and cotter pins seem to be again not for Load or tightness other than to keep the bolt from vibrating or sliding or dropping out while being hidden from normal inspection.
        E- as long as the bolts were in place held by a bit of friction, the 150 percent pressure load ( hi blow ) would have little effect and the door would not release.
        F_ However – hi blow does ‘ stretch’ things a bit and full rebound of the overall structure is unlikely. Thus IF ( big IF ) the hi blow less rebound allowed the unsecured bolts to ‘ drop out AND not be later checked….
        All of which goes to say IMHO- the ‘ strength ‘ of the missing bolts is really NOT the issue- and lack of proper inspection and observation IS the issue- and squarely in the hands of Boeing during final assembly – NOT the basic design and installation methods- or in simple terms RTFM

        • IMU you’ve got it.

          Are the (lifting, weight countering) springs actually in place?
          superfluous and only lead to issues linked to missing bolts.

      • There is not vestigial switch. As its not a door, there is (was) no need to monitor it.

        The Warning is triggered by a wrong cabin pressure.

        Its in theory possible to have failed sensors, in this case with a blown exit blank the suspicion is it was leaking.

        The issues also looks to be a failure to install bolts and then the follow up confirmation and inspections/sign off.

        The Airlines only inspects the complete aircraft and have no way of knowing if its been assembled right though they do flight tests which should show significant deficiency (like an engine missing) APU not starting.

        In this case it clearly passed initial pressure check and was very intermittent.

        Alaska Airlines should have identified the issue but as often is the case, they check it, can’t find anything and use passenger flights as follow up tests.

        That resembles the Indonesian crash with its multiple failures and also failure to do a valid test.

    • It’s not an emergency exit door, it’s a permanent plug of a door opening that Alaska doesn’t use. It’s not designed to be opened in day-to-day service, but can be opened (or removed) for service or maintenance.

      The previous pressurisation warnings could be entirely coincidental, since they disappeared when switched to the alternate pressurisation system.

      • If you believe in coincidence, yes it could be non related.

        In this case it is a smoking gun and the usual failure to do a real ID of the issue.

        Oh, we cleared the fault, nothing to see here, just move on.

        There are sound devices that will show an air leak up like a screaming loud alarm, you just have to use them

      • “disappeared when switched to the alternate pressurisation system.”

        errors that go away with switching to an alternate
        need to be investigated on their own. This should be mandatory.
        ( the alt. system that shows no error could just be broken as an indicator. )

  7. Scott I’d be interested in you expanding on this:
    “Some Boeing critics and the uninformed suggest that the door plug is a remnant of the 1997 merger with McDonnell Douglas Corp. and that MDC-inspired cost-cutting led to the door plug design. Some others suggest the same cost-cutting culture is responsible for launching the MAX.

    Both of these theses are wrong, fundamentally because this is a quality control issue and not an airplane issue like the MCAS design.”

    It seems self-evident to me that the change in culture as a result of the merger has had a negative impact on both design (MCAS but likely not the plug) and Quality Assurance. If your employees know that management encourages and rewards profits above all else, then other things get squeezed.

    • Sort of true but the hard reality is for something like no bolts in the Exit Blank, you have many failures of quality control from install to the sign off (probably 3 sties).

      Sucre things like brackets wrong is one thing, but a total flat ass failure to install and then log compliance for something as simple as bolts is stunning.

      There are multiple failures within this incident and that is where the wheels fall off the wagon.

      Clearly there is not only failure in quality control but pencil whipping going on.

  8. “MAX” was a design quality issue : the design did not comply with the input requirements (set by certification rules)
    As1282 seems to be a production quality issue : the produced aircraft did not comply with the input requirements (set by the design)

    Doesn’t seem fundamentally different to me.

    It is reasonable to expect similar underlying causes of rushed work by inexperience/less-knowledgeable workers under pressure to deliver more, faster and at less cost, as mandated by management types living completely disconnected from reality in a world of KPIs, 1-pagers and pseudo-business-cases defined only to boost their performance reviews.
    None of which is specific to Boeing, by the way…but still an indication that Boeing still has a long way to go to correct the bad habits that led to MAX.

    • The difference is that the Exit Blank dedign and construction is not an issue.

      The failure to not install the bolts is a pure mechanical task that was not done, no different than not installing bolts to hold the engine on the aircraft.

      MCAS was a software design fialure as well as insane assessment of the risk with cherry picking of data to lie about the failure.

      think of it as your car mfg did not put any bolts in the wheel and it falls off.

      There is nothing wrong with the wheel design, there is nothing wrong with the bolts or their spec, its all to do with a screw up to install the bolts and no one catches the failure that is grossly obvious.

      There is no way you can determine if the connecting rod bolts are put in or torques right in an engine (once the engine has the oil pan on it).

      but you can SEE there are no bolts in the wheel.

  9. Oops.

    P.S. Whether it’s a “MAX” story or Boeing doesn’t matter to the general public. The MAX is an aircraft from Boeing. So is @Scott suggesting here more aircraft from BA have to go over with a fine-tooth comb?
    Nothing would focus the mind of members of the board faster than a hit to their pockets.

    • What would focus minds fastest is, uh, Jail Time. Of course the wrong (little) people would be the ones sent to jail..

      Boing’s really turned into a self-caricature. But hey, the stock price is still up..

  10. I’m not going to disagree with what has been said here, but suggest that there is yet another layer below the quality story and the Deming story. That is the cultural story, which is not too far below the other two. A convenient entry point is the recently released film of the book “The Boys in the Boat.” If you haven’t seen the film and read the book (there is material in each that is not in the other), I recommend it. At least three members of the 1936 gold medal rowing team went on to become Boeing engineers including Joe Rantz.

    Dan Brown interviewed Rantz, after meeting his daughter, a neighbor, and she told him about an absolutely astounding story about a cedar fence in their neighborhood that her dad had built. Early on in the interview, Rantz made it clear that any telling of the story had to be about the boat, not him. In this case, “the boat” is both a reality and a metaphor for their all for one and one for all spirit which they developed. It’s a story of selfless devotion to task and doing one’s best out of respect for one’s teammates, and everyone else who feels like they have an interest in what they are doing.

    This spirit exactly typifies the culture they took with them into Boeing and which was still palpable when I joined the company in 1983. To say that it was profoundly different than what I had experienced in the world of the automakers growing up in Detroit is an understatement. In the literature, other than “The Boys in the Boat,” the only thing that I have found that come close is the recent book by Will Guidara titled “Unreasonable Hospitality.”

    The example of that kind of devotion was modeled by most of Boeing’s leaders that I encountered before the merger, the big exception being Phil Condit. After the merger, Stonecipher gave several internal speeches where he explicitly stated that it was his determination to replace Boeing’s old culture that he described as “a family” with a new one that he described as “a team” with repeated comparisons to professional sports teams where players could be traded and replaced as needed. It was actually quite shocking to hear him be so open about that.

    Almost immediately, status reporting stopped being honest, and stoplight charts became watermelon charts as a matter of routine. You quickly learned that you only reported what people wanted to hear, not reality. So of course this immediately crippled the entire management process. A manager’s job is to allocate resources where they are needed, and if they don’t know where they are needed, then they are just a useless cost on the payroll. That quickly became the state of the entire management culture. Talent started draining out of the company as fast as people could find something where people cared about the basics of teamwork, honest, trust, and commitment to quality.

    So yes it is a quality issue, and yes it is a Deming principles issue, but even more fundamentally, it is a leadership cultural issue. Oh, and BTW, much of what Toyota does they got from Boeing, which Boeing then quickly forgot due to the early 1950s tooling approach to assembling aircraft that fly faster than 400mph, but that’s another story, and a fairly long one, but it too has roots in that 1936 Olympic rowing team.

    • Yes, Boys in the Boat is a great film. Nothing embellished and a good story of a different time.

      Something changed in this country and at Boeing. One poster has said: There is no vaccine.

      There are a lot of great engineers at Boeing and in aerospace working on a lot of new exciting projects. The biggest problem is leadership and the people (majority stockholders) who hire them. They only care about the bottom line going out one year.

      • Yep, bottom line is when you get whacked for doing the job right you soon learn to shut up and toe the line.

      • To my way of thinking what changed was the nature and role of religion in American life. In the 1930s most people went to some sort of church once a week, and at least half of the time got a sermon about ethics and what it means to be a good person. But religious leaders back themselves into a corner with dogma which is too slow to adapt to the rapid pace of accumulating human learning. As science has gained more insight into the nature of things those in the preaching business have doubled down on the dogma stuff and stopped talking about the ethics stuff. As a result fewer people pay any attention to them, and those that do are hard over dogmatic types who support policies that are antithetical to basic ethics. Pride, greed and the rest of the seven deadlies become virtues.

        This is easy to validate, which I have done recently. Pick a large church, one with a congregation of at least several hundred. Take a watch (don’t use your phone, that would be very crass), and simply make a note of how much time, if any, is spent talking about the “do unto others” type of stuff versus everything else. If even a couple minutes out of the two or three hours they ramble on about praise and salvation is spent on that, it would be unusual. Religion has simply dropped out of the ethics and values business and it shows.

        Taking some time to talk about values on a regular basis is critically important to success in any endeavor. This is the essence of what Simon Sinek talks about, and it is exactly why Alan Mulally insisted that every meeting start with his 11 point “working together” chart. He openly credits what he learned going to church as a young person for that approach to his meeting structure.

        Values matter, but you have to constantly remind yourself of what they are, and have leaders who walk the talk and demonstrate very visibly what their commitment is. Mulally often said that one of the most difficult tasks he had to work on was remaining humble in the face of success. T Wilson made the same point, but in a different way. He chose to go home every night to that first small house he and his wife bought on Crown Hill when he was a young engineer. He once quipped that “it’s not arrogance if you are the best” but at the same time he was saying that you have to keep your head out of the clouds and remember that you are just one person contributing what you can to the effort of the whole. This current crop of leaders doesn’t understand any of that stuff.

        • and Bill Allen insisted on driving to work in his T bird and parking it in the parking lot outside in Plant 2.

          Philbert insisted on an up armored company car

          Frank shrontz took extra effort to invite grunts to meet with him

        • @RTF

          I would think the changing of many people’s spiritual counseling would be part of the overall cultural shift in the country. Some attribute this to a backlash to LBJ’s civil rights agendas.

          But I read an article a long time ago about the general trend in society that started around 1980, give or take five years. This laissez faire approach gave business and in this case aerospace more autonomy to “watch over” themselves. With profits being the motive, we see how that has played in Boeing’s 737MAX program. This article went on to say this trend or era will be around for about 60 years. I think that’s why many people feel there appears to be nothing on the immediate horizon that indicates substantial change in business practices or how the country operates.

          “Think tanks” are finally being funded to look at all the out-sourcing that has taken place. That may be a point for optimism.

          • I think that Americans need to invent a new kind of institution in order to keep us on track with the basics of ethics and values. I don’t expect the religion business to ever return to its former prominent role. The leadership and kind of messaging that would be required for that to happen shows no signs of emerging. Even the super tiny steps that Francis has taken have been meet with stiff resistance by American bishops.

            The first few sentences of the Declaration of Independence combined with the Preamble to the Constitution are pretty good values statements, but they are aspirational, not some sort of binding law. Thus, SCOTUS is of no use at all, expecially the current version of it, when it comes to moving us ever closer to the aspirational journey which the founders set us on. It’s even popular among conservatives to claim (quite falsely) that as apart of their concept of orignalism means that the intent of the founders was some permanent 18th century starting point as the end state, and that there was no aspirational aspect to what the founders were doing it at all, which of course is patent nonsense.

            I’m beginning to think that what need is an institution of some sort that is outside of government, that is of a secular nature, and whose mission is to both provide a forum for talking about values and for making some sort of periodic pronouncements that set goals that the three formal branches of government should strive to enshrine and manage toward. Guys like Simon Sinek can’t do this job alone. Something much bigger and more formal is needed.

            As for Boeing, the situation there is pretty much hopeless. Kellner and Calhoun are never going to do what is needed. They can’t, since it is crystal clear that they are perfectly clueless about what the true nature of the mess is that they have helped to create. The old saw about the necessity of stopping the digging when you want to get out of a hole is apropos, and they are highly committed diggers.

    • I’m glad you pointed this out. I was at Boeing from 1989 to 1997 marketing commercial aircraft. I suppose you could say I was a “victim” of the merger as consolidation happened in the marketing andsales ranks however, it was the best thing that ever happened. I moved on to bigger and better things. I fortunately did experience that 1936 rowing team culture pre-merger and I will always say that all of Boeing’s travails since 1997 are a result of the merger and resulting cultural transformation. Just a few tidbits:

      – They opted to move HQ to a “neutral” location (ie. Chicago) where EVERYONE was far away from the major manufacturing locations. VERY dumb IMHO.

      – One might recall that MDC was on its heels (at least the commercial side was all but done) pre-merger. Harry Stonecipher was not only CEO but their largest shareholder. The merger came as a “miracle” save for him and his only focus going forward as the largest individual shareholder of the merged company was to maximize the value of his shares. Hence, his focus on changing culture accordingly.

      – Every single CEO at Boeing pre-merger came thru the ranks being exposed to all sides of the company. Quite clearly Allan Mullaly was to be the next CEO pre-merger. Once the merger happened, he saw the writing on the wall and bolted to become CEO at Ford in effect saving that company. Since then all CEO’s have been “outsiders” (ex-3M and ex-GE) except Muilenburg. Unfortunately Muilenburg’s entire Boeing career pre-CEO was on the defense side of the business. He was never “groomed” by being exposed to all sides of the business and it showed during the 2018-19 B737MAX accidents and subsequent grounding.

      – Between 2012 and 2018 Boeing stock buybacks totalled $90 BILLION. Pretty easy to figure out that since a big portion of the execs compensation is based on share price, they are VERY focused no matter what in keeping share price as high as possible even if its at the expense of the company’s well being. A vast majority of that “equity” disappeared when COVID took hold and as a result Boeing had to seek $50 BILLION in debt relief in the marketplace to get thru COVID related drastic drop in deliveries and the B737MAX grounding.

      – EVERY single aircraft program launched at Boeing since the merger has had one or more of the following: delivery delays, design issues, manufacturing issues, FAA mandated groundings. Aircraft involved are B737MAX, B787, B747-8, KC-46 and it continues today with the B777-9.

  11. Obviously,if the 4 bolts and split pins were missing,this part of the aircraft cannot have been inspected.
    There is now good reason to doubt everything and the production line should be stopped until a thorough audit has been conducted.

    • Actually that’s probably wrong.Maybe a large part of the problem is that the production line went cold (or very chilly)with the MAX and Covid crises

      • I disagree.

        We are well past re-start and Covid.

        At least one person failed to install the bolts and at least one inspector pencil whipped the sign off.

        Minimum of gross negligence and outright criminal in my opinion but the culture is such its not being addressed.

        Stop the line and Boeing should re-certify all steps including dealing with the quality issues from Spirit.

        Oh and the Inspectors should report to the FAA as they did in the past.

  12. The term “quality escape” is standard in Aerospace. It is not Boeing-specific and its usage is normal. It indicates, as you would imagine, that the quality issue (whatever it might be) has escaped to the next step in the chain without detection. In this case, to the customer. All suppliers have metrics to track escapes. It says nothing about the severity or otherwise of the incident.

    • I disagree.

      Its a case of gross cancelling.

      Someone failed to install the bolts and then lied about it.

      The inspector signed it off without inspecting the work and lied about it.

      Quality control is not a single failure. Whatever your system is, for it to blow an Exit Blank off you have had not only multiple failures but cultural failure for it to happen in the first place.

      Things don’t just magically go off trakc (bad pun) they go off track k due to multiple failures.

      You have the panel bolt holes and process (grounding) the bracket failure, loose fasteners in the rudder, no fasteners in the Exit Blank.
      This is a multi headed monster with a system failure at its heart.

  13. I wonder if this incident would change AS’s view about future fleet commonality.

    • Not only Alaska. How about LUV?

      They’re expecting to get the Max 7 soon. (as early as Dec 2023)

      Now I would suspect that the anti-ice issue is going to be put on the back burner by the FAA, until the pressing Max 9 issue is resolved.

      Now the FAA has egg all over it’s face again, thanks to BA.

      • Well AS is supposed to acquire HA, an A321 operator.

        Will take too much trouble for LUV, I fear.

      • The FAA has egg all over its face because of themselves.

        The deep dive failed to correct the ODA situation and clearly there are failures up and down the chain.

        • “The FAA has egg all over its face because of themselves.”

          Be careful of what you wish for, FAA might tighten the screw!! Watch out.

      • “Now the FAA has egg all over it’s face again, thanks to BA.”
        The MAX 7/10 can wait, I guess.

  14. Although it does look to be a quality issue, there may be a design dimension as well. ie a better design would not have led to a catastrophic outcome in the case of incorrect fitting. Generally you want safety to be multilayered.

    • I agree, 4 bolts with a Cotter Key is an atrocity to a mechanic, its not a quality system.

      I have never seen a cotter key used in a critical application and rarely used period in this day and age.

    • disparity.
      you want fail save
      you want error disclosure *

      * having to switch systems was error disclosure.
      this should have led to a check : pressurization failure /
      AND/OR indication failure ( indication on the alt system could have been broken.)

    • I’ve been saying this all along. The door plug does not seem to be designed to the same standards as a regular door. But it has the same effect on the plane’s integrity when it fails. Door fittings seem to require that the locking function is clearly visible from inside the aircraft. Obviously, this is not possible on a door plug as there is a fully fitted interior panel covering it. It would be interesting to hear the FAA’s reason for not requiring that standard.

      • Uhhh LesD ? The ‘plug’ latches and dozen ” pads ” and frame are the same as a real exit door. . The biggest difference is instead of 4 bolts to keep it closed, they use a mechanical latch arrangement which removes/pulls the 4 pins which replace the bolts plus an solenoid arrangement which locks st a certain altitude after takeoff to prevent the pins from being ‘ removed/pulled’ Anyone can find the details with a bit of searching on the internet.- or you can send your resume to Boeing and request to be assigned to design team or as FAA inspector.

      • “dynamic lock” vs “static lock”.

        The plug is “static locked” ( 4 screws ), the mechanical interlock
        keeping it in place is the same as on a “dynamic” door.
        As with anything secured by screws you have to ascertain
        proper assembly during manufacture … and before delivery to the customer 🙂

        i.e. I would not tag it as a design shortcoming but laxness in manufacture.

  15. design has been around for at least a decade.
    But going from foolproof to idiot proof and/or ‘faster-cheaper’ higher stock price overrides it all.
    For those doubters

    ” When I say I changed the culture of Boeing, that was the intent, so it’s run like a business rather than a great engineering firm. It is a great engineering firm, but people invest in a company because they want to make money. ”
    Harry Stonecipher, 2004, former CEO of The Boeing Company, reflecting on the late 1990s

    Boeing’s McNerney apologizes for remark about ‘cowering’ workers
    Boeing CEO Jim McNerney apologized Friday in a companywide message for telling analysts that “he won’t retire after turning 65 next month because
    the heart will still be beating, the employees will still be cowering. “

    • You can never make something foolproof because fools are just so ingenious

      • That is why you have layers and it requires a system (Boeing management) failure to get to where the layers do not catch it.

        This is not a single idiot, its the system that is an has failed and in multiple regards, its just the latest in a long long long string.

  16. Did UA switch some order of the MAX 10 to MAX 9 for 2024 delivery?
    Can anyone provide a source for this info.? Thanks.

    BTW a short 1h 10m flight in Asia is enough time for airlines to provide a hot meal? Wow.

  17. Salt and wound … ??
    “Pleased to share we delivered 735 aircraft to 87 customers in 2023 across our #A220, #A320, #A330 and #A350 Families. We also booked a record 2,319 gross orders, including 1,835 #A320 Family, 300 #A350 Family aircraft, as well as 15 #A350F We thank all our new and existing customers for their ongoing trust.

  18. Fit hitting Shan at FAA-Boeing from Cantwell per seattle times

    Cantwell blasts FAA oversight of Boeing after Alaska Airlines 737 MAX 9 blowout
    Jan. 11, 2024 at 12:33 pm…
    …In a letter to the FAA Thursday afternoon, Cantwell, D-Wash., said “it appears that the FAA’s oversight processes have not been effective” in ensuring Boeing’s planes are safe.

    She pointed to a January 2023 letter where she requested the FAA conduct a special technical audit of 11 areas related to Boeing’s production systems. The regulatory agency responded that April and declined to take action, according to Cantwell’s most recent letter….

    …Former FAA acting administrator Billy Nolen told Cantwell the audit was not needed because the agency had already implemented tools to complete these types of reviews, Cantwell continued.

    Last Friday, another incident involving a Boeing aircraft reignited Cantwell’s concerns. …

    ..On Thursday, Cantwell asked the FAA to provide a full account of its oversight of manufacturer’s compliance and quality control standards. She asked the regulatory agency to send copies of notification letters from the last 24 months for all quality systems audits of Boeing and audits for one of Boeing’s suppliers, Spirit AeroSystems. …

    When BA loses Cantwell it is not a ‘ happy day ‘
    The Annual meeting should be interesting- its too late now to submit a shareholder proposal- and BA will try to dodge questions from the floor. For a while- they allowed attendees to submit comments and simple ( must fit on card ) questions during the dog and pony show portion and then pick ‘ at random’ several cards or perhaps a person or two to ask, etc.
    But that was over two decades ago and I havent been to a meeting since. But I have and did submit a few proposals in the early 2000- and got 30 to 50 million votes in favor for each time when meetings were in Chicago ;))

  19. These will be the first and final examples of a loose door plug at Boeing. The bigger question is when and if the FAA asks for a full audit of a completed aircraft to look for any other examples of missed assembly steps. As an operator I have to ask what other steps were missed or overlooked

    • Agreed and in spades

      And there are going to be other examples of quality failure, its not just one installer, its the inspectors both Boeing and FAA ODA.

      The loose bolts in the rudder system is another manifestation of this.

      • They need to pick an airacraft that was just about to go to paint and send it off for a D check. Painful…but at least it would be a good anchor point on any other warts snorkeling in the background.

        • “Most scrutinized aircraft in history” already, right? So how many more nightmares lurk within?

          we might yet find out, ex post fatso 😉

          • Quantum science!
            Schrödinger’s Cat.

            joke aside.
            This is no longer a “quality escape”
            as quality appears to be low down flat.

  20. A thought to ponder;

    Renton is the home of Boeing. Airplane guys and gals for decades in that area and people in the vicinity either have family or know someone who works for the company.

    South Carolina is hardly a hotbed of aviation activity.

    If this happened up in Washington, what’s the quality of work like in SC?

    • Boeing was unable to deliver a 787 for just about a year because of shoddy assembly.

      • Any quality issues public from Airbus @ Mobile ?
        touching on A320 or A220 deliveries?

        FAA attitude should be divided on “neck breathing”:
        Devil Airbus, bad
        US aerospace manufacturing site, good
        Does right to work matter?
        For Airbus : yes : they have taken extreme care to qualify their domestic workforce there.

  21. The ‘Bolts’ Need not be fully torqued or tightened. They simply hold a Pin on the Plug from moving out of its’ fixture Slot. Like a Gate.
    A cotter pin properly installed through a Castellated Nut keeps the nut from vibrating off and the bolt falling out. Different situ on lower bolts but they too must be secure from falling out of hinge holes.

  22. In the latest capt Chris you tube video,he makes the point that 737 900 ER should really be grounded and inspected as well if the door plug is the same.In theory,if the manufacturer can make an assembly mistake,so can maintenance contractors make a reassembly mistake.
    Initially MAX9s that had been through C checks were exempted by Alaska,which begs the question,had any operators already corrected the problem on any other aircraft,and if so,who knew?
    Dave’s gushing praise for Alaska is one of the things making me suspicious

  23. Alaska’s first B737MAX-9 was delivered at the end of January 2021. Typical interval for B737 “C” checks these days is 36 months which implies that only maybe 1 or 2 MAX 9’s may have headed to the hangar for their 1st “C” check so far.

    Their youngest B737-900ER was delivered in March of 2019. First B737-900ER was delivered October of 2012. Their B737-900’s were delivered between May 2001 and February 2004. All of these aircraft should have gone through at least 1 if not many more “C” checks since delivery. If during inspection of those airframes it had been discovered that a similar issue has occurred (loose bolts) I am convinced this would be reported to the FAA and Boeing for corrective action going forward.

    • Apparently 31 MAX9 were exempt from Alaskas initial grounding for whatever reason,why?And why did the FAA decide that this wasn’t good enough?”It doesn’t make sense

      • Wasn’t it because the initial mandate was to ground and inspect only aircraft that have accumulated 4,000 or less landings since delivery ?

          • Good question. The accident airplane I believe only had 175 cycles (landings) prior to the event. Maybe the FAA thought be covering 4,000 cycles or less it would include aircraft that have not yet had their first heavy maintenance check. I’m really not sure how they arrived at that number.

      • Last Saturday morning, AS put 18 back into service which had gone thru inspections during heavy checks IIRC.

  24. Probably because those specific versions did NOT have the optional door due to their size and max passenger capacity.

    • All of Alaska’s 65 B737MAX-9’s are in the same configuration and include the door plugs.

  25. My tailor on Tuesday asked me if I thought Boeing’s were safe to fly on anymore. I didn’t feel able to reassure him.

    He and his son are going skiing soon. When these things filter down to that level it bodes ill for BAC.

    The last airframes I was involved in buying were built across the Pacific from Boeing in Komsomolsk-on-Amur. It was considered a risky decision at the time. I feel vindicated. At least nobody died this time.

    • I agree with you about the photo. One has to wonder if someone at United Airlines got in there and loosened the permanent bolts and properly installed a castellated nut, cotter pin and pin bolt before taking the picture. It wouldn’t surprise me, with all the subterfuge and sleight of hand that apparently is taking place in all of this. Who is overseeing the inspection process? All it would take is a phone call to the right someone at UA, with the promise of a healthy payoff, all to throw Spirit Aerospace under the bus. In the end, I believe Spirit will be gone when the dust settles from this, as they should be, if what I’ve read about their safety compliance culture is true.

      • Hey RJ- Cool your jets-you have no clue about nuts, bolts, and what would happen to anyone even attempting to do such.

        • Hey Bubba, how about you try not insulting someone when they posit a scenario and instead address the concern. As to what would happen to someone who even attempted such a thing, far worse atrocities have been committed for far less personal gain. How many people are in prison for crimes of passion, simply because they were tired of their partner? Now back to my question. Who oversees these post incident inspections. Obviously we cannot count on Boeing or even Alaska Airlines who is Proudly All Boeing. We know that Boeing sends lobbyists with briefcases full of money to Wash.DC to stall bills that affect them. Are you telling me there’s no way they would try to influence the outcome of these inspections? And what about the photo in question. Since I clearly know nothing about nuts, and bolts please school me because the photo does appear to show entirely different bolts loose than the ones that have been discussed throughout the comments. Again I propose the idea is to throw Spirit Aerospace under the bus.

          • –Since I clearly know nothing about nuts, and bolts please school me because the photo does appear to show entirely different bolts loose than the ones that have been discussed throughout the comments.”

            Exactly – and IF you spent a few minutes reading or researching, they were on the other side and in a different location attaching different part(s ) for a different reason than the 4 bolts under discussion.

            The 4 bolts under discussion and shown in several diagrams IF installed simply kept the ” plug ” from raising a few inches off the multiple restraining pads which would then allow the plug to eject.

            And who else checks – FAA NTSB non compamy inspectors- certified Airplane mechanics- etc along with normallly asssembly mechanics plus a lot of paperework and signatures in the system.

            It is/was a process failure. And you can be surre those responsible arer known.

            Please try your conspiracy theories somewhere else

        • Again with insults Bubba. Really? Would someone besides Bubba like to respond to the discrepancy in the photo submitted by United Airlines. As the missing bolts in question appear to be fully installed, castle nuts and cotter pins in position. I just want a straight-forward answer without the condescending snark. Anyone? Besides you Bubba. Anyone? Anyone?

        • Thanks for the respectful reply Bubba. With all due respect, the linked article in your last reply only seems to add to the question that both I and Jan originally raised. The photo from UA does indeed show a lower locking bolt/nut assembly fully installed, and a compressed hinge spring beneath it, dead center in the photo. It is the other 3 (and likely a 4th bolt which is hidden by structure) that are loose. The bolts in question are in the right to lower right quadrant of the photograph. I implore you to take a very close look at the UA photo linked to in Jan’s comment. As you will see, when compared to the excellent drawings in the article you linked to, the locking bolt/nut assembly is not loose or missing in the UA photo. The other 3 (or 4) bolts that are in the picture are loose, but why? It would seem that they should be in a permanently tightened condition as they would never need to be loosened to either open or remove the door plug. As I understand it, only the 4 locking bolt/nut assemblies need to be removed to allow the hinge springs to push the door plug up and out of the upper guide tracks and misalign the stop pads and fittings. I wasn’t trying to raise a conspiracy theory, just wondering what the UA photo was supposedly proving. I offered my theory to spark a discussion, which clearly it did.

          • Please- the ‘other three or four bolts which appear to be loose were identified as such by UAL and really had zip to do with the 4 bolt nut cotterpin bolts which IF at least one had been installed would have prevented the ‘plug-door’ from ejecting. The only thing in common was/is that those bolts were/are part of the door frame assembly such that to ‘install’ a real door would probably have to be removed or mayvbe just loosened a bit to accomodate installation and alignment of the real door. That they should have been tightened after door or plug install is an open question- that they were loose is another ‘escape’- but even so-without access to the standard paperwork one can only guess the net result of them being loose may not be a ‘safety item’. Most ‘permanent ‘ ‘ Bolts ” ( I prefer fasteners ) use clenched collars ( huck ) or twist off hex ” nuts ” ( hishear ) or rivets. Unfortunately your so called “theory ” clouded some mainstream media coverage and added to the confusion of the issue and IMHO came close to defamation.

        • OK. Now we’re getting somewhere. Let’s put the UA photo aside for now, but don’t completely discard it, and discuss what really has you hacked off about my original comment. I don’t care if someone’s feelings are hurt about my theory. I fly often enough that I inevitably end up on Boeing products multiple times a year, so my personal safety is involved. I want there to be culpability for these safety escapes, and I want it to hurt and send a message. Heads need to roll! Defamation? Really? It is not I, but powerful lawyers with briefcases full of money who cloud the issue and distort the judgement of those in a position to affect such change. I’m not a technical aviation geek, nor am I a retired Boeing line worker. I may not have the terminology correct. I am a passenger in one of those seats near one of those door plugs. I want to know that the aircraft I am on has been built correctly and hasn’t been pushed through to meet a quota or satisfy a delivery schedule. So, will I cool my jets? Not until this quality issue has been adequately addressed. Thank you for the discussion Bubba.

  26. What I do not understand is why a carrier like Alaska or United would want to order an aircraft with this plug. They are not LCC’s and so far none of the Max-9 operators are LCC’s. It is unlikely that they will ever want to stuff more seats inside these planes and if they ever did they would have to completely replace the door plug because it has a full-size window and cannot be converted to an emergency exit. This plug is a completely useless feature that adds more weight and reduces the safety of the airframe.

    As a solution to prevent future loss of this door in flight, I would recommend the removal of the lifting springs. They serve no purpose in an inoperable emergency exit and it was the springs that ejected the plug. In addition to this change, I would like to see a special fitting that would go over the stop-pad and stop-fitting so that it is impossible for them to become misaligned. I would like to see this fitting at at least four locations.

    If these changes are made I believe that we will have a failsafe solution. Going forward Boeing should only supply operable exits at this location when specified by an LCC. When delivering to main-line carriers there should be no plug at this location. It should be a normal fuselage cross-section. The saving in weight alone should be a compelling reason for making this change.

    • @Keith: The reason for the door plug is that from a manufacturing point of view, it is cheaper and more efficient to produce one fuselage with the cutout than two, one with and one without the cutout.

      A second reason is that for lessors, remarketing the airplane from an LCC to a legacy airline, or vice versa, gives better residual value for the lessor and a broader set of customers to whom to remarket the airplane.

    • One more important reason: If the door is activated as an emergency exit then they must have a clear aisle for everyone to exit, similar to front and aft doors and definitely wider than the extra legroom required at exit windows. With the door plugged then they can instead place their seating in a normal configuration. Since this door plug is aft and in the middle of the economy section it actually means they can add 6 more seats (1 more row) but still keep total number of seats below the threshhold which would require them to activate the door. Those extra 6 seats are all about economics, lower seat costs per trip and potentially more revenue.

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