“Unplanned” removal, installation inspection procedure at Boeing

By the Leeham News Team

Jan. 15, 2024, © Leeham News: It’s not supposed to happen.

The door plug on the Boeing 737-9 MAX isn’t supposed to separate from the airplane in flight, as it did on Alaska Airlines Flight 1282 on Jan. 5 this year.

There is conflicting reporting whether the emergency exit or door plug is opened on the Boeing 737 final assembly line for access to the interior. Examining Google images, two photos show the exit or plug closed while over-wing exits are open. Credit: Unknown.

The investigation by the National Transportation Safety Board (NTSB) is in its infancy. Early evidence suggests four bolts intended to prevent the door plug from shifting in its attachment brackets either failed or weren’t installed. Inspections after the 1282 incident by Alaska, and United Airlines found loose bolts in other MAX 9s. The Federal Aviation Administration (FAA) on Jan. 6 grounded the 171 MAX 9s operated by the two carriers until inspections and repairs, if needed, are completed.

This photo of a Boeing 737-900ER for Turkish Airlines shows a door plug closed on the 737 final assembly line. The over-wing exits are open. Credit: Unknown.

Boeing CEO David Calhoun, while telling CNBC that he wasn’t pointing fingers, did precisely that. He said Spirit AeroSystems had a “quality escape,” adding that Boeing failed to catch it, so it also had a quality escape.

How could this happen? The NTSB probe will presumably figure this out. Spirit ships the 737-9 fuselages with the door plug installed. Conflicting reporting suggests that Spirit is supposed to install the door plugs in the final, secure condition; or these are shipped with the plugs in place but in a condition that Boeing would later secure. The NTSB will sort this out, too.

Regardless, Boeing should have inspected the door plugs and assured these are in final condition prior to delivery. The Seattle Times reported on Jan. 14 that contrary to other reports, Boeing doesn’t open or remove the door plug when the MAX 9 is in final assembly. A retired Boeing safety employee with assembly line experience says Spirit ships the door plugs in a temporary condition, expecting that Boeing may remove them during final assembly.

Special inspection procedure of the door plug

LNA outlined Boeing’s inspection procedures in a Jan. 8 post. In the event, for whatever reason, Boeing does open or remove the door plug, there is a special procedure that should be followed to ensure the plug is properly reinstalled.

Related Article

Here is that procedure.

The quality escapes referred to by Calhoun are inspection procedures. Failing to catch something in an inspection is also called an inspection escape.

What is outlined below is a theory, and not proven fact with the MAX 9 involved, or others in which discrepancies have been found. This procedure is related detailing Boeing’s procedure, just as LNA’s Jan. 8 post outlined procedures.

If Boeing, for any reason, removed the door plug on Alaska’s MAX 9, failure to reinstall the plug properly may not be an inspection escape. An inspection escape means that a planned installation/re-installation operation was inspected, and the mechanic and inspector got it wrong. While not impossible, this is a tough theory to accept, given the four-step inspection process outlined in the Jan. 8 post.

On the other hand, unplanned removal and installation calls for another procedure.

Boeing goes to great lengths to document unplanned removals by logging all the disassembly steps on the ship’s record paper.  Quality Assurance inspects the reassembly process of the unplanned removal event.  This door plug’s poor installation could, in theory, be the result of a production shortcut where the shop needed the door out of the way. The door could have been reinstalled incorrectly. The retired Boeing safety employee says the door plugs are often removed.

Unplanned removals happen “a lot,” the retired Boeing employee told LNA. “There are a multitude of reasons,” he said.

Cost-cutting on inspectors; new workforce

If the unplanned removal proves to hold water, and as noted, this is only hypothesis, then how could the inspection process break down? And how could experienced assembly line workers miss either escapes from Spirit or reinstalling the door plug properly?

The roots may go back years.

Under the regime of former CEO Dennis Muilenburg, quality inspectors were laid off and their duties assigned to others. Boeing’s touch-labor union, the IAM 751, protested that this was unsafe. The protests largely fell on deaf ears.

“I don’t call them quality escapes anymore. I call them safety escapes because Boeing doesn’t have a quality organization anymore,” the retired Boeing safety employee said. A procedure called “Quality Buyback” has been reduced over the years, he said.

In its May 2019 Aero Mechanic employee newsletter, the IAM 751 wrote that it continued to object to Boeing’s plan to eliminate quality assurance inspectors. The union vowed to have its members “reveal instances where Boeing is not following its own internal process.”

“Removing inspections and discovering defects further down line will cause an abundance of out-of-sequence work, [and] more damage to the airplane through rework….”

“We have engaged…in what we see as a long battle to protect the integrity of our manufacturing process,” the union wrote in its newsletter.

When the MAX was grounded in May 2019 for what would be 21 months, Boeing laid off many of its final assembly line workers. When the COVID-19 pandemic began in May 2020, Boeing laid off or offered early retirement to thousands or workers company wide, including more from the 737 FAL.

When production resumes in May 2021, ahead of the recertification the following November, Boeing had to hire new employees without FAL experience. A learning curve is necessary for efficient production.

Returning the MAX 9 to service

The FAA grounded the US MAX 9s on Jan. 6. Some other airlines followed the FAA’s lead. Initially, it was thought that inspecting the door plugs and making any fixes would be a quick process. But more than a week later, the FAA was still requiring details from Boeing and that 40 inspections and repairs (if required) would have to be completed before return to service was approved.

Why is the FAA being so slow? There are a couple of theories.

The first is that the incident involves Boeing and the MAX. The FAA was burned by the certification process of the MAX in the beginning, which was revealed during the 2019 grounding and accident investigations of Lion Air and Ethiopian Airlines. One theory suggests that the FAA isn’t going to get burned again.

It’s common knowledge within the airline community that the relationship between Boeing and the FAA has never recovered from the original MAX crisis. The FAA removed authority from Boeing to certify new MAXes as airworthy. The FAA must sign off on each delivery. This hand slapping was later extended to the 787 when production and quality problems were discovered at the Charleston final assembly line.

Certifying the MAX 7 and 10

Recertifying the MAX after the crash-related groundings proved to be an arduous process. So is certification of the MAX 7, which otherwise is ready to go, and the MAX 10, for which flight testing is in its early stages. But certification of the MAX 7 has taken far longer than anyone expected.

The FAA asks questions and Boeing responds. This generates more questions and more responses. And the cycle repeats, over and over again. Shortly before the Alaska incident, Boeing asked for an exemption for the MAX 7 from a safety regulation. Doubts already existed whether the FAA would grant the exemption. Now, doing so seems unlikely.

Another theory why the FAA is moving slowly on the MAX 9 is, perhaps unsurprisingly, politics. Some members of Congress were quick to demand hearings about the FAA oversight of Boeing, again. The FAA has, once more, come under criticism for its handling of the entire MAX history.

The FAA launched a formal investigation into the MAX 9 incident, in parallel to that of the NTSB.

The FAA is also expected to receive this month a draft of a safety audit authorized during the original MAX crisis. Members of the special committee included experts from across aviation. LNA has learned that the draft conclusions won’t be favorable to Boeing. There is no public release date of this report that’s been announced.

Stan Deal message to Employees

Boeing today made available a message to employees from Stan Deal, the CEO of Boeing Commercial Airplanes. It’s reprinted here in its entirety.

Updates on 737-9 and quality actions

***This message is to all Commercial Airplanes employees.***

As we continue to respond to the Alaska Airlines Flight 1282 accident, our team has been working with the five affected airlines to inspect their 737-9 fleet. They have been examining and collecting measurements around the mid-exit door plugs to ensure they are installed per specifications.

While we complete these tasks to earn Federal Aviation Administration approval to unground the affected 737-9s, our team is also taking a hard look at our quality practices in our factories and across our production system.

We have taken important steps in recent years to strengthen our Quality Management System’s (QMS) foundation and its layers of protection. But, the AS1282 accident and recent customer findings make clear that we are not where we need to be. To that end, we are taking immediate actions to bolster quality assurance and controls across our factories.

  • More quality inspections: We are planning additional inspections throughout the build process at Boeing and at Spirit. These checks will provide one more layer of scrutiny on top of the thousands of inspections performed today across each 737 airplane, and build on the reviews we have implemented to catch potential non-conformances. Since 2019, we have increased the number of Commercial Airplanes quality inspectors by 20% and we plan to make more investments in the Quality function.
  • Team sessions on quality: We are planning additional sessions for our teams to gather and refocus on the fundamentals of our QMS, take advantage of our expanded training programs, and recommit to improving quality and compliance.
  • Boeing review of Spirit work: We have deployed a team to work alongside Spirit AeroSystems to complement the existing teammates on the ground. Our team is now inspecting Spirit’s installation of the mid-exit door plug and approving them before the fuselage section can be shipped to Boeing. We are also inspecting more than 50 other points in Spirit’s build process and assessing their build plans against engineering specifications.
  • Airline oversight inspections: We are opening our factories to 737 operators for additional oversight inspections to review our production and quality procedures. Spirit will do the same and we will learn from our customers’ insights and findings.
  • Independent assessment: An outside party will be brought in to thoroughly review the Quality Management System at Commercial Airplanes and suggest further improvements.

And as we prepare new 737-9s for delivery, we will conduct the same thorough inspections of the mid-exit door plugs as mandated by the FAA. Customer representatives will continue to have access to anything they want to see onboard their airplane before delivery.

These actions are separate from the FAA’s investigation and the agency’s plan to increase oversight of 737-9 production. We will cooperate fully and transparently with both as we work to restore trust with our regulator and our customers. And as the National Transportation Safety Board’s investigation proceeds, we will take additional steps to improve our practices as the facts and findings dictate.

Everything we do must conform to the requirements in our QMS. Anything less is unacceptable. It is through this standard that we must operate to provide our customers and their passengers complete confidence in Boeing airplanes. Let each one of us take personal accountability and recommit ourselves to this important work.




461 Comments on ““Unplanned” removal, installation inspection procedure at Boeing

  1. Quality ‘escape’ is something of a euphemism. What we have here is quality FAILURE. Inspection itself is a cost of failure, licensing assembly workers to get stuff wrong and rely on later inspection. Better to spend money on prevention, licensing assembly workers to stop the line whenever they see an issue that needs remedy, and rewarding them for getting it right first time. It costs less in the long run.

    • McDonnel Douglas tried a similar thing in 1989 in Long Beach CA and the result was a disaster. So many things were found to be faulty that deliveries literally ground to a halt. The program did not last long and was named Total Quality Management System (TQMS).v I understand that it is used in business schools as an example of what not to do.

        • Whenever a new, obfuscative, fancy-dan name
          is put into use, you *can be sure* that the actual product throughput is going to be worse, worse, worse.

          It’s still PR über alles in the ongoing Boeing Saga. I don’t actually know if even another
          MAXCrash would make a difference, honestly.

          • The US management domain is saturated with techniques of projection. These people have zero access to other ideas and methods. A world of smoke and mirrors.

            Replace Boeing Management fully with Japanese professionals. do the same to the workforce :-))

          • Boeing believes experience and knowledge does not count and new people and diversity are the best path forward. My 39 years of experience and lessons learned are not valued. I see evidence of this daily. My voiced concern are not acted upon.

      • It’s very telling that business schools use finding issues with your corner-cut product as an example of what not to do while engineering schools use cutting corners and killing people as examples of what not to do. Of course, business leaders always suddenly discover the value of human life if there’s is at risk.

        • IMHO and by ‘casual’ observation of many companies which have had ‘cost/quality/performance ‘ problems bad enough to hit lamestream media- one consistent management ‘training’ background seems to be prevalent.
          McKinsey and company. That includes of course the current sec of transportation.

          But thats just my .000002.

          • Was a stewardess with Pan Am, flew for 11 years
            Once on trip outbound from LAX to Honolulu we lost part of the propeller. Sliced through cabin wall, no injuries, A D C 4 One. Of many aircraft in pioneering days of air travel
            Get over it
            Correct and keep going forward.

          • Pan Am and propellers?

            That was back when the industry was working its way up the moat of safety. Followed by a plateau of very good achievements. Now and for Boeing it is “down the slope at increasing speed”.

            “Correct and keep going forward.”
            It is not as simple as that.
            “Today we stand on the cliff side
            and tomorrow we will be a step or two further.”

      • So if McDonald Douglas had such poor performance why was the former CEO of MD made CEOof Boeing and allowed to reinstitute the failed system? It also seems like most of the former GE executives that were running Boeing and other cos. Are not qualified to do the Job. Look at what they did to GE . Lastly I bet some of the $ 60 B or so dollars Boeing used to “ reward” stockholders could have been used to retain some qualified engineers and inspectors. Boeing seems headed to the same fate as Other former outstanding American companies . Matter of time untill airbus and the Chinese surpass Boeing

        • It’s almost as though that fate is intentional.. and the hollowing-out continues apace.

          There could be a large-scale geopolitical angle
          to this stuff with some explanatory power.

          • That is MoO.
            We’ve seen this in Europe with US “investors” buying up companies.

            First get your “invested” money back out by converting that to a credit on the company. The dissect and sell off the valuables.

            Lots of job losses, a viable product ranges killed …

          • Capitalism works nicely while expanding into a vacuum.
            With no (easy) further room to expand into it starts to self digest.

        • I think it depends on your definition of “success”. The shareholders, who actually own the company, are very happy with the behavior of Boeing management. Otherwise they would have fired them. This is one of the dangers of being publicly owned.

          • The shareholders cannot really fire the Board members. to understand why read SEC rule 14 a 8


            (i) Question 9: If I have complied with the procedural requirements, on what other bases
            may a company rely to exclude my proposal?…….
            (8) Director elections: If the proposal:
            (i) Would disqualify a nominee who is standing for election;
            (ii) Would remove a director from office before his or her term expired;
            (iii) Questions the competence, business judgment, or character of one or more nominees
            or directors…

            Goes on but the above extract should be sufficient

            Most would be surprised at the various other methods/arguments available to exclude a proposal- but sometimes . .
            And yes- I’ve been there done that and got 30 to 40 million votes- but not enough to require change. And no one does not need to own a lot of shares to submit.

        • “Matter of time until airbus and the Chinese surpass Boeing”

          They have. Their mass is real while Boeing is “facade”.

          That “facade” thing has been brought up regularly for a decade+ now.
          Always derided as “sour grapes”. “antiamerican”, “socialist”, or even “communist” pushed by Euro Weenies.

          • FACADE can be easily explained: BOEING management has many times laid off large quantities of experienced engineers. When business came back, they hired but, of course, the accumulated experience of laid off people was lost.
            In this industry, the europeans behave totally differently: Chomage tevhnique or kurz arbeit systems allow you to retain the experienced workers at a minimal cost.
            Accumulated experience is a huge asset, very often ignored by MBAs or bean counters

        • That $60+ billion could have been used for a lot of things: retain experienced employees, keep more work in-house, hire better suppliers, launch new programs, etc.
          But it wasn’t and it won’t be in the future either. Unless it can find a way to purge itself of the GE beancounter shareholder value tripe management, Being is doomed.
          Sad to say, but for the future of Boeing and the commercial aviation industry it might have been better if a few people had been sucked out of that Alaska Max9. Seems like more people have to die before anything really changes.

        • The merger was a reverse takeover. MD used Boeings money, as a result MD could place who they wanted in top positions.

          It never should have happened. There was a time when many people used to say “If it’s not Boeing, I’m not goeing” all before MD took over.

          Can every last MD person and clone.

        • I was there in ’97 and the years that followed ,myself and my coworkers saw the degradation of processes and quality standards. Extremely difficult to keep an assembly line going and fix things that never should have been an issue because someone saw a way to “reinvent the wheel “. I don’t know if Boeing can be saved in the long run. Govt bailout is a sign that they’ve given up. Higher-ups will(if not already) be quietly putting on their golden parachutes. The sound of Mr Boeing spinning in his grace . . .

        • Easy answer. After the MD acquisition by Boeing, Stonecihper and Sandy McD became the largest Boeing shareholders

        • Because when that happened, only one thing mattered, share value of Boeing on Wall Street. That’s when things started going downhill as quantity became more important and many line inspectors were taken out of the loop.

        • Airbus has been way ahead of Boeing for years.
          Better products, better portfolio, better quality.
          The A320 platform is no match for the B737.

          Against all the odds, Airbus still retains an engineering culture.

          Then, they were just lucky that Boeing failed first: this probably halted/slowed the slide into financialisation at the cost of quality.

    • 100% inspection is only 90% effective (per ASQC experiments). Per MIL-STD-105, it takes 3 inspections to yield a 99.7% confidence level. That is why it is important to have a final inspection and a Government Manditory Inspection Point (GMIP ). The Boeing Designated Customer Representative (DCR) program delutes this process.

      • When it comes to building 4000+ airliners, 99.7% is 12+ aircraft with loose plug door bolts.

        I’d never come across this notion before, but one can see why and appreciate its importance. Thanks for mentioning it!

        I find it quite interesting seeing how, for example, car engines are built these days. For critical operations like attaching cylinder heads, very often these days (even on “hand assembly” production lines) they’ll have a jig that automatically tightens down each head nut in the correct order, to the correct torque, measuring the torque in the process and the data is logged and kept indefinitely. This data coupled with verification and maintenance of the jig calibration is all that is needed to strongly assert that lots of cylinder heads were correctly installed.

        Heavily automated QC seems quite possible, in this day and age. I wonder how much of this kind of technology Airbus use, and how much Boeing are using.

        Once can see how one could have a system where every bolt, nut and hole has an RFID tag, and every torque wrench has an RFID reader and a datalink to the QC Brain. Such a thing would allow one to audit every bolted fastening, so long as only these torque wrenches were used by the workforce.

        • while a lot of the assembly drill jigs have their birth in automotive assembly history- the assembly ( bolt or rivet together ) have limited access such that such techniques as you propose are not practical for the several thousand bolts- rivets typical.

          • If one could get a conventional handheld torque wrench in to a space to tighten a bolt, there’s no reason why it’d couldn’t log an RFID token and torque applied too (the electronics is very small for small).

            Tohnichi effectively already make this kind of thing, adding the RFID bit would be the last piece. Parker-Hannifin seems to have a patent on the complete idea, damn it..

          • matthew- have you ever been close to an aircraft assembly line ?
            Do you know what a huck bolt or hi lok or hi shear fastener is ?
            Or a cherry lock blind fastener is
            Suggest you study up on what type of ” bolts” are used in aircraft assembly and where
            and why the ‘ bolts’ with cotter pins on the panel latches are rare/unique to rest of aircraft structure.

            Thank you

          • Matthew, you should listen to Bubba2. Let me give you one recent example of just how incredibly difficult these challenges are. I’ll pick on the 777 assembly line reinvention which included an attempt to do something similar to what you are talking about for fuselage barrel assembly. The goal was to automate it as much as possible, solve so rather awful biometric issues for the assembly technicians, and to replace individual tools that look like the beginning skeleton of an steel i-beam super structure of a new building that holds the panels in the correct positions while they are riveted together, and overhead cranes are used to move sub assemblies through two or three of these stations, first upside down, and then rotating them to right side up, all to be replaced with a new concept that has them on carts and tracks so they can flow through it, and stay upright the whole time. It was called the FAUB- fuselage assembly upright build.

            Millions were spent on this concept. First, a team of assembly engineers worked for months laying out the concept and identifying what needed to be developed. Then a boat storage facility was rented and a prototype of the concept was built. Then a new building was built on the Everett site and a full scale version of the tool was setup, and over a couple year period they slowly assembled a few barrels this way. It failed miserably because it could not make rate and retain acceptable accuracy.

            Now the whole thing was a wrongheaded stopgap anyway. This was just a reinvention of the assembly process for aluminum planes using flush rivets that was pioneered by Howard Hughes back in the 1930s. The future is all about composite structures formed on single sided molds using robotic tape layup methods. The 787 and A350 are built that way. But the 777 is bigger and would require methods and equipment not yet invented. Also, the result would require a full certification program including static and fatigue test articles, flight testing, and a destructive test of a relatively new plane that has a few thousand cycles on it after a preliminary service period. Boeing has had that kind of money since Stonecipher began the decapitalization program.

            There are other problems that deal with the cultures in the tech industry which as infected their customers. There are several ways of putting a chip in an RFID tag and then leveraging it for a number of purposes. Using cellular based tags for precision manufacturing location measurement is a complete non-starter. It’s no where near accurate or fast enough. Maybe one could do it with WiFi tags, but you would have to reinvent the whole stack the way the Israeli company AeroScout did (now a part of Stanley Black and Decker). But that would require IT networking people who get off their butts and spend time in the factories and have even the tiniest clue as to how to think out of the box and look at the whole problem. Boeing does not have that kind of talent (Cisco doesn’t either, but that’s another story).

            This is yet another example of the limiting factors that are self imposed by trying to do too much in software and high level programming languages. That approach to life creates an enormous barrier between the engineer and the real world You can’t count the number of layers of abstraction they have quite voluntarily allowed to become between themselves and reality.

            Now, I do think that if the stringers on the preassembled barrel panels had some precision mounting locations – maybe extension of the embedded titanium bits that are used for some of the joins – and then you developed some easy to install and self calibrating WIFI base stations that could be installed in less than five minutes, and then you developed a custom version of the stack not using IP addressing, but sticking to layer 2 to talk to the moving tooling heads, and throw in some laser measurement components as a second channel, that the two working together might have a chance of getting you there – but that would require a level of innovation that you just aren’t going to find in most aerospace companies any more. Maybe the boys and girls at Relativity could be trusted to build something , but Boeing? Not since before 2007 has Boeing had the kind of talent AND engineering leadership support required to pull off something like that. Plus, even in aerospace (except at Relativity) all the best engineering talent they do have is in DE not ME. This is sad because I’m convinced that most of the biggest breakthrough opportunities in aerospace are in manufacturing, not basic design. That said, you have to give those folks at SYPAQ a lot of credit for their cardboard drones that come in a flat pack. Of course that is the result of a joint DE/ME effort of the first order. and to be fair, Relativity has done a fantastic job of breaking down the DE/ME barriers also. It’s not all ME down there in the old Boeing/MD C-17 facility.

          • Goodness, someone suggests automated production line data gathering and it’s as if the world has fallen in.

            Yes I do know what a hi-lok is, and I also know you can’t tell if its been put in the hole and done up without going and looking at it. Similarly for knowing if one of the right specification was used. I also know that you can snap the nut off under-torque, if it is installed incorrectly.

            Good fastners are good to use, but they do not eliminate audit / inspection. Nor would automated data capture on a production line eliminate audit / inspection, nor would it be suitable for every single fastner. The job is all about putting as many barriers in the way of mistakes as possible, and making mistakes as visible as possible when they occur. Simply shrugging off the opportunities afforded by modern technology and musing “we’re doing a good enough job as it is” is missing the point (especially when it seems some in the industry seem disinclined to install any bolts at all). In a safey critical field, if something can be done better, it is worth doing it better.

    • Another scenario: Spirit Aero ships the fuselage and the plug in the “temporary condition” per agreement with Boeing so Boeing can remove it to move equipment or parts in and out the fuselage during final assembly. But for some reason on this particular aircraft, Boeing DID NOT NEED TO REMOVE THE PLUG, so no one went back to re-tighten it to its final condition. It didn’t get caught because it was never removed in the first place as it normally would have been, and the assemblers and inspectors only saw it as being “installed” thinking someone else must have torqued the bolts already, not realizing it’s still in its temp condition from Spirit. In this case it’s really hard to assign fault because everyone did the job including Spirit. You can’t fault the installer for NOT taking the plug off if he didn’t need to. You can’t blame the inspector for not inspecting it because there is nothing to inspect since it was not removed and reinstalled. If there is a problem, it lies within this “temporary installation” agreement between the two companies or “remove as required” on the assembly line.

      • This is the most plausible scenario I’ve heard yet. Wouldn’t be surprised if this turns out to be exactly what happened.

        • Not excusable. There should have been a directive in the QaQc procedures to make sure the bolts were secure before plane left the factory. This is Quality Control 101

        • It may well be the most likely scenario.

          The only thing is, how does that explain the “loose” bolts subsequently found on other aircraft, were they similarly installed in a “temporary condition” but BA had no need to remove, reinstall & inspect ?

          The final report will be very interesting reading.

      • There’ll likely be a “condition of supply” document that details that the plug will be delivered from Spirit not fully installed. In Boeing’s aircraft build plan there should then be a job card to carry out the final install, whether the access has been used or not.

      • When retired tech fellow (RTF) said ” The future is all about composite structures formed on single sided molds using robotic tape layup methods.”
        he was/is exactly correct- And while the famous FAUB Foul Up was long after my time- I fully agree with his comments and suggestion :)))
        BTW the single sided mold using robatic tape layup was used extensivly by boeing and others on the B2 bomber in the 80’s- for which I WAS involved.
        Boeing built/assembled the B2 cab section, the bomb bay section and a major part of the wing. Wuz there

      • I know the correct answer is known now, but I want to point out that per your indication of a standing agreement to ship the door plug in a temporary condition, a job at Boeing would be required for each airplane coming through: to fully install the door plug and inspect the installation, REGARDLESS of whether it was opened or not.

        Production accountability requires any and all planned and scheduled work to be accounted for, so if they planned on opening the door there should have been a job to do so too. Any change to the configuration of the airplane, even removing a temporarily installed part, cannot be done without traceability as to how the removal is to be done and attestation that it was done as prescribed, or that it was not done at all, with the approval of the person authorized to make such a decision indicated, or it was done in the revised manner indicated, with the identity of the person authorized to change the build process indicated and also the approval of the person authorized to accept the change in build process as revised (usually the shop Lead or Supervisor).

        If any of those elements that provide accountability and traceability for performing the work to plan or inspecting it to certify that it conforms to the as-designed airplane is missing, the part or assembly has lost configuration control and cannot be put on an airplane.

        I hope you can see that the process you described was lacking that traceability or accountability in many areas. But good try to envision what may have happened.

        • Pete.
          Every plug door installed by Spirit is mounted complete. That accounts for all attachment hardware and prevents issues in transit. Every plug door is opened in the paint shop at a minimum so the door jamb and seal may be masked and painted to match the topcoat color chosen by the operator….. The process failure seems to be pointing to an unplanned opening of the door at some point in time. The opening of the door seems to be in the center of a semantic argument where opening the door by manufacturing is seen as different than a removal of the door. Removals require RISR forms to be executed so QA has an inspection path on reassembly. Opening the door, being viewed as different by manufacturing since the door is still connected to the airplane and not technically “removed” didnt cause mfg to get an RISR issued even though the safety locking bolts are removed in both cases. This is sure looking like a case of Boeing Everett stepping in it. Ironically, this was covered in Heliopter Maintenance Magazine in their Oct/Nov issue last year. Look at pg10 https://edition.pagesuite-professional.co.uk/html5/reader/production/default.aspx?pubname=Helicopter%20Magazine&edid=90fdba75-c2ba-46fc-9de1-fd55d5faac2c

          • Good article. I was also perplexed at the concept of “reopening” a job… doesn’t that corrupt the build record? There’s also the fact that the door plug has a latent failure mode in that it may be lacking the 4 retaining bolts but appear from the outside to be securely closed, no “visibility” tags or flags that pop into view like on a proper door to indicate that it’s not actually locked. Does that “fail latent” possibility necessitate something special by way of QA or on the install job?

            BTW, small world… learned to fly @WHP, later instrument training @VNY, was ME @EVT late 90’s then various engineering incl KC-46, early ret ’15

          • “Does that “fail latent” possibility necessitate something special by way of QA or on the install job?”

            difference between regular use ( if possible expose $missing with flags or other obvious indication like “hangs open” )

            in the case of assembly (once) or repair (rarely) there are very few designs that do not allow for buried invisible errors. ( that is what you have a paper trail for.)

          • Boeing Everett? I thought the MAX in question was built at Boeing Renton.
            Opened, removed, or unsealed…. there does seem to be a semantic problem.

          • The Everett 737 line (the “North Line”) was to open this year in the old 747 bay. On indefinite hold.


      • Except Boeing has stated the plug was removed to repair 5 rivets incorrectly installed by Spirit. This should have generated a repair ticket (NCR) by QA that, because it’s now in final assembly, would in all likelyhood need to go to Engineering for repair instructions. This is then sent back to QA for review. Somewhere in there should have been removal and reassembly instructions. Repair instructions would be generated, and both the NCR and repair pages would be attached to the original assembly instructions. This was computerized the last time I was there.

        The NCR and repair instructions would need to be closed before the plane can move on. These should have included instructions to reinstall the doorplug, torque instructions, etc. QA and the Planner who reviewed the NCR and repair pages should have verified those instructions were there. Each step would be electronically stamped, the QA would buy off the NCR and the repair, and the plane can move on. This was the established process. NCRs cannot be delegated to Manufacturing per AS and FAA regulations. If this has changed, or someone had figured out a way to bypass this system, then the investigation will discover it. EVERYTHING on an airplane is documented.

        • Stacey- you are correct- but what seems to have happened is IMHO “word games ” and two incompatible ‘ reporting’ systems between Spirit and Renton.

          start here

          Now consider that the 4 locking bolts were never installed by Spirit.
          HIgh Blow at renton may have damaged the seal by allowing some leakage re door movementas fuselage expands. And close inspection revealed a few bad rivets on the fame and the damaged seal.

          The door-plug cannot be ” opened ” but only ” removed ”
          Bolts that are not there cannot be ” removed” and thus do NOT generate a ‘ replace ‘ or ” install ” tag at Renton.

          So the door got ‘ replaced’ or maybe ” closed ”
          No locking bolts ‘removed’ so no bolts ” replaced”
          And the Renton types involved – some or one took pics showing NO bolts and NTSB seems to have said 0-infereed Never installed.

          So the not so subtle diff between remove and replace and open and close AND two fubar reporting systems were major contributors.
          So we are back to ‘ thee Janitor did it- not my fault ‘ game

          • Bubba, you are incorrect that the plug door can only be removed. The opening track has a position where the door moves outboard 15 degrees for maintenance opening. There are 2 retention straps attached between the door sill and the plug to allow for this. Spirit installs the plug door complete with all the hardware. The apparent failure here is a matter of semantics. Opening the door is being viewed as different than removing the door. This fails to generate an RISR even though the unsafetying and removal of the safety lock bolts occurs identically in both cases. Your presupposition that high blow may have damaged the door seal sort of gets derailed by the gact that a door leqk is a very noisyvevent and nobody noted it. Thats a low probability event. The high probability path is that the door rework was closed out without a risr inspection and the risr disassembly notations were not followed because it was never started.

          • RE Scott C- As I stated- the main issue- problem is one on semantics and two so called “reporting” systems – one legal and one ??
            And the door -plug seal was reported as damaged and had to be fixed or replaced- along with the rivets in/near the frame section.

            I also note that in the link I posted in respone to stacey and earlier mike, there was mention that the an actual ‘ door’ emergency exit
            locking pins are in the frame but as a plug they. are part of the ” plug”

            I agree it is a ‘ supposition ‘ that the door-plug seal may have been damaged by High blow but since Boeing has not or will not provide ‘ documentation ‘- nor are the details mentioned in the NTSB preliminary report -it remains just that – a supposition. BTW IF all documentation nowdays is on computer- what is the excuse _ computer failed? “hard drive “- ( SSD) failed ? accidently erased ?

          • RE my response to Scott about pin location on exit door versus plug

            My description was backwards

            about 2:12 in and section labeled Guide Tracks it states (paraphrased )

            the ROLLER PINS are ON the other 4 ” exit” doors but on the plug they are attached to the frame – as illustrated.

          • GREAT YouTube video!!! It is worth considering the wisdom of using the same retention system for both an emergency exit door (EED) and a door plug panel (DPP). One needs to eject totally clear of the aircraft the other is supposed to be (semi) permanent.
            As a result, the semi permanent DPP was left in a “ready-to-eject” configuration, and it did.

          • mike M said ” As a result, the semi permanent DPP was left in a “ready-to-eject” configuration, and it did…
            But but but look how much money we saved and how fast we could produce them.

          • Semantics…… I’m going to introduce yet another term for what they do to those things that fill up the hole in the plane. How about “Unsealed”?
            If it stays sealed and has passed Blow Down it’s “Good” and if anyone f***s with it for any reason (open remove eject whatever) it needs to be inspected and signed off. Sorry if that causes a production delay.

            Now, it’s been said that the door plug panel (DPP) is ALWAYS unsealed for paint and livery. Is this true and correct? ALWAYS. Not just “if needed”.

            What about the emergency exit door (EED)? Is it unsealed for paint and livery?
            Boy that seal can get a real workout and the plane hasn’t even left the ground…

            Does anyone have a picture, drawing, video etc. showing the seal path? Is the seal “robust”? Does it have a specific number of times it can be unsealed / resealed before replacement is mandated? Is that worthy of consideration?

          • Figure 15 in the NTSB Preliminary Report is the closest encounter I’ve had with the seal. I sure would like to get even closer.

            It looks to me like the install and tuning of both the DPP and the EED involve careful adjustment of the twelve Stop Fittings and Stop Pads (SF and SP) with the panel in the location set by the 4 pins (EED) or 4 bolts (DPP) and the Hinge Guide Fittings (HGF).

            In auto parlance we would say up/down (U/D) is set by the pins/bolts and cross/car (C/C) is set by the 12 SFs and SPs. Fore/aft (F/A) is already set by the HGFs at the bottom being slid over the spring posts.

            It’s worth noting that in one video the mountings of the spring posts to the brackets allow them to “float” C/C a bit- Just enough to allow the SF and SP to locate the panel C/C without interference.

            When are the F/A locations of the pins set in stone? Is one “tight” F/A while the other has some F/A float?
            Either that or the spacing of the pins could be set by the distance between the HGFs on the panel, then the F/A location of the whole tamale is set by some dimension measured between the sides of the panel and the sides of the hole before the posts are set. Either way, measurements would be used to set the F/A location (there must be specs!). It is likely the same specs, for both gap and flush apply all-around both panels.

            I would love to see the sequence of 1) the seal being installed then 2) the emergency exit door being pushed down onto the spring pins then 3) the door handle then being turned to engage the upper and lower locking pins then 4) the adjustments to the stop pins (for C/C flush) and 5) whatever is done to adjust for F/A and U/D gaps. This would normally be done at Spirit, right?

            After that any “openings” are just a matter of unsealing, removing/opening, and re-sealing, with no adjustments. Unless a different panel is installed…

    • Boeing CEO Dave Calhoun’s comments last week on CNBC on “Quality Escapes” have been discussed widely in the media.

      Having watched Boeing closely over the years, I would submit that is a misdiagnosis.

      The real problem at Boeing is a “Management Escape.” It is when a company has defective or even no leadership.

      Scott – if you decide to write another book on Boeing, feel free to use that for a title.

    • This is not the first time Boeing has a break down on the 737 lines.

      There was a period a long time ago that they had to stop the line to get it sorted. Forget the era but I believe wrong wiring was involved.

    • In the “olden Boeing Days” there were Zero Defect signs everywhere and inspectors were required to inspect and report deficiencies and assembly lines were actually “slowed down” in some instances to determine the cause of a serious identified defect (e.g. missing bolts, etc.) Supervisors were held accountable to identify the seriousness of process or defect issues and recommend next steps if a “systems failure” or an employee issue. I remember photographs and descriptions of the consequence of defective or “sloppy” work throughout Boeing plants. What’s happened? (I always said that moving executive management to Chicago was the start of a bad idea.)

  2. ‘Boeing asked for an exemption for the MAX 7 from a safety regulation. Doubts already existed whether the FAA would grant the exemption. Now, doing so seems unlikely.’

    What are the ramifications of that?

    • @Frank P

      You bring up an important matter:

      There are literally hundreds of these exemptions for the 737 over the life of the airframe granted by the FAA.

      Exemptions are used by the manufacturers in order to skirt around complex CFR’s for certification. They are applied for thru the FAA.

      There’s some sort of problem discovered with max engine inlet anti ice and puts another burden on flight crews to manually manage. This system has been used on all Boeing jets for years yet the max has an issue. I’m not clear just what this problem is.
      But Boeing requested an exemption for the max 7&10 so they can proceed to certification!

      It’s BS and unsafe. Boeing should not be allowed to apply for exemptions any longer with their abject poor safety record.

      • The MAX has a composite nacelle, which would be damaged under certain circumstances IIRC.

        • If BA was looking for an exception for the MAX 7 & 10, how did they certify the 8 & 9, I wouldn’t think the nacelles are different on the 8 & 9 if both 7 & 10 are affected ?

          Is this a case of the condition being found during work to certify the 7 & 10 but as the 8 & 9 are certified already BA don’t HAVE to address it & are hoping that if they get the waiver for 7 & 10 that they can then retrospectively apply it to the 8 & 9 ?

          Has anyone got any links to / sources of the actual issue on the 7 & 10 and why it wouldn’t also apply to the 8 & 9 ?

          • @Pedro, The nacelle issue is a bit different as FAA certification testing including fan bladeout test is in a testcell with a testcell inlet “Bellmouth”. No testing at full climb speed with flight nacelle required. Now modern analytical tools can can calculate the nacelle vibration deformation and aero loads at fan blade out much more precisely, not possible in a realistic way back then.

          • JakDak
            The -8 and -9 were certified prior to Congress rewriting the regs on derivative cert by commonality. This is a simple matter of the rule changes congress demanded closing the doors to a multitude of cert by XXX paths that previously existed.

        • I read that if the crew leaves the de-icing system on for as little as 5 minutes after they pass into dry air that the fasteners of the leading edge of the nacelles (carbon fiber) can become damaged and detach allowing the engine to ingest them. Boeing says this is highly unlikely and asked for an exemption from having to prove that it’s unlikely. Makes me feel GREAT that they don’t want to have to prove what they claim! At this point, I wouldn’t believe Boeing if they told me 1+1=2, but realistically they would probably claim 0+0=2 and ask to be exempted from proving it.

          • @pedro so the same issue could well be present on the 8 & 9 & if something happens BA will push back with “it was certified according to the rules at the time”.

            @Claes would they check the de-icing issue using modelling then?

            Crew distracted by some other urgent fault, working through the checklist & forget that de-icing is still on as aircraft passes into dry air … what could possibly go wrong given that the conditions are the same for BOTH engines …

            All of these safety items should be fail safe, de-ice auto cut out after a certain period with alarm for crew to switch on again if necessary (but again with a busy crew if it was necessary & they didn’t turn it on again when needed …) maybe fix the underlying issue BA?

            At this point, it’s like waiting for the other shoe to drop, 737 MAX variants are likely to be in the skies for the next 30 years or so, BA can’t afford another complete hull loss.

            BA need to go back to a “belt & braces” way of thinking rather than “we don’t need the braces & the belt is a bit restrictive so it’ll be optional at extra cost to the customer”.

            Could we have the old BA back please.

      • Airdoc. The problem is that the Max nacelle nosebowl is composite, the NGs was aluminum. The existing deice system will overtemp a composite nosebowl in clear conditions, The waiver is to place the crew into the position to turn the deice off when entering clear conditions within X minutes instead of creating a new subsystem that would turn it off automatically when clear conditions are met.

        • Thanks Scott,

          So the sensible way to go is to create a subsystem to turn de-ice off & have the crew verify it (belt & braces), but instead “let’s leave it to the crew” …

          What happens if the crew is distracted for any reason, worst case both engines ingest composite materials & shut down ?

          It really does sound like an incident waiting to happen. Again it’s a numbers game, what is the possibility that this might occur across a particular type of aircraft in the next 30 years ?

          Will it be a “we couldn’t have foreseen that the crew would neglect to turn off de-ice while they were performing an emergency checklist for an unrelated serious issue” – “we thought that the pilots would recognise & act on a run-away trim that didn’t act like run-away trim within a crucial short period of time due to a system that we didn’t tell them about”.

          I have a very deep interest in human factors, using systems to aid humans is far better than leaving critical decisions up to humans alone. We have the technology to do this, if we don’t do it, it’s all about the money.

          • JakDak.
            You are of course missing the fine point here. The system is actuated manually when the crew encounters icing conditions. Your argument doesn’t make sense in that you are burdening the crew with identifying Ice and and yet screaming that we need to reduce workload by adding automation to turn it off. Please pick one.

          • Scott

            Let’s use an analogy: You have to turn on your electric toaster to make toast, if you don’t turn it off in time, your toast gets burnt, if you have to go & answer the door after you turn on the toaster & are gone too long, your toast burns or catches fire.

            That’s why there is a timer (set for how toasted you like your toast) – automation to assist you in not burning the toast.

            I’m advocating for assistance to increase safety. If the crew have to manually turn on the de-ice system, they already have the burden of identifying ice, automation isn’t adding to that burden. The consequences of not turning off de-ice could be serious, so provide assistance to mitigate the issue.

            BTW I’m all for automation to assist the crew in determining icing in the first place.

          • JakDak wrote. So the sensible way to go is to create a subsystem to turn de-ice off & have the crew verify it (belt & braces), but instead “let’s leave it to the crew” …

            NO….. The sensible thing to do is to realize that the -8 and -9, with identical cowlimg use the crew to observe icing comditions and manually apply heat as needed. There are 3 types of ice, clear, rime and impact. All 3 are dealt with differently as the effects on the airframe and the accretion rates are different. You are actually championing 2 different methods of operating the same deice system on the same cowlings. This adds to cockpit confusion as it creates a subfleet non-çommon cockpit situation. The waiver is seeking that the -7 and -10 be flown identically to the -8 and -9…… this waiver is a byproduct of the inability to continue to cert by commonality……. I do not support your added complication although your heart seems to be in the right place

          • @JakDak

            “we thought that the pilots would recognise & act on a run-away trim that didn’t act like run-away trim within a crucial short period of time due to a system that we didn’t tell them about”.

            I believe you are not quoting anyone and the statement is your creation. I see there are a number of accusative or conclusive elements embedded… What data did you use and what analytical process, including any human factors principles did you apply to validate them?

    • Boeing has shot itself in the foot again.

      In an of itself, a reality check based on success of identical previous systems working correctly is not an issue.

      But when a routine job has a blown Exit Panel in mid air, then stuff hits the jet engine. No matter how justified the de-ice exemption (really a continuation) is, the FAA can not politically take that hit.

      What compliance looks like I have not a clue, but there will be some kind of edict on it being different.

      The Exit Blank does not a new design either, the process failed (where it failed is still open, we have nothing from the NTSB yet).

      Reality is even if true, Spirit should never ship anything “loose”. If Boeing wants to remove it, then it should be part of the build process at Renton, remove, install, inspect, sign off.

      The laugh is Airlines reps inspecting stuff they can’t begin to have a handle on. Yep, it sure looks like a fuselage! Do you issue them a torque wrench and have them check each and every fastener on a 737?
      Oooops, some of those require disassembly to get to.

      Airline Mechanics could do some of it, aka D checks. Oh, we need another 1000 D check mechanics in structures, electrical and engine!

      How about you build it right in the first place!

      • ‘Reality is even if true, Spirit should never ship anything “loose”. If Boeing wants to remove it, then it should be part of the build process at Renton, remove, install, inspect, sign off.’

        If that’s how the customer requested it – that’s how you deliver it.

        • Not that it didn’t or doesn’t happen but shipping anything “loose” from Spirit is no norm. It makes no sense. Me, 34+ years Boeing most in Renton on 37’s. Think about it, those body sections roll by rail from Witchita KS to Renton WA. Anything not securely bolted down WILL rattle about and HAS damaged stuff, major structure included. Yes, 737 bodies are inspected upon load in final assy and yes, dozens or even hundreds of defect items are documented. There are also documented prior eacapements, travel-tags we used to call them, that the ship schedule does not allow time for repair by Spirit. And yes, as previously mentioned, there is a Spirit team on site, been there for decades, seriously. Rotating teams of mechanics who can do the work but cannot signoff the Boeing paperwork, so yeah, another potential escape point. Oh, and Stan Deal, come clean, Boeing has been shipping and inbedding quality and engineering support in Witchita for a long long time.

        • No you ship the a/c with door plugs completely installed so that your company(spirit) is out of the loop hands clean. Too many of these good guy deals between company’s fail and both company’s take a hit Boeing is always the first one to point to the other

          • but if the door or surrounding has ‘ faulty ” fasteners or seal, then whose problem or fault ?

      • You state: “But when a routine job has a blown Exit Panel in mid air, then stuff hits the jet engine.”

        You do realize the exit door plug is AFT of the wing, and hence AFT of the engine… … …

        • Suggest the reference really was a sly- polite way of saying the sewage effulent hit the fan or SHTF and had zip to do with the relative location of turbofan

        • The exit door plug is AFT of the wing, but it’s in front of the horizontal stabiliser. It was sheer luck that it didn’t hit the horizontal stabiliser, things could have turned out a great deal worse for Alaska 1282.

          Dan-Air flight 240 in 1981

  3. Scott and team, excellent report! Thank you.

    Stan Deal’s too little too late in my book. Should have started all this after all those people died in the first accidents! Boeing is in full damage control. Fools!

    Stan Deal will keep his job just like all the others.

    One thing I’m sure the FAA and the NTSB will investigate: even if these door plugs received from Spirit in the fuselage are safetied per drawing, there’s no interior installation yet. Why didn’t the FAL crews do an inspection to check those bolts before the sidewall installed??
    It’s right out in the open. But then that takes too much time.
    Airlines Alaska and United suffer needlessly because of this poor safety culture at Boeing.

    I just don’t know how they can trust this company anymore.

    • Airdoc:

      I agree with your overall assessment.

      But as far as details go, interior installers are not structural mechanics.

      You might as well ask them to inspect that bolt in the rudder system that was loose. That is not how a process works.

      If you have a One Off, say a Door Blank, then it needs its own process and people trained in the job of what makes it secure.

      Flight attendants can check the galley for its ops, they don’t check the engines, that is someone else’s job.

      Its easy to say that is a cop out, but when you call an Ambulance, you don’t use your Car Sales neighbor as the EMT. (yes you do the best you can until one arrives).

      You set up the process, you adhere to it, you don’t need nor do you want people that don’t know what they are doing mucking in it.

      • @TW
        You misunderstand and don’t know how factory work is accomplished.
        Of course we don’t want interior installation guys doing any inspections, that’s an inspector job. The planners can create a task to have the doors inspected and ok to close prior to sidewalls. Maybe Boeing does this already?

        But you and I both know, in the aviation world people are taught to, “if you see something say something”
        Ramp workers out on the airline are taught this. It’s all about safety!

        • Airdoc:

          I agree on the alert but I have also seen far too many cases of where, this is none of your bussiness.

          I asked a Contractor one time about an install that was clearly wrong. You know better than that! Yea, well been there done that and

          1. Even if you can get someones attention, they tell you to mind your own business

          2. I did it once, all the hate and discontent that cause, nope, not doing that. Its on the drawings and that is how we install it.

          3. Sure we fix this stuff latter but only once its caught or does not work.

          So yes in principal, everyone is alert but doing a close look at 4 bolts and nuts with cotter keys? No, they have their own jobs to do and they will have people nagging them to go faster.

      • I’ve just been reading along but was reminded of an adage from auto plants in Detroit; “We don’t build cars. We design processes that build cars. And we can spit out a Ford F-150 every 57 seconds.”

    • Return with us now to those thrilling days of yesteryear- or more specicically around 2002-2006 when the excellent DER system was morphed into the DMS system to essentially avoid the power of a DER to halt Delivery and maybe even production. And take a close close look at who was ‘ involved ‘ in that change despite many voiced objections. Compare to the last BA stock split year and the combination of major commercial aircraft companies .

      Now compare the KNOWN escapes in the previous to 2020 with the recent from 2020 to date escapes.

      is there a pattern ?

        • This is the consequence of greed, of outsourcing, of wanting to make more and more profits without worrying about the safety of human lives. It’s pathetic, all these CEOs should be fired

      • Once upon a time in a factory not so far away, but in a year very far away (1992) and on a Boeing program VERY well done was a vice president – program manager -military aircraft division -who was a leader. He had pushed a in house system known as a RAR- rapid action reques- which clearly said (paraphrased ) ” Write ME if you see something that needs attention or fixing. “- and for a short time, the system worked, mainly in the office sector. But in the factory, the supervisors and factory managers had made it known that such writings to that level was verboten. In fact the factory was proud of the ‘fact” that NO RAR for the last several months.
        So one fine day- I notified said VP that the factory was ‘proud’ of their record. The NEXT day I got a copy of a handwritten letter from the VP to about 5 ‘ managers ‘ ( still have it ) verifying that HE (VP) doesn’t get RAR from their domain any more- and he wanted to know an answer why- that his perception they had scared the hell out of the troops- and that the ONLY person who should fear such reports was one who was trying to hide something. My later discussions with the VP were almost funny as to the responses he got but even so things changed greatly for the better.

        • Yea, I am a retired 1st line QA manager. I was asked by my 2nd level why my guys had more write ups than other units. It was because thats what I want…for them to do their job! Upper management always wanted less…and here we are. So sad.

          • Same here, every time I objected to performing a final delivery inspection of the airplane to the delivery customer. Yes, I worked at the Seattle 737 Delivery Center and my job was to inspect the airplane in a completed state before it was given to the airline customer and my signature was on the delivery forms. I received negative feedback from 2nd level production managers. Finally, my 2nd level manager found a solution. I was informed a half an hour before my shift ended that I was being transferred to another area. I retired a year later when given the chance. Not surprised at the continuing problems we seem to be having. Funny how every time I was required to attend workshops deigned to increase production the first items that came to the table was to reduce or eliminate inspections of work performed. Self-acceptance was the preferred method of new technology.

          • For various retired quality types a suggestion from a long retired Engin-ear who ran into similar issues ( 1980’s) about 5 years before I retired. I was able to squelch some of the hammering I got for setting up a meeting with the director of Quality who had attended a meeting I chaired and remarked in a very positive fashion re the meeting and issues handled. So when I wanted to find out what it was that resulted in his positive, my then Manager told my supervisor that IF i met with the director for any reason He ( MY supervisor ) would be fired ! So the meeeting was cancelled- but I later got even. ;))
            My suggestion follows- WhenI retired, I was able to get/copy all of my paperworkre raises and transfers and some supporting documentation. Did i get all ? probably not- but they ARE your records. IF you got or have those records, you can establish time – dates- and perhaps check box reasons for transfer. What those jerks did borders on criminal and forwarding such details/evidence might be worth considering now.

        • One of the most critical cultural aspects of a continuous improvement production system is to celebrate the discovery of things that need attention. Finding things to work on has to be rewarded at all levels. This is one of the things that feels contrary to what it takes to have steady career growth. Hiding issues is a normal human reaction. This is one of the many reasons why a routine review of values is so important. Mulally’s start of meeting chart is a great example of something that can be done to help in this space.

          When the auto assembly plant in Fremont, CA was operated under the name “New United Motor Manufacturing, Inc. (NUMMI – a JV between Toyota and GM, and which is now the main Tesla plant) they would give employees “Kaizen rewards.” These were the usual sorts of things that one would buy with points at a company store.

          All visibility systems have this issue to overcome. Interfering with issue visibility should be a firing offense, with no more than one warning. Since it is exactly equivalent to sabotage of the production system, it should be clear that there is no recourse, and that needs to be reflected in the contracts. That said, the issue is seldom with the actual production workers. It is almost always with the management team. Visibly march a few managers out the door and off the property, and everyone will get the message. The production workers will probably go home smiling and feeling relieved. The management team will be learning a valuable lesson about ethics.

          • Also, worked 737, 757 delivery that whole area is full of hidden problems. I delivered a 757 full of fuel it developed a leak on delivery fuel coming out of the pack area My manager told me to get the airplane in the air. I told him we needed the defuel,deplane the customers he told me get that airplane in the air When it finally went away that’s when that manager got scared because I told him that’s the same issue that they were blown in the 747 exploding over New York and he let it go Seattle delivery center has a lot of problems

      • and why did Boeing push to get rid of the DER system?

        because in 2000 the Boeing engineers (and most DERs) went on strike over fallout from the McD buyout (its wasn’t a “merger”), and Boeing couldn’t deliver any airplanes. Boeing management swore to never let the uppity engineers ever do that again.

        • ex-Boeing- EXACTLY – I had retired in 1995 but worked the phones at SPEEA as a SPEEA retiree for a while during the strike and helped in a few other ways. And many who were not there or involved simply do not appreciate that it was( and maybe still is ) the largest ‘white collar ‘ strike in U.S History. And some still wonder why IAM did not go out in support. The reason was simple under long standing rules and contracts it was illegal for them to do so. however there was much ‘ legal ‘ and not so subtle support when SPEEA techs and Engineers walked out in the AM, Ever banged on a trash can or plastic jug ? ;))

          • Bubba2
            Do you remember the SPEEA guy that taught himself to play the French Horn on the sidewalk in front of the HQ Bldg

          • re PNWguy- nope re french horn- but do/did know a few of the burn barrall crew.

    • Agree 100% Boeing and the FAA escaped accountability for 300 deaths ! Why are these faulty planes still certified?

      Here’s an idea. How about building am entire fuselage? Why the heck are we even talking about door plug bolts? Why do they need door plugs ?

      This entire examination shows Boeing is at fault and not committed to safety at all.

      My entire organization is now telling employees not to fly on MAX jets. I surely will not.

    • There is information in the news that the mechanics doing the right side of the fuselage installation discovered it on its “door plug” and corrected it but that information did not flow thru the system to the left side installation mechanics.

      • A real case of right hand not knowing what left hand is or is not doing.

        But but but we met all diversity goals so pay up !

        • See throwawayboeingN704AL below for a likely series of events leading to 4 missing bolts.

  4. So, the plug gets opened according to some & not according to others. Recipe for oversight. Explains why multiple aircraft have the same problems. I’d love to be a fly on the wall at Spirit & know what their documentation calls for. Ditto Renton.
    The root cause, at least for this particular problem, is failure to deal with a non-standard airframe. Unfortunately, given recent history, it’s not just the one issue. How many of the other problems come from non-standard or out of sequence jobs? The AIM claims refer to “further damage,” which seems to imply that there have been quite a few

    • Agreed.

      It boils down to, if there is a one off, then there is also a process in place.

      Clearly there was a multi level process failure though when it gets by 3 layers of safety then its not a process failure, its a multi level deliberate intent.

      To correct this specific failure, we need to know where it occurred and in what step of the process. That is easily fixed, the Exit Blank design is not at issue as was MCAS.

      In this case, if there was not a process to deal with the Exit Blank, that is a failure. If there was and it was not followed, that is deliberate.

      When that occurs as have so many other failures, then you have an organizational failure and that is a management failure.

      We all make mistakes, the aircraft build process safety layers are there to catch that.

      • Agreed, not having a system in place to deal with non-standard jobs is a no no in this day and age, if that turns out to be the case. Sounds like different plants are working to different spec sheets in this specific case. That’s a failure in the very building blocks of the production system.

      • @TW

        Excellent points! Thank you.
        They are called Latent failures. Many checks and balances put in place and not followed.

        Dr. James Reason Swiss cheese model perfectly lined up unfortunately.

        • Thank you but it was another poster who supplied the One Off term.

          I am used to the concept but had not seen it in that term, which like Normalizing Deviation is perfect description and says exactly what is required to understand the issue.

    • “The root cause, at least for this particular problem, is failure to deal with a non-standard airframe.”

      The Max 8 and shorter Max 7 airframe is the same regarding exit doors. The Max 9 and Max 10 have the longer airframe and the same exit door layout. of course seating density decides which are active and which are plugged

      Which is what the A321 now does with it higher density cabin flex….more doors on some and plugs in some locations

      “Core to the cabin flex concept is the number of exit doors and the ability of passengers to easily access them in an emergency. Traditionally, the A321 has four exit doors along each side of the aircraft – a forward door, doors just forward and aft of the wing, and a rear door.”

      “Under the cabin flex concept, the plane would have five exit doors on each side. This includes the forward door, the two overwing doors, the door aft of the wing, and the rear door. Closed is the door forward of the wing. ”
      Even the A380 had a variable number of ‘active’ doors on upper deck

    • Since the production line images all show both fuselage and door plug in unpainted condition at final assembly, I find it likely that the door will be opened for prep before and cleanup after painting…

      • The door plug photo released today seems to show the outside painted with shiny white topcoat and the edges/sides painted with white primer .Unless Sprit painted the edges,the door plug must have been removed
        My guess at the moment is that Boeing didn’t refit the 4 bolts and Sprit are getting the blame for not tightening the bracket fasters . I would have thought that this was all part of the final tweaking process,Boeings problem?

  5. The 737 (MAX) Emergency Warning System, that came out as insufficient, outdated and ineffective 5 years ago after the crashes, is it still on the agenda?

    Maybe time, lobbying, other drama’s/ priorities helped Boeing to get it out of public, NTSB and FAA spotlights?

    I understood FAA approved it’s absense for 737-8/-9 based on questionable statistics in the period they were pushed around (and therefor couldn’t come back on it). But decided to not extend the exception for the “new” -7 and -10 after the issue has surfaced.

    • I have seen the video’s of the Ubber Cockpit on Airbus where the so called modern system did not work either.

      As long as the system alarms and the pilots follow procedures for it, it matter not what form the system is.

      This is a case in point, it had nothing to do with warning systems, it had all to do with quality control failures and violations of inspections.

      In the case of different warning systems you then split fleets of not only NG but within the MAX fleet and what seems like the same is not causing confusion.

      If the issues are addressed then it does not happen. If they are not, then the best Super Computer in the world does not save you from a blown off Exit Panel, only luck does.

      • FMS has proven itself over the last 40 years. The 737 cockpit is pre 1980. A confusing warning system played a role on the MAX crashes and some 737 NG crashes.

        Powerplay to reduce costs & smart statistics made FAA exempt Boeing from finally introducing FMS on the 737 MAX.

        I wouldn’t be surprized if the FAA, since its power was restored, wants a good FMS for all passenger aircraft. Putting safety first. Haven’t heard much on over recent years though..

        • Keesje:

          I have to disagree on the whole statement.

          As MCAS was hidden, there were no related alarms.

          You can argue there is problems with the underlying logic bust, ie when two AOS disagree with each other and no alarm function.

          But the so called alert that was “optional” also did no good if you had not trained on it.

          Just because its modern does not mean better, its just different and products may follow that longer term, but the reality is that the first thing a so called Modern Alert system does is start with checklists.

          What if you can’t see? What if the issue is not in the computer system?

          In modern or old era, the issue is not the alert system, its the failure behind it. Sometimes they are obvious and sometimes it takes extended fleet time for it to show up.

          The A330 has had some sudden nose dives that to this day have not been diagnosed. The Alert system is the nose dive.

          As I was told lo many years ago about the Alert system on a piece of equipment, ie, it works really well for what we know about but of course it can’t alert for something not known or programmed in.

          A post example of ???? was the requirement to re-progam the computes on the MAX for a fault that was mathematically possible but so far out to the center of the Universe it never occurred with the any 737 let alone the NG fleet.

          Unlike an AOA failure, it did not need a fix but it got it.

          And then the FAA fails to catch the quality negligence Boeing is conducting. Put your time and money where it counts.

          • For other posters, pls see @keesje’s reply to duke below.

        • So this is not exactly right. The LRUs in the EE bay on the newer 737s are all new. The change began before the cut over to the so-called MAX planes. Some number of -800s were equipped with stuff that was being developed as a part of the MAX programs. I’ve never been clear on exactly how these unconformities, in terms of the approved configurations of the previous models is handled in the certification paperwork. Maybe Bubba2 knows that stuff.

          What I know for sure is that the newer LRUs have newer model chips in them, and that is a huge problem. That’s the thing that scares me the most, because it enables the Jurassic Park Syndrome in spades, and Boeing has super serious problems in that space.

          For example, when it was developed for the 767, the MCAS was its own LRU. Turning it off would actually disconnect it at the hardware level. In the MAX, the MCAS is in the same LRU running on the same chip and OS instance as other flight control stuff. What does the word ‘off’ even mean in a world like that?

          The first time I ran into this problem was when I was listening to a KUOW interview of the Amazon exec in charge of their Alexa hardware program. This was about the same time the got into trouble when it was disclosed that their employees were listening to what was going on in people’s homes. The interviewer asked if the system could be turned off and the exec assured them that you could. All you had to do was command it to turn itself off. OK, and how did you then turn it back on? Well you just gave it another spoken command using it’s attention getting word. This guy clearly did not understand the meaning of the world ‘off.’

          OK, so now let’s talk about John Tracy and his relationship to the CEOs at Boeing. Did he know when to tell then ‘no’ and also when it was critical that he not ask the engineers if they could do something? Of course not. He was a glad hander par excellence. So there were no leadership safety controls in Boeing to prevent the engineers from trying to do something that they should not, at least not unless the FAA had written a very explicit rule telling them not to. To me, that was utterly terrifying. It made things like the MCAS design failure inevitable.

          Humans are very bad at comprehending large numbers, regardless of what is being counted. It can be time, money, mass, it doesn’t matter. Make the numbers much bigger than a thousand and billions are not distinguishable from trillions. It’s actually much worse than that. If we start talking about when the proto-Sumerians invented money some 9500 years ago, do people really have an intuitive sense that that was as far back in time before the pyramids of Egypt were built as the pyramids are removed from us in time? The answer is clearly no.

          This has serious implications for the design of anything that has chips in it because of the marginal cost of software versus hardware. Software has virtually zero marginal costs. Hardware has to be produce on an assembly line with significant marginal costs. This creates an enormous pressure to do things in software that should be done in hardware. It gets worse – much much worse.

          How many functions (separately running threads or programs) can be run on a single chip and OS instance? 30 years ago ten was a big number. Now there is no practical limit. Comparing a new plane to an older one at the systems level is like comparing flint knives with laser cutting tools. There is no comparison. Doing safe engineering of flight deck systems in this environment requires super high caliber leadership. At the very least, a boundary needs to be in place that make the FMA (some prefer the term FMEA) possible. If the number of lines of code is too great, then the number of failure modes simply gets out of hand making the analysis impossible. On top of that, nothing is done in assembly languages any more.

          Ask a software engineer how their code works. At a very fundamental level it is humanly impossible for them to know if the chip on which it is running is much more complex than an Intel 386, and significant portions of the code were written in assembler. Even then they are half a dozen layers of abstraction removed from the 1s and 0s that actually do the work. Then there is the bloatware part of the problem.

          High level languages are just calls to routines that someone else wrote in another high level language, all of which is in link libraries that get pulled into the runtime during the compile process. A task that would require a few hundred lines in an assembly language program ends up consuming hundreds of billions of bytes of code. This is fine for web tools and video games. But for safety critical systems in infrastructure?

          Failure Mode Analysis has been reduced to a joke because it has simply been allowed to become an impossible task.

          OK, then there is the distribution of engineering talent in the economy. When I was recruited into Boeing’s Advanced Research and Technology organization the second time, which I finally accepted, it was stunning the amount of talent that was there. One of the technical leaders was Ken Neves, who later went on to head up Lawrence Livermore. The place was oozing with that kind of talent. Aerospace used to be like that. It isn’t any more. the vast majority of top engineering talent has gone where the money is – big tech. So as the problems in safe software and hardware engineering have become dramatically more challenging, the talent pool working on them has declined. Sure there are still very talented people in aerospace, but if you were to look at a normal distribution curve of the location of talent across the economy, aerospace has shifted from being at the far right end of that curve to being way over on the left.

          And yes I am quite deliberately trying to scare people.

          • RE RTF ” Maybe Bubba2 knows that stuff. ” Nope not in my wheelhouse and a bit after my better years.

            I agree with and applaud the rest of his post-

            As to the rest- I do have perhaps a little related experience- information re software and chips- going back to the mid 60’s and early 70’s plus classes in pdp8- fortran. And a great interest in Visicalc and Basic ,etc.

            I note that thru the 777-boeing always had a simple cable backup system for major flight controls and 767 had /has a great emergency backup via prop driven power and minimum hydraulics (look up Gimli Glider)
            How many know the first two-three 767 airframes had a Flight Engineer station and when the two person cockpit became allowed
            it was removed for all following the beginning of the ‘ glass cockpit era.
            And the super deluxe tanker boom operator station with gee whiz capability . .

            Point is the drive to all on one chip game has always had drawbacks and hidden gotchas. now about MCAS . . .

  6. This problem is very simple to solve. If Stan Deal’s email said:

    Going forward we will immediately terminate any line manager, senior manager, or executive who creates an environment through direct action or inaction where quality inspections are short cut or defects are encouraged not to be reported or under reported due to schedule or cost pressures. Any employee reports of such an environment will be immediately investigated for their validity and the results of those investigations will be provided to the FAA/ODA.

    The problem with that is of course they have to fire almost the entire BCA leadership structure…

    • Amazing, but the aerospace business asked for no oversight, then proceeded to self-destruct without it.

      • Its been an change in engineering oversight worldwide for all types of projects.

        The organisation doing the building does its own checking , with minimal outside intervention depending on the reliability and experience of the builder.

        • Can a low inspection or oversight system produce a high quality and safe product? Or put another way, how much inspection and oversight is needed to accomplish what is needed? The answer to this question is not an engineering question, at least not one within the scope of most engineering disciplines, with the possible exception of some process engineers, but then that is not a certified designation.

          Quality and consistency are a product of the underlying culture. How thorough is a given team as it does its work? What is their sense of ownership, duty, and responsibility? Is anything in their life getting in the way of their performance of due diligence, and if so, does the culture ensure that such conditions will be noted and dealt with in a timely manner? In other words, do the assembly technicians have the support they need to ensure that even if they do feel an adequate level of ownership, duty, and responsibility, that they will be able to consistently perform to their own satisfaction, or given a break so they can deal with whatever is getting in the way of that?

          What all of this comes down to is short term greed versus a long term view of industrial relations. If you put people first, include everyone, provide a compelling vision, have clear goals that are tied to customer value, have a single clear plan that everyone understands, base your process design on facts and data, have everyone alert to unexpected things that are either potential disruptors or opportunities, have adequate communications, model a positive “find a way” attitude, approach things with some emotional resilience, and make it all fun, then much can be delegated and processes can be streamlined.

          But, to the extent that people do not feel appreciated, that they feel excluded and merely treated as a costly factor of production, are only presented with a vision of investor greed, have metrics that only focus on meeting your numbers, haven’t a clue about any vision or plan, are managed by unsupported biases flowing from leaders that have never actually done any of the work involved, assume that there will be no surprises because everyone will just do what they are paid to do, that keeping people informed of what the so-called leaders are thinking is a needless cost, that creativity and improvement in processes are mere slogans with no substance in action, that so-called leaders have no interest in what they are told by the line workers, or aren’t hearing because the workforce has just given up on them, and there is no trust, or resilience, and definitely no joy at the end of a shift from knowing good work was done and appreciated – well in that environment you can do all the inspecting and oversight you want, and you still won’t be able to produce a safe quality product.

          Culture and values matter. Problems in those areas cannot be fixed by added inspections and oversight. In fact, the added displays of mistrust that come with them will probably just make things worse. If someone wants to fix Boeing’s problems, a good place to start would be by holding Stonecipher and McNerney personally accountable for the lives lost in the three crashes. That would send the kind of a message that would start to get the attention of these jerks who call themselves leaders at this once great company. Oh, and put the company into receivership, admit that it has been bankrupt for quite a while, and stop this nonsense of liquidating it to maintain cash flow.

          • You mean like the Paris court didnt find Airbus and Airfrance guilty of corporate manslaughter over the AF447 A330 Atlantic crash – merely because of the criminal standard of proof was so high

            However the court did find Airbus and Air France guilty of negligence over the faulty pitot tubes and the poor training which meant the crew didnt understand the complicated FBW system and the effect in high altitude stalls. The stall warning ‘stopped and started’ repeatedly confusing them.
            Air France also used barely trained *2nd officers* on their flight deck
            228 people died because of the proven negligence of Airbus and Air France

          • Well stated RTF. It leads one to wonder how Boeing will approach contract negotiations with the IAM this year.
            Then again, there’s probably no need to wonder. We already know.

          • I am a
            retired Technical Fellow who retired early in 1999. I objected to the new culture at Boeing which seemed to have emanated from McDonnell Douglas after the merger. This “inspection escape” is a result of the emphasis of cost instead of safety. If it’s Boeing, I ain’t going.

          • Top management’s isolation from production, engineering etc, its fixation with accounting, profits and most of all the share price is slowly destroying Boeing. It’s reckless, long term treatment of shop floor employees stems from the same source. Avarice.

          • DoU, wasn’t this the AF447 FO Bonin “freezing”, overriding at the stick & the other two crew members noticing too late?

            If the FO had fainted or put his hands before his eyes, the aircraft would have automatically stabilized.

            Various interest groups have been trying to steer backgrounds for this tragic accident into their fav streets.

            Not excusing Air France (training) or Airbus (design) but it was a freak accident by a very experienced crew in a very mature aircraft. People still wondering how this could happen today..


          • Startle factor. cerebellum override.
            Reflexive action while being inattentive?

          • Keesje thats not what the court found after all the evidence.
            Sure the crew did some silly things, but a root cause analysis shows the air data probes, were known be faulty, were a primary cause of the flight upset.
            Air France training was faulted – they should have been trained for high altitude stall but werent -and they did silly things – and because the training about the type of FBW system used wasnt second nature about how it changed modes , and even didnt display this mode change clearly an Airbus issue.

          • The heater element on the pitot probes were inadequate for the low temps at their cruising altitude. The airplane had been scheduled to be fitted with a better unit when they got back to Paris.

            There was a design issue that helped compound matters. The engineers thought an AOA above a certain value to be impossible in an A330, so they programmed the ADIRU to flag the AOA data at that value and above as invalid. The stall warning won’t sound if the data is invalid. Well-entrenched in a stall, Bonin was urged to lower the nose, so he did—cautiously, but the stall warning just kept sounding… he had quite a ways to go. He became convinced he was correcting in the wrong direction and reversed, pulling up again… and the stall warning stopped! He dropped the nose a bit and the stall warning restarted so he pulled up into a pitch that was quiet. Ironically, the stall warning system was guiding Bonin to remain in a deep stall.

          • “AF447 comment”

            your story is wrong in some places. and for A3* aircraft:
            Below a certain speed AoA is judged to be invalid
            and thus a stall warning is not activated. ( a KISS design decission. have a better one? )
            This lead to inversion of the stall warning indication.
            slower -> off ( due to invalid sensor data )
            faster -> on ( due to actually being in a stall )
            pilot did not understand that and floated in and out of the min speed for valid determination.

            The installed pitot tubes did meet specs (reason why there was no rush to replace ) but the specs did no longer meet reality. ( Airbus did rather extensive test flights later on.)

  7. I can’t help but think back to the time during COVID lockdowns and travel restrictions where Boeing was offered US Government money to keep staff on payroll but out of arrogance and fear of reporting requirements, declined. That wasn’t the prior leadership, but the leadership in place today. After laying off inspectors and having hundreds of quality escapements,Boeing is going to have even more.oversight because of this arrogance. I used to work for Boeing, and I’m glad I escaped this mess, but I still have friends there and they will feel the ramifications.of this, even though none of this was the result of their decisions. Instead, the leaders might get let go and get multi-million dollar severance.packages. who said.life was fair.

    • US Fed bailout would have led to government ownership stake

      “what Boeing chief executive David Calhoun said in a Fox Business Network interview last month: that Boeing wouldn’t take government money if it had to give taxpayers an ownership stake as part of the deal. “I have no need for an equity stake,” Calhoun said. -Washington Post

      Your claims are imaginary dont match the facts

      • What? When did the USG “take ownership” of airlines that received loans from Treasury?

        • This is what the CEO of Boeing said.
          Instead of a government loan Boeing raised the $25 bill in the commercial market.
          Again the facts dont match the claims , *most airline aid* was as grants with a lessor amount as loans. I dont know what the CEOs said but they were presumably happy with the potential share ownership

          “Out of $54 billion, airlines must repay $14 billion, or 26.2%

          • Boeing did turn down the government money from the CARE Act that would have required warrants to be issued. Instead, Boeing issued billions of dollars in bonds and we were told the government bought some of these.

          • @Scott & Duke

            …and to that point bout an Equity stake;

            Seems I remember a time when BA went to NY to see of they could raise some $30 billion in an equity offering, but wanted an unreasonable price for their shares and the smart money walked.

          • It’s important to understand a bit how the American and most western financial systems are setup. Central banks are not a part of the government in the sense that they are either part of the executive branch or a quasi-judicial body like the SEC. In fact, the U.S. central bank (the Federal Reserve system) came into existence in a secret meeting of private bankers who did what they did in order avoid a government takeover. Legislative authorization came later, and can be fairly said to have been purchased by the banking industry.

            Central banks invent money out of thin air. They typically do not make direct advances to the government’s treasury, but rather let money flow through the economy and let the government get some through taxation and fee for service operations. But, they can advance money to anyone they want, including the government.

            Our Fed, gave a lot of money directly to Boeing. So Calhoun is technically correct, but it is a might skimpy fig leaf that makes it so. The full extent of the Fed’s advances have not been disclosed, but they may have been in excess of $30 billion. There were two large issuances of bonds in 2020 that coincided with the Fed’s market interventions.

            When the Fed does things like this, it makes up terms for them to obfuscate what is going on. They like to call such interventions opening some sort of a new “window.”

            This is quite different from systems that existed before the rise of the Italian banking families in the 14th century, and which have continued to exist in many totalitarian governments. For example, in the Soviet system which somewhat persists in the current Russian system, and in the current Chinese system, the central banking and governmental treasury functions are combined. Totalitarian governments that control their central banking processes successfully tend to have very modest taxes, if any in most cases, because as money is invented out of thin air, the governments just take what they want.

            Money creation by central banks is not inflationary so long as the amount of money chasing goods and services is only slightly greater than the amount of goods and services the economy can produce. A tiny amount of inflation is a good thing, as it applies pressure to expand the production of goods and services, provided such pressure can be met with a growth response. Keynes famously put it this way: “Anything we can do, we can afford to do.” This suggests some interesting opportunities for Fed policies that have not yet been tried, but that is beyond the scope of this discussion. The salient point here is that anyone who thinks Boeing didn’t get a monster bailout three years ago has fallen prey to this chicanery, which was the intent of those involved in it. These GE trained folks running Boeing are thieves pure and simple. They are con artists of the first order.

            The underlying problem here is the way corporations are chartered in this country. In effect, even discussing corporate chartering was avoided during the original constitutional convention, because doing so would have almost certainly prevented getting the country launched. This is a problem and it keeps getting worse. Guys like Calhoun and Kelner belong in jail for what they do.

          • CBSNews:
            * American Airlines said the Treasury Department approved $5.8 billion for the airline — a $4.1 billion grant and a $1.7 billion low-interest loan.

            * Delta Air Lines said it reached an agreement with the Treasury Department for $5.4 billion — a $3.8 billion grant and a $1.6 billion loan.

            * Southwest Airlines said it expects to get $3.2 billion, including more than $2.3 billion in cash and the balance in an unsecured loan.

            * Delta said the government will get warrants for about 1% of its stock, and Southwest put the Treasury Department’s warrants at less than 1% of its shares.

          • was mutual exclusion of gov. help and paying out bonuses an issue? the deciding one actually?

          • “Our Fed, gave a lot of money directly to Boeing. So Calhoun is technically correct, but it is a might skimpy fig leaf that makes it so. The full extent of the Fed’s advances have not been disclosed, but they may have been in excess of $30 billion. ”

            Yes the Feds bond buying was disclosed they listed something like 800 companies . Boeing Capital and Boeing were amoung them

            Boeing wasnt even in the Top 10
            Most were sold by end of 2021

          • So there is some very bad data being bandied about here. Now admittedly it was easy to miss because the announcements by the Fed and the bond issues by Boeing were not at all explicit about what was going on. Given how much news was flooding us on a wide range of topics at that time, one should not feel bad about having missed it. The only reason that I saw it is because I was specifically looking for it at the time. After seeing Harry and Prince Jim’s behavior up close, I stopped trusting anything any exec at Boeing had to say about anything, even if it was something innocuous such as what they had for lunch. However, not everyone was asleep at the stick. A pretty good article on the first and largest of the two big advances was written up by Robyn Shapiro at the American Economic Liberties Project. You can find her paper here: https://www.economicliberties.us/press-release/boeing_fed_bailout/

            One other thing that gets a lot of confusion in the financial press at times is the separation between the Fed and the U.S. Treasury. It is not uncommon for terminology that is used for the transactions of one to be inappropriately used for the other. I’ve seen Fed advances referred to as bonds as though they were U.S. Government bonds when they are not even remotely the same thing, or at least not yet. Anything could become possible I suppose given the turmoil we seem to be headed toward.

      • “what Boeing chief executive David Calhoun said in a Fox Business Network interview last month: that Boeing wouldn’t take government money if it had to give taxpayers an ownership stake as part of the deal. “I have no need for an equity stake,” Calhoun said. -Washington Post

        Keeping skilled workers on the payroll is safer than laying them off and then training replacements. This is proof that Boeing put shareholder rights over product quality.

  8. Systemic issues, start to finish, nose to tail. The AS1282 incident is not THE problem but a symptom of a wide spread disease.

  9. Shocking! Seems like we have entered the era of if it’s Boeing I’m not going.

  10. The aerospace industry does not value hands on experience! What I have witnessed is assemblers with no manufacturing experience, Engineers with no related experience, Managers who don’t know how to read a blue print! Personally my manager asked me if I was being too picky about a few employees workmanship, even after I and the manager verified the specs on his computer!

  11. Thanks for that comment, airdoc. I agree with those who say that more inspections will not solve the problem, whch is systemic, cultural, and fear-based.

    I’m interested to see
    if anything real comes of the Spirit whistleblower lawsuit, as something of a proxy for what so far has only been noise.

    • Yes, who checks the checkers. The culture and pay must reward skill and quality. Often management cannot see the difference and the ones that agrees with management and smells good are promoted in a such a system. The system must test and rate everybody in skill and quality, a bit like diving were ratings on jump difficulty and jump performance are rated.

  12. Why do the NTSB, FAA, and many others dismiss the pressurization warning lights Alaska ignored (and in a maintenance note said, “oh, we need to check that”)? If they do the check and find the cause the aircraft never flies. Regulators and others talk out of both side of their mouths – we need more warning lights and aids for new and less experienced pilots, but, oh, by the way, if a warning light goes off it is unimportant or irrelevant (or so says the star struck head of the NTSB). Can’t have it both ways. I get a warning light on my car, I don’t ignore it.

      • Mike has an excellent point, its not the mechanic who determines what happens it is the supervisor (unless forced into it by specific regulation languages)

        I was watching the take on ETOPs and the ability to dispatch despite an issue like that as there are backup systems and then the ability to drop to 10,000 feet and continue (did anyone think a door would blow off and WHAT????? does that do to your fuel burn………

        Well other than a few pesky fuselage blowouts …….

        That said, you are counting on backup systems when you have a serious question hanging out.

        Those backup systems are there for an UNKNOWN event, so you whittle away and dispatch it counting on backup systems.

        And if you are wrong about all your assumptions? Yea, its a slippery slope.

        The FAA is supposed to deliver a perfectly working aircraft (and the airlines won’t take it if it has an issue) then they whittle away from the Golden Concept and degrade it.

  13. Didn’t Alaska have three prior warnings on this plane, and decided “in abundance of caution” not to do the Hawaii route? Decompression over land could have been a catastrophic problem – fortunately that didn’t happen – but wasn’t that, in retrospect, a significant misjudgment?

    • There’s nothing so good as having a company head who has worked their way up through the company. That’s a trait shared by many successful companies…

      I’m an engineer. I’ve never had the good fortune to have an organisation head who is also an engineer. It’s really irritating.

  14. I keep thinking that Boeing can’t fall any lower than it already has. Yet, this instance with the Alaska flight, proves me wrong. WTF happened to this once mighty American company?

    1) Opening the 787 plant in SC to avoid Union rules, seemed radical and contrarian to their Pacific NW heritage.
    2) Subbing out major components and shipping them thousands of miles, instead of making everything (or nearly everything) in the same region.
    3) When their HQ moved to Chicago years ago, it made no sense to me. Now, they’ve moved to Arlington, VA (to be closer to the politics). They need to move the F back to Seattle and get back to their roots!
    4) As for the Max, it’s lipstick on a pig. Designing a system that the pilots weren’t trained on, much less knew about, costing 346 lives… It should have stopped with the -500 series and they should have kept on going with the 757, or designed a whole new plane.

    It’s truly a sad state of affairs, the poor decisions Boeing continues to make.

    • While I agree with the overall, there are specifics that are not correct.

      Boeing has been shipping fuselages from Kansas since the 737 was started. Maybe someone can enlighten us on the specifics though it seems that Boeing had a plant in Kansas and someone had a great idea how to use it.

      All the Boeing activity would have been in Renton at the time and they did move to Everett for wide body.

      Oddly I don’t think the MAX is by itself a bad aircraft. Yes it should have been replaced two generations ago, but its viable.

      The issues are one small design factor (MCAS) that was lethal. The other is management failure in quality control.

      Management has been undercutting the system for so long getting it back is going to be rife with these kinds of failures (it was just incredible luck it was not a lost aircraft).

      • This isn’t quite right, but it’s close. There was a period of time when Renton was called the Triple 7 plant because it produced 707, 727, and 737 aircraft. After the new final assembly building was built in the 1960s, fuselage assembly was split between two buildings, one of which is long gone. The layout of the Renton streets have changed a bit, so it’s a little had to describe the exact locations.

        The 737 was begun as an IR&D project and is the only Boeing airplane ever created without a board presentation and approval. If my numbers are right, it was funded 85% by NASA and 15% by Boeing, which is why the prototype aircraft was delivered to NASA (it’s now in the covered air park at MOF). The goal was to see if a plane to serve smaller cities with short or no runways (i.e. grass fields), and not much of a terminal building could be created for low cost by reusing as much tooling and existing parts as possible.

        Wing stub/wing body join and build up (sections 44 and 45) were done in the 4-20 building in the same tooling used for the other two planes. This was sideways and special carts were used to move the assembly over to the final assembly line (later in the new building). The rest of the fuse assembly or barrel build-up was done in a building that no longer exists.

        When the assembly process for all of Boeing’s planes began being redesigned subsequent to the 1989 Japan Study Trip (a result of the JAL-123 crash and Jim Blue’s report), it was decided to do the wing join in final assembly and build the fuse as one integrated piece on a new line in Wichita. My memory is a tad fuzzy on the timing. Most of the -300/-400/-500 fuses were built using the new system – maybe all of them. I just don’t remember when the cut over to Wichita occurred. There would be an easy way to check if someone can locate an early production -300. After the move of the fuse assembly to Wichita and the change in where the wing join was done, the crown panel was simplified into a single piece the entire length of sections 42-46. Before that, it was a separate panel for each section.

        As for the sale or spin out of Wichita (Project Lloyd, named after Lloyd Stearman, the founder of that company which became part of Boeing’s vertically integrated company that Congress partially broke up in the early 1930s, it actually could have been a very good thing. However, it is important in a virtual enterprise to act as though there are no corporate boundaries, otherwise queuing costs develop that are wasteful, and there is a bunch of finger pointing at across the boundaries. So the divestiture was not in and of itself a bad thing. The way it was handled was horrible.

        Spirit could have been a big win/win/win for BAE, Boeing, and the airlines. There was a lot more production capacity in Wichita than Boeing was using. This should have given them the freedom to grow the buisness and diversify a bit. They did start down that path, but the GE cultural issues with short thinking incompetent management infected them too. Fortunately, I’ve never seen anything to suggest that they also suffered the corruption that came into Boeing with Stonecipher and McNerney (i.e. the unconscionable compensation package thievery, and the decapitalization program that has been so devastating to Boeing. Project Lloyd, from the Boeing perspective, was a part of that decapitalization, and not a genuine effort to improve the asset utilization of the Wichita site.

        Anyway, that’s part of the story of the 737. The fuse was NOT always built in Wichita. Certainly none of the -100 and -200 planes were built that way.

        • AMEN AMEN AMEN. A little bit more on 737 history from my recollection. Around 1967-68 at about the same time as 747 everett building were being erected, and the 2707 sst was in progress, the first of the 737s were underway at what was then called the Thompson site about a half mile north of Dev center and south of plant 2. ( later used for B2 wing assembly ) In the process after assembling the first one or two 737, they found a problem with wing join such that there was a slight but measureable discrepency between left and right sides. I was working on 2707 at DC and my then lead nee supervisor was routed to 737 program.I’m not too sure how many were assembled at thompson site.

          • “measureable discrepency between left and right sides.”

            Ah, a Renault 🙂
            R4 has offset rear wheels 2..3″

          • Ah, the Renault 4. Tremendous car.

            Interestingly, there is a Quality and business / politics angle to this too. At the time the Renault 4 went out of production, Renaults were truly notorious for rust. I can remember seeing brand new zero miles cars in the dealership with rust on them (it was that bad). The reason was that the company (bearing in mind this was at the time socialist controlled France) had a deal to use cheap steel from the USSR. Politics / business motivations overriding quality. Today, if you can find one, the only R4’s left are even older, dating back to when Renault had been using French steel.

            The car industry is a good thing to look at for good / bad patterns. Renault / Nissan merger; French flair, Japanese engineering? Nope, they ended up with Renault engineering. Mazda / Lancia? Same thing (though even worse). Boeing / McDonell Douglas?

            Are there any such mergers where a bad company has been turned round by a merger with a good company? I think, not.

            Given that business / industry seems to have bad form in this regard – that the good is always fatally corrupted by the bad in a merger – perhaps there ought to be some government control. If it happens too much, it becomes a matter of national economic significance, because your entire industrial base can get trashed. So, I think there is a reason for governments to intervene in mergers to prevent the rot spreading.

          • Matthew:

            There is no such thing as Mazda/Lancia. Lancia belongs to FIAT which again is Stelantis today

        • “The 737 was begun as an IR&D project …”

          At the beginning stood Lufthansa with a qualified bouquet of desired features. They did not want a tail mounted engines plane.

          based on that the 737 was created. With NASA money or without. whatever.

          in the first years the 737 was not a love child. Selling it off was considered.

      • “one small design factor”
        What an understatement for a defect that cost almost 350 lives. Yeah I know, they *aren’t* Americans!

  15. I’ve been trying to read these comments but had to stop: they’re disappearing up their own jetpipes.
    The way I see the article, it tells me one thing and one thing only: shortcuts at every level, of production and safety oversight.
    Airplanes are expensive and unforgiving if stuff fails. Boeing should treat them as such. The customer is unlikely to be able to take them back to the dealer for a warranty claim, it’s likely to be in a million pieces on the ground. The Board, Directors, and Executives need to remind themselves of this every moment of the day and night, and NOT dream of untold profits: the shareholders will survive lower dividends etc; passengers and customers will not survive Board generosity to said shareholders.
    KISS: no more cost cutting, no more shortcuts. That’s it. There’s a reason why Airbus charges more. And why their reputation is unblemished.

    • You can say that all day long but its wish in one hand and spit in the other and see which fills up first.

      Or as my wresting coach said, if a Frog Had Wings It Would Not Bump Along On its Ass.

      What is your path to fixing it other than just saying something that we all see but have not had a solution for?

      Should have, would have, could have does not cut it.

      I am disappointed in the comment as it starts on a high plane (pun) that criticizes but adds nothing other than wishes to a situation that needs to be fixed.

      We know what the problem is, what we can’t do is make the fix.

  16. Please ask the shareholders permission if they are willing to contribute in the process.

    • Down to $205 today. I think they’re starting to run. Some will jump in and call it a great deal, citing the duopoly, backlog and cash flow, but they’re in for a rocky ride methinks.

      • To buy now would be to assume nothing else is back there
        in the dark places, esp w/ the MAX. I would not be that optimistic.

        • It hit $199 and change today, but has climbed back out just over the $200 mark.

          We’ll see where the floor is…

    • AS the fine article says: it’s all a matter of public record, albeit under-reported. Thanks for the link. I didn’t know that The Leverwas David Sirota’s work- kudos to him.

  17. Boeing has slipped down to $205 today, off 4.5% in a year.

    I wonder what’s going to happen when 2023 Y/E results are posted? The effects of the Alaska accident probably won’t be reflected in the 2023 EOY, but will hit in Q1/2024.

    It’s going to be a bad few months for BA on the reporting front. All the cash flow hype isn’t going to wash this away.

  18. The shareholders should have not say in the way Boeing is run. They have no equity stake, and in fact owe the company just shy of $16 billion at the beginning of last year, not counting what they owe for the fake asset called “deferred costs” which is that much again.

    The reason that this insanity is able to continue, with fake “owners” getting a voice in the future of a big corporate entity like this, is because of the way we charter corporations in this country, and then enforce the provisions of those charters. It is done at the state level. States compete with each other for the chartering fees, and those with the fewest requirements and the least amount of oversight get the most business. States like Delaware (where Boeing is chartered) and Nevada win most of the business.

    Delaware doesn’t even require disclosure of the principles in a corporation for 30 days, but they didn’t even require that until a couple years ago. Using rotating shell companies, a corporate entity can be created and dissolved within that period of time, and thus never have to disclose anything, so the change was just a way to get more chartering fees.

    Much of the world’s illicit business, including drug cartels and the thieves running authoritarian countries use these tools to hide their wealth. Interpol and the ICC (International Criminal Court) bitterly complain about this enablement by us, but so far the political will to fix the problem hasn’t been there. The crooks in control of Boeing are really small fries compared to some of the folks taking advantage of our chartering mess, but take advantage of it they do.

    Oh, and Calhoun gets a lot more than the $22 million in salary that the article mentioned. He doesen’t pay for any of the expenses that the company takes on to support his lifestyle, including the jet and crew that is in effect his plane.

    • The salaries of the executives is one thing, but the targets, stock price related bonusses have to go. I’ve sypathized the idea to give them relatively high fixed salaries + bonusses based on nett results, long term portfolio health, supply chain relations and creating value for the USA.

      • Keesje:

        I am on board with that being the right approach but why would they change it?

        Right now they get paid stupid money for failing and then when they get booted they get a huge payout despite the fact they failed was why they got booted.

        As I see it, national legislation would be needed and I don’t see that happening.

      • RTF:

        If you did not have shareholders you wold not have a public company, mixed feelings on that, but reality is its a way for a company to be what it is.

        In theory being a Corporation takes away the liability to making decisions that can be terribly wrong.

        I fully agree that Corporations ahve turned into cess pits, I worked for one big one and was around a 2nd for 35 years.

        They are big behemoth elephants that plow their way through the world – bulk wins.

        To correct that we would need legislation.

        In the meantime I get pestered all the time about stocks I own and voting the shares. Yea I am a shareholder but have no idea what is going on with those companies, I can barely keep up with my own life (or not as my wife would be the first to tell you)

        If someone came along that was going to fix a company I had shares in and I understood at least the broad issues, I would allocate those shares to them.

        So in theory, yea we are part of the company we own but its too big for us to grasp and what are our alternatives? Mine are all in group funds, so I don’t even have the direct shares if I could do something.

    • Well the article is part true and part myth and small part fact- with an interesting mix of ???- lets look at one ‘ minor’ statement which might be a typo or juste plain carelessness.
      ” The only reason the system didn’t crash long before it did was that Boeing had a core of veterans who understood it better than most, had worked with it man and boy and could make it function. But they were mostly not high-level people, and when Boeing offered an early-exit package in the 1991-92 slump, a lot of them took it. ”

      The early exit package was announced in Feb-March 1995 and with some exceptions had to be gone by July 1995. About 8000 plus jumped- including yours truly. But many were brought back as contractors- and a year later as I recall, production came to a halt- for the first time. True DCAC-MRM was fubar- mainly due to head in sand Boeing Computer system folks.

      Many of the 777 players had transitioned from about 10 years on the B2 program in dev center- and had used two or three computer systems like NCAD NCAL Catia, and a few other- some of which were cousins of an earfly Lockheed computer system.- and the 777 was the last plane top come close to budget and schedule. The 737 NG was contaminated by several mcdummy aero types who spent bucu bucks on a ‘ new’ wing only to find the gains were somewhat less than minimal. and on and on

      • As per Duke’s comment earlier: It isn’t just Boeing. 20 years ago at the largest supplier of parts to Boeing, management was constantly belittling and hamstringing the Quality Department. This east coast located company makes everything that goes in an airplane and fighter jet. These managers loved to show off their MBAs. They loved lean manufacturing and (LCC) low cost countries. I understand ethics classes in MBA schools are poorly attended…

      • A bit more as I have time- until about 1993-94 Engineers in ‘ Manufacturing ” ( Tooling and Manufacturing research and similar ) were paid on the average about 10 percent less and were essentially capped at one level below the ” real ‘” engineers in design and flight test and structures and sero etc. And this fact was well hidden. Yet several of the improvemets in manufacturing and assembly and tooling came from that same group. 777 partly broke that lmit. Example Coldworking to improve fatigue life was developed by a NON engineer ex supervisor in the mid 1960’s about the time of the first 707 AWACS- and largely first used in production on 757-767. Electromagnetic Riveting developed in 1967-68 in Manufacturing Research and used on 747,767 and morphed into ElectroImpact now used around the world. Ditto on certain drilling techniques and equipment.

        ALL before stonecipher and welch types. Saturn 5 and lunar rover, lunar orbiter first pics of earth from moon on first launch. Boeing BBJ with winglets from Aeropartners- ex Boeing aerotypes pooh pooed by. mcdummy aero types re 737 NG. But things like giant windmills not a winner by boeing. Commeercial hydrofoils- all before stonesphincter.

        • Obs: in the initial process of converting the 747SP NASA must have kicked of a major check! Note the outcome as described by LH Technik!

          In the space hardware and remote sensing domain I’ve worked with Dutch, British, Soviet, Russian, Brazilian and US entities.
          US entities combine overbearing behavior with qualification escapes additionally they invariably try homesteading your IP.

          Due to fickle politics and the desire to push partners under the bus SOFIA readiness for flight was delayed by NASA for a couple of years. “parked” .
          People in the back end instrumentation projects were forced to move on long before SOFIA ever “worked”. My last job in the SOFIA domain was “resocketing” some of these projects. Others were dumped and started from new.

        • NASA has no airliner maintenance facilities , they would use a commercial shop for modifications and overhauls.

          ” Originally delivered to Pan Am in 1977 it was later acquired by United Airlines[takeover of PA routes and equipment] in February 1986 and spent nine years with the Chicago-based carrier as N145UA. Retired and stored in December 1995, it was acquired by NASA in 1997 and sent to L-3 Integrated Systems in Waco, Texas for a conversion programme that lasted from 1998 to 2007.”
          DLR had organised maintenance at LHT from 2011 ( and Hamburg had worked on 747SPs as well)

  19. I see the Crew Alerting System / EICAS popping up soon again unfortunately when a NG/ MAX gets in trouble. Despite politicians pushing it through.


    But in Aviation if it’s not ok, it just isn’t going away.

    The inlet design and engine anti-ice system exemption seem a decoy. It’s more likely EICAS. Some believe the exemption is based on questionable statistical safety evidence. With decision makers suffering from forgetfulness (NTSB, 2020 law), not capable of understanding it. Or being unwilling to do so..


    • Absolutely. From AW regarding the MAX 7 exemption BA currently is seeking:
      ‘ “Clearly, the flight crew forgetting to turn off the anti-ice system is a foreseeable single failure,” it continues, noting that the 737’s lack of a modern flight crew alerting system thanks to other regulatory exceptions granted years ago only adds to the probability of pilots not realizing the system is on when it should not be. “The probability of single failures is assumed to be one,” the FAS states. “Boeing is petitioning to allow the use of a probability analysis to circumvent the fail-safe requirements, which are the foundation of the aviation industry.”

  20. I was working at Boeing in St. Louis when the company started using “escape” as an euphemism for a foul-up, after the 7373 Max crashes. All of us white collar, working stiff engineers had a healthy laugh at this. As if no longer calling something a mistake would make people forget about Boeings MCAS foul-up and deaths of hundreds of people. We joked, after someone had passed gas, “Oops…I had an escape in my pants.”

    • You have to develop some rotten humor when the uppers get stupid with their attempts to divert.

      The “Moon Shot” nonesense (being very polite) is nothing more than an excuse that it was management failure not the 787 itself that was the issue (yea a few tech problems but for a leap into CRFP and More Electric its been a huge success – let down by more management failures) .

      The company I worked for initiated a third party report line just before I quit. The comments were, why would I use that, its just bait to catch me.

      When I quit I sent a letter to the management about the abuses and violations I had seen. Never heard a peep from them. Par for the course these days

      Quality is more than a slogan. Calhoun and his crocodile tears is particularly disgusting.

      • Right. Management sabotages these new programs, so the lowly CEO exclaims: No Moonshot! He only got away with that proclamation because Wall Street loved it, and the major shareholders had so much stock in other endeavors that they find it a chore to pay attention.

    • If the grounding of the Max 9 is determined to be their responsibility, I would say so. It won’t show up in the 2023 financials IMO, but in Q1.

      We’ll keep an eye on customer compensation numbers:

      ‘Commercial aircraft programs inventory included amounts credited in cash or other consideration (early issue sales consideration) to airline
      customers totaling $3,862 and $3,586 at September 30, 2023 and December 31, 2022.’

      It went up a little less than $300 million in the first 9 months (not sure for what) but it’ll be in the Q1 financials

      • Yeah how about the expenses incurred by AS/FR etc for stationing additional engineers at Renton?

    • As well as the FT article linked to in that tweet there’s one on the BBC – https://www.bbc.co.uk/news/business-67994140

      “Asked in an interview with the BBC if he had complete confidence in Boeing’s quality control processes after the incident which saw an unused door fall off, the Ryanair boss said “no”.
      But he added that his airline did now have “more confidence” in plane maker Boeing.
      Mr O’Leary also said that a delivery of 12 planes towards the end of last year had been “in terms of defects the best deliveries we’ve had in three years”.

      Mr O’Leary said that Boeing made good planes, but compared the relationship to a marriage: “I can be in love with you and still occasionally criticise some of your personal habits. I think that’s the same with Boeing.”

      He suggested that the management team at Boeing “needs to be improved” following the incident, although he gave his support for Boeing’s current chief executive David Calhoun, stating that he is “doing a stellar job in very tough circumstances”.

      Mr O’Leary added: “We don’t need more senior management changes in Boeing.”

      • -> The Irish airline, which is one of the largest customers of Boeing’s 737 Max narrow-body aircraft, increased the number of engineers it has on site at the US group’s production line in Seattle from six to 12.

        Ryanair has also raised the number of engineers on the production line of Spirit AeroSystems, one of Boeing’s largest suppliers, from four to eight. […]

        “To be fair to Boeing from last September they have significantly increased the number of engineers on quality control. I would have to say we have seen a marked improvement in the quality of aircraft deliveries,” [MOL] said.


  21. Why not just tie wire all bolts together as is done for internal machinery parts. No need to use the plugs for maintenance if windows are designed as all others.

  22. Thank you for taking up my comment from the article earlier and turning it into an article. I had been looking for some more time the days but did not find a single picture where it was open at Boeing. There is never an access platform. It will not be opened for final production.

    The question is, are emergency doors actually opened there at Boeing or are they already arriving full from Spirit as well? If there is no working platform, and I did not find a picture where this is the case, where at what point in the case is this very door or plate being processed at Boeing? It never seems to be the case.

    Has something changed to the FAL 737NG9 where there were also such plates? Has this work step been cancelled in order to produce more aircraft per month? Has this been outsourced to Spirit with the request for complete installation?
    When at Boeing is the acceptance of this plate, door, etc. ? How does this work out?

    • All the questions that NTSB will be asking and the FAA does not want to know.

      Clearly the FAA is more in cover its butt mode than ensuring Boeing does its end right.

      • Agreed 100%.

        Big deal about his being a rear admiral from nuclear propulsion and the fact he is the Chairman of Ingals Shipbuilding maters not.

        Good old boys rubbing each others backs.

        • Just a hunch, but I’m betting you’ve never met the man nor anyone who ever worked for him. At best all you know of him is what you read on the Internet.
          If my hunch is right, you probably should step away from the keyboard before you attempt to type another critique of the man and his character.

          • I have never dealt with a company upper that had any integrity. So the guy may be a one off but he has all the hallmarks of the usual cushy job in Industry when he retires on a fat salary paid by the public.

            So yes there are some good people in the upper echelons but can you say you have watched the Ford Carrier debacle and think the US Navy is well run?

            A Chairman with HII has nothing in common with me and is a natural for Boeing to grab.

            Yea I can comment on his character until I see otherwise.

            It occurs to me he is Kelnors associated and is going to be used to rein in Calumnious of finish him.

            I go with Verify then Trust.

        • US military nuclear propulsion linked VERY low incidence of safety escapes ( to use modern terminology ) has been brought up as the template on how to manage such things.

          • And we have had Nuke subs ram a passenger boat off Hawaii and at least two run into objects in the ocean failing to follow protocol.

            What we do know is the guy was in the Navy, retired and is now Chairman of HII. That does not give me a warm fuzzy feeling.

          • Yes, because it’s prohibitively expensive, and it doesn’t fly.

          • -he assembly and delivery rate of nuke ships and submarines is a bit less than 30/month- thus fewer parts and assemblies per month.

          • “Nucular Admiral”

            my post was about the “why”
            not a judgement on good/bad. 🙂

            It is probably one of those “Duh, simple, just ….”
            solution offers that are just plain wrong.

    • So the admiral does know the 737 does not have a prop, no nuke propulsion and not even sails ? And where is the anchor locker ? helms alee !

      • I frankly do not care someone has no Aviation experience, a tech background is what is needed and some things cross.

        I have issue with he looks to be part of the revolving door where an Admiral or General retires and then becomes big in the Industry he was overseeing.

        I know one guy who retired from that same position and Industry wanted him badly as he could give them all the inside info on enforcement. I admired he stayed retired, its the people like those who go back to work that worry me, they are greedy and a good retirement is not enough, back to often its about money.

      • Transworld said …” What we do know is the guy was in the Navy, retired and is now Chairman of HII. That does not give me a warm fuzzy feeling.”

        So the choice is between warm fuzzy and glow in the dark ? I’ll pick the warm-fuzzy

    • The Navy and Huntington Ingalls Industries just announced a one-year delay in delivery of the JFK to July of 2025 – plus an added $400 million in costs.

      US Navy inspections of Ingalls-built ships uncovered significant problems, report shows

      • Hey, Boing picked just the right [clueless] guy to oversee their QC debacle.


        • Hey why a defense contractor would put a retired Admiral as chairman of the board?

          The Pentagon itself failed audit for sixth year in a row!

        • Vincent:

          Clueless? No. Rich? Yep.

          oh, we are not supposed to impune his character.

  23. Amazing how the media just blatantly lies these days. The bolts that hold the door in place are not the same bolts that are supposedly “loose” ( Probably found that they were at 79 ftlb instead of 80). [Edited as violation of Reader Comment rules], they could print that bigfoot was on top of the plane and ripped the door off and half of the world would believe them.

    • As I understand it they are the bolts that hold it in place.

      By preventing the movement they lock it to the tabs.

      Clearly no bolts no restraint and it launches.

    • A couple of things here;

      This is in 2018, before the Max crashes, when BCA was at it zenith.

      List price of a Max 8 is $121.6 million. At $53 million, this indicates a discount of 56% off of list.

      We know from the financials that BA has an average discount rate of 61%, for all the aircraft they delivered in the first 9 months. In 2022 the rate of discount for the entire years was 65%, based on this:

      BOEING Max 7 $99.70
      BOEING Max 8 $121.60 387 $47,059.20
      BOEING Max 9 $128.90
      BOEING Max 10 $134.90
      BOEING 747 $418.40 5 $2,092.00
      BOEING 767-300ER $217.90
      BOEING 767-300FR $220.30 33 $7,269.90
      BOEING 777-200ER $306.60
      BOEING 777-200LR $346.90
      BOEING 777-300ER $375.50
      BOEING 777F $352.30 24 $8,455.20
      BOEING 787-8 $248.30 9 $2,234.70
      BOEING 787-9 $292.50 10 $2,925.00
      BOEING 787-10 $338.40 12 $4,060.80

      Total 100% of list…………………….480………..$74,096.80

      Actual Revenue: $25,867


      The flip side questions I have are:

      1) If the BA is actually getting $53 million a pop for a Max 8, what aircraft are they discounting in the 65% range, to bring it back to an overall 61%?

      2) If they got that kind of money on a Max in 2022, what was discounted even higher, to bring it back to a 65% average.

      3) You’ll notice I used the lowest list price aircraft available for the calc – no Max 9’s, which bumps the list price and makes the discount rate even higher.

      4) If the ‘value’ of a Max is $53 million, but BA get’s less…why? Do thy have a bunch of bad deals they signed?

      IMO these ‘value’ figures don’t match up with reality…

      • So called Fair Market Value. Well when UA/FR/WN order, they get better prices than smaller airlines.

    • I’m not defending anyone here, but for the record:

      This happened one month after Biden assumed office. Who was chairman of the SEC at that time, circa Jan/Feb 2021?

      Commissioner of the Securities and Exchange Commission

      Allison Lee
      In office
      July 8, 2019 – July 15, 2022

      That would be someone who in that seat and appointed during the Trump presidency.

      Not to say that it wouldn’t have been any different and both sides are known to have ‘helped’ corporate ‘Murica…but facts do matter.

  24. Boeing as an organization has suffered 4 hits with potential existential consequences.
    1. The engineers and technicians who designed and built the 707 through 777 planes have left the company taking a lot of undocumented wisdom with them.
    2. The headquarters got moved away from design and build locations depriving decision makers of important details.
    3. Production was globalized with big sections made remotely and then assembled at an assembly factory.
    4. Recreational cannabis was legalized in Washington where design offices and assembly factories are located with no way to keep workers under the influence out of the plants.
    All of these happened bout the same time at the design and assembly problems afflicted the 787 and 737Max planes. Some resemble lapses in short term memory, some bad judgement, and some a don’t care attitude. My Dad was a Navy airplane mechanic in the 30s and 40s. Years after he became a high ranking offices he still had a “belt and suspenders” attitude toward doing a job right and would always check and double check his work. Anyone working on airplanes should have that mindset.

    • “4. Recreational cannabis was legalized in Washington where design offices and assembly factories are located with no way to keep workers under the influence out of the plants.”

      funny idea.
      do you think that legalization has done anything to the volume of consumption?
      Up front it is an easement for legal enforcement.

      We have that discussion here. Some see it as the skies falling.
      they miss out on the fact that Canabis is an established recreational drug, widely used. Easy to get. Legal or not.

      • The difference between Legal and not Legal, is that the engineers can be smoking the stuff in the Staff Canteen without being challenged. Then 30 seconds later they are putting parts on an aircraft.
        In the railway and aircraft industry, there are more restrict limits for Alcohol use, whilst performing a rail or aircraft duty. Generally 25% the drink/drive limits.

        • Normally- Engineers are NOT allowed to do touch labor on any part of any aircraft.

          Even in video games

        • May I turn your attention to:

          “do you think that legalization has done anything to the volume of consumption?”

    • George R:

      The biggest issue is that Boeing broke up the close association between engineers and the production lines.

      If you have toured the Everett facility you will see hundreds of offices so engineers could be in contact with their work.

      Boeing has dismantled a system that worked to one that is failing.

      Stan Deal no longer has an office, he floats with his entourage following behind him. No wonder he is considered only a sales buy by O’Leary.

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

    A couple of things to cover before we begin:

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

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

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

    The mid-exit doors on a 737-9 of both the regular and plug variety come from Spirit already installed in what is supposed to be the final configuration and in the Renton factory, there is a job for the doors team to verify this “final” install and rigging meets drawing requirements. In a healthy production system, this would be a “belt and suspenders” sort of check, but the 737 production system is quite far from healthy, its a rambling, shambling, disaster waiting to happen. As a result, this check job that should find minimal defects has in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations (so both actual doors for the high density configs, and plugs like the one that blew out). That is a hideously high and very alarming number, and if our quality system on 737 was healthy, it would have stopped the line and driven the issue back to supplier after the first few instances. Obviously, this did not happen. Now, on the incident aircraft this check job was completed on 31 August 2023, and did turn up discrepancies, but on the RH side door, not the LH that actually failed. I could blame the team for missing certain details, but given the enormous volume of defects they were already finding and fixing, it was inevitable something would slip through- and on the incident aircraft something did. I know what you are thinking at this point, but grab some popcorn because there is a plot twist coming up.

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

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

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

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

    • As an “original source” of this information under the False Claims Act, you could be entitled to recover somewhere between 15-25% of the total value of 737Max-9 sales as something called a qui tam relator. I am at a law school rather than in practice and so wouldn’t be the guy to help you, but I know a fair amount about qui tam and would happily connect you with a lawyer in practice. You’re probably going to need one anyhow if Boeing finds out who you are–and of course a nice thing about FCA whistleblower suits is that it’d protect you from retaliation against Boeing separate and apart from the eventual monetary award. I don’t particularly want to get involved other than sending you to someone qualified, but if you’re interested shoot me an email at b.brink381@passmail.net.

      • You’re not an original source under the FCA if the NTSB is already looking at the build records, which they are.

        • if you think the NTSB already has this full story of what went wrong, with supporting interstitial testimony from a person with knowledge, you’ve lost the plot. the fact the NTSB has pulled the build records is irrelevant–just like the fact the FAA had legal authority to access the build records, and undoubtedly they were audited by an FAA contractor at some point.

      • Just curious, since this individual disclosed this publicly first before telling the government, how do they qualify for this? I thought that was the requirement before going public.

        Not a lawyer just curious.

        • Way, way too tidy. What’s the backstory?

          Trust no one, these days. Why is that conveniently anonymous commenter doing so many nice things for us, in this particular forum?

          “That which appears to be be too good to be true, almost always is.”

          No, I don’t buy the *tidy*, provided story, which has a Corp/PR feel.

          • I’m sorry, do you think this somehow paints Boeing as less culpable? This is scarlet letter type stuff, it should make you never want to step foot on a Boeing again, which is why the above commenters warn that Boeing would be all too happy to sue the pants off OP

      • Over the last 6 decades I have come to the conclusion
        that lawyers are more of a problem than a satisfactory solution.

      • You need to study more in law school. Alaska Airlines is not operated by the federal government.

        • No, but the airworthiness certificate obtained from the FAA is federal property, fraudulently obtained, which is why I said for the entire run rather than just those sold to Alaska. I should know what qualifies as defrauding the feds, given I spent 10 years prosecuting it at Main Justice and now teach at a law school. Speaking of, where’d you go? Embry-Riddle?

          • Hyperbole may work in a court room, rarely, but tends to be anathema in engineering and the technicalities of producing an airplane. Are you trying to teach us a new definition of fraud or that lawyers can see things in the text that nobody else can? Also, a Certificate of Airworthiness is required for—and is carried aboard—each airplane.

          • @Pete P, fraud is lying for money.

            1) Failing to disclose material information to a federal authority is lying to the federal government.

            2) Obtaining an airworthiness certificate is prerequisite to selling the aircraft — Boeing isn’t in the business of selling hangar decorations.

            3) Selling things is how most companies make money.

            So, to review, Boeing 1) lied to the federal government in order to 2) be able to sell the aircraft and 3) make money.


          • @fraudunderstander

            Your definition of fraud being equivalent to lying, and lying being the equivalent of failing to disclose is valid—IF the material information in question was known or possessed and the action to conceal and suppress was deliberate, not when the failure to disclose is an inexorable automatic consequence of not having that material information to disclose. So what was not disclosed, deliberately?

          • Side note for the legal beagles- 737 Max 9 in service for about 7 years. seems to me the issue comes down to how many repeat ” escapes” on a critical part(s) have been noticed- found- recorded. if more than a a small handfull- say a dozen or so and they still continue, that would be grounds for drastic action. How many workers have filed complaints and been ‘ reassigned ‘ ? A collection of such IMHO would be sufficient to establish some sort of ‘ criminal ‘ action against the various levels of management/supervision who tried to or did suprfess such complaints.- but probably not as high as the Board but second or third level assembly and inspection level ‘ supervisors ‘ or ‘managers’.

            IMHO its very apparant that such actions are long overdue by the appropriate federal agency. It should NOT take two years to take action or report on the ‘ missing’ bolts and similar. Anything over 90 to 120 days to ‘ correct’ or report is suspect and probably the result of political interference or back scratching ( to be polite )

            just my .00002 worth

          • “So what was not disclosed, deliberately?”

            Reality has gone past such triffles quite some time ago.

            Today such things are handled with a foam of “unintentional” fallout.
            Existence of that “foam” indicates that the system is intentional in its effects.

            the eager legal beavers have to progress to a new set of trees to gnaw on. 🙂

          • @Bubba2 By definition escapes would be found by the customer airline or contract maintenance or retrofitter for customization, etc. There should be a pretty good record of escapes from Spirit. As described by “the whistleblower” it doesn’t seem like anyone is trying to suppress anything, though the Spirit workers doing warranty rework at Boeing and covering up B.QA-indicated badly installed rivets with paint is called “hiding defects” per Boeing’s employee behavior guidance, the corrective action for which is termination. Hopefully Spirit’s HR rules are the same. Although the w.blower says it is in black & white that Boeing didn’t install the 4 bolts on that Alaska airplane, it actually isn’t. What is in evidence is that Spirit’s work was reworked by Boeing and a seal was replaced. The seal replacement required opening of the plug so—by inference, not b&w documentation—Boeing must have removed the 4 bolts to open the plug and then must have closed the plug without installing the 4 bolts. Far from hiding or suppressing the bad work, it seems Boeing is accepting them all into a software tool that perhaps was meant to provide visibility and status of issues but gradually was burdened with the detail work instructions for addressing each issue, and the tool gradually became the ad hoc repository of out-of-sequence work/rework to do and whether it was already done or not, with no accounting against the official work instructions.,There used to be a principle called SSPD Single Source of Product Data which prohibited the existence of multiple copies of the design specs of a part because creating, revising or deleting a design must be done ONCE, in one location where the design resides. Failure to abide by SSPD would mean a loss of configuration control of the design. Don’t manufacturing plans have to abide by similar?

          • RE Pete P feb 3 “@Bubba2 By definition escapes would be found…”
            What with most ‘paperwork’ being on computer there should be better
            configuration control and tracking. That being said- MY guess is the silly ‘ game ‘ between the use of the term ” OPEN ” versus “REMOVE ” may be the “ROOT” cause of the blowout of the ” DOOR” versus “PLUG”. When I open my door to replace the weather stripping, i do NOT take it off the hinges or remove the doorknob -latch. When done I simply close the door.

            But when I REMOVE the door to ‘ fix’ it for whatever reason, I pull the hinge pins. So when I put it back to use as a door or a PLUG, I muste REPLACE the hinge pins, even if I no longer use it as a door for whatever reason.

            With 2 different tracking systems- then we get into the silly- deadly game of loss of configuration, loss of comparison, etc. For it to happen once or twice would be an oversight- but IMHO for the system to be firmly entrenched is the result of MISS Management which may border on criminal, especially as it affects Safety. I?ts one thing to allow or have a system to mismatch paint or carpet colors, another to allow missing parts due to Daffynitions..

          • Re: Bubba2 Feb 3
            (Got distracted, forgot to post…)

            Not a silly game of definitions. In fact, the root cause could be ID’d as a failure to recognize or consider the function of a plug as NOT the same as a door. An installed door has operational functions: “create an opening to provide access” and “close an opening to block access.” In your door example: opening a door that has been installed—to access and fix the weatherstrip—is exercising the ‘provide access’ function. A door may have securing mechanisms to keep it in one operational function or another, but those are designed to be bypassed when necessary such that the door can be operated into its opened/closed/secured/unsecured functions at will, without affecting the installation status of the door and any ancillary mechanisms in any way.

            An installed plug has one operational function: “securely plug an opening.” Obviously, securing mechanisms must be installed to consider the plug ‘installed.’ A plug that is not plugging the opening and left hanging on its hinges may LOOK like an OPEN DOOR, but to make it appear ‘open’ requires REMOVING (uninstalling) at least its securing mechanisms—a change to the build configuration.

            The failure to consider and contrast the functional natures of a door and a plug was a cognitive failure which enabled the paradigm for a door: “Opening a door does not invalidate its installation, a removal does” being applied to a plug and then operating on the plug as though it was a door, another cognitive failure, which led to two process errors: 1) (opening it like a door) failing to create a manufacturing plan to maintain build config accountability for the removal of the previously securely installed plug with inherent obviation of inspection and verification processes, and 2) (closing it like a door) failing to install the plug with securing mechanisms—a build error with error correction mechanisms eliminated.

            Root cause: inadequate competency in manufacturing planning—a failure to recognize the job as also requiring an UNDERSTANDING of the functionality of the parts and to integrate it into the analysis and decision making.

            Vocabulary is not just semantics, it is critically important, because as you say, you do. For future operations, don’t use ‘open’ & ‘close’ w.r.t. the plug, try using ‘uninstall (and leave hanging by the hinges)’ and ‘securely install’ respectively.

            P.S.: There was nothing willful or devious in the errors that occurred, perhaps inadequate supervision. The notion that all human errors must be anticipated, intercepted and eliminated (so we can live the immortal lives we were promised?) is absurd. Also, it wasn’t two systems that were tracking the build config—there were none!

    • On behalf of the management and entire Boeing family, “No harm, no fowl.”

    • This may well explain why the plug failed on the Alaska Airlines 737-9. But reports are emerging now about loose bolts during inspections on other airplanes (including the 737-900.) Don’t know if they are authentic but, if true, how would you explain those anomalies? Is there some other cause like some sneak vibration???

      • most likely just NOT properly installed. One must be careful of the use of the term ” bolts ” in aircraft structures. Many are not the simple bolt with a threaded- torqued ‘ nut’ but specialized types with special ‘ collars ” which simply twist on with a socket wrench and by design at a predetermined torque break off the nut ( hex) portion. Problem is if wrong length ” bolt” is used, when collar breaks off, joint is not tight. Look up ‘HI-LOK” for details.
        Some use a swaged on collar called ” Huck Lock bolts. Both are normally used to ‘ permanently” fasten two or three parts together and rarely removed.
        Then there are rivets with sizes normally up to 3/8 dia machine installed by Gemcor or Electro_Impact (magnetic hammer ) machines with are automatic or semi automatic installed combination drill and rivet. smaller rivets up to about 1/4 may be hand driven with pneumatic hand ” gun” and bucking bar- a ‘ teamwork” process. All can be mis-installed for a variety of reasons commonly too long or too short or twisted. The above is an overly simplified explanation of what the press calls a ‘ bolt’ or a ‘rivet “‘ which brings up pictures in mind of a simple open end or socket wrench and twisting until tight. and long explanations of why didn’t ….. or who didn’t twist the ‘ nut tight enough ‘ games. Then there are ‘ taperloks’ and ‘coldworking’ processes to improve fatigue life.

        Just my .0002 having developed , worked with or improved-both drilling and fastening and riveting stuff over 20 years.

        • Which reminds me -From time to time in days LONG past ive been inside the 747 wing box, inside the 767 body sections on assembly ine, dealt with some assembly and fastening issues on the production line, etc. And while being reasonably famila with ‘ permanent’ structure and ‘ replaceable structure, I have have little memory of seeing or dealing with castellated nuts and cotter-pins. MY guess is that of the thousands of fasteners other than rivets, such items are very rare- probably less than 100 per aircraft ? hopefully those closer to the assembly line can correct me.

          • From the pictures posted online, the 4 arrestor bolts on the plug look like they are of the bolt/washer/castellated nut/cotter pin type.

    • Former Chairman DeFazio here. I find the Boeing employees account to be very credible and consistent with the findings in my Committees investigation published in 2021. We passed legislation that totally overhauled the ODA process and authorized significant increases in funding for FAA inspectors. Obviously not enough to prevent the hack former McDonnell Douglas managers who took over Boeing to continue to ignore quality and safety to rush planes out the door to please Wall Street and of course fatten their own portfolios. Justice should rescind the Deferred Criminal Prosecution agreement and go after the management.

    • Boeing qa’s are terrible there’s been a lot of times where they won’t even watch the process of installation of critical flight parts and still sign off on it they like to cut a lot of corners. [Edited as violation of Reader Comment rules.]

    • The sensible action to take for the future should be to force CMES to be the only recording system, accessible to all the engineers. SAT should be shut down or linked to the CMES.

    • Dear throwawayboeingN704AL,
      Thank you for such a concise accounting of what should have happened, what didn’t happen, and what doesn’t happen at Boeing.
      I have faith that Boeing will now correct its criminal behaviors and focus on reinstating the tradition of the finest aircraft in the skies.
      The question that I have, that has persisted in my mind is; why do the majority of 737 Max fuselages STILL have that exit hole anyway??
      Everything that I have read points to the fact that there are only a very few airplanes with crowded seating that require that emergency exit. Why can’t Spirit simply continue the fuselage past that point with a regular style side-of-the -airplane construction without the hole??
      Thank you,

    • Quick question: Are emergency exit doors and door plug panels (anything that fills that hole in the fuselage) unsealed at Paint & Livery? Always/Sometimes/never?

    • Hi, Marc Wortman here, journalist/author. Exploring an indepth feature article for a major global magazine. I’d like to speak with you off the record or not for attribution, as you wish. Please email me. Thanks, Marc

  26. 2/2

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

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

    I told you it was stupid.

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

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

      • Suggestion for Throwaway- IF you have ever used your personal computer to check your Boeing benefits or other comm to any boeing address, suggest you check for any pki certificates that may be on your computer issued by Boeing. You can be sure Boeing will go all out to find you.

        I speak from personal factual knowledge having dealt with the then ethics dept and then finding any access to my benefit accounts blocked regardless of email used. Boeing claimed that such was only used on Boeing computers and never on personal. problem was I had copies of such that were somehow installed on my computer. using a diffferent computer had no problems .Long story short- eventually a high ranking employee took sudden retirement and who had come over from mcDouglas
        Was it illegal – yep
        Of course that was over a decade ago

        • I would go further. Get rid of that machine. Create a paper trail that verifies that you got rid of it before your posting.

          Also, there will be sys admin records of everyone who accessed those databases. This is how Dominic Gates’ source code named Kodiak was discovered and fired. Now in that instance, only a very small number of people knew how to access the records he did, so narrowing the list was not that hard. In this instance it will be a much longer list, and next to impossible to narrow things down without further evidence. But, they will already have someone working on it full time.

          Also, bless you for your integrity. Your posting has a real potential to save hundreds of lives.

          • If you have direct knowledge of how Boeing identified Kodiak, please contact me.
            There is one piece of that story that still remains a mystery to me.

            Dominic Gates
            (206) 683-5329 cell

        • My guess is that throwaway either a) has very good opsec or b) doesn’t mind being doxed. Their tone implies one or other to me. The quality of writing is so high that Boeing could probably identify them just from that intersected with the user ids accessing the databases.

        • If he’s a mechanic, he doesn’t have his own PC. They use shared workstations which are everywhere.

          • He/she probably has a PC or Mac or smartphone/ipad, etc at home and an internet connection. How he//she got the info may sell have been by verbal off the record conversation with a knowledgeable person. You can be sure the full resources of Boeing are in use to track the perp.(s)

    • Context:
      CMES – Common Manufacturing Execution System
      SAT – Situation Action Tracker

      Spirit employees cannot get write access to CMES, by process.
      Going back to P poor quality of fuselage deliveries in 2018 Spirit teams have been onsite in Renton & Moses Lake.

      It was common that Spirit could be doing out of sequence work all the way after factory rollout.

      Frequently Boeing Senior Managers demanded CMES access for Spirit teams, but it can’t be allowed. Access to SAT is fine because it is not a production system.

      When Wichita was part of Boeing system access was not an issue.
      The only way to integrate Spirit SAT entries & info into CMES is manually, and that is tedious and error prone. Information escapes are unavoidable when 2 companies are working in multiple systems of “record”.

      The known solution, going back to 2018, is procedural. Either Spirit delivers the product per spec, or Boeing does the re-work.

      That a removal may have been executed by Spirit using SAT is mind blowing.

      • So as Throwaway details, SAT becomes the platform where Spirit employees CYA and becomes the unofficial documentary location of the work done on an aircraft, when things aren’t done properly in the first place.

        If CMES is the official record and then investigators find all of this ‘off the books’ work done, the question will be asked:

        “Why wasn’t this documented in the official recording system?”

        Furthermore – moving forward, this whole SAT/CMES workaround would (most likely) be deemed verboten. Assuming it’s used for all Max’s coming off the line, not just the ‘9s’…how is this going to effect production?

        How far back do regulators look, to see what else has slipped through the cracks?

        No wonder why Calhoun got out in front of this, so fast….

        • Calhouns platinum plated posterior cover er parachute just got a few escapes to the gold plating before being locked in place. If the perps havent yet been isolated or at least sent to an office far far away or the parking lot to document the snowflake count or skidmarks-then the DEI team must be involved.

          • ‘-then the DEI team must be involved.’

            To protect the Irish heritage CEO? Deal? Pope? Kellner? These guys here?:


            Aerospace Safety Committee Charter

            a. Chief Aerospace Safety Officer
            b. Chief Engineer
            c. Vice President for Product and Services Safety
            d. Chief Legal Officer
            e. Boeing ODA Ombudsperson
            f. Chief Compliance Officer
            g. Chair of Boeing Quality Operations Council
            h. Chair of Enterprise Manufacturing Operations Council

            Not that I know what the background is of those people, but if Elon says it – it MUSK be true!

        • If throwaway’s information is correct, a removal was executed and not documented in the system of record.
          Will be interested in hearing the justification for not removing the 737 Production Certificate

          • Several footpaths between HQ and DC seem to be showing signs of extreme wear and may need to be refurbished. Didn’t know concrete could wear that fast.

          • “Didn’t know concrete could wear that fast.”

            Dragging your feet does.


    • Of course, the plug is not a door, but a structural panel and isn’t something that gets “opened”.
      In CMES there is no process to “open” it, only to remove.

      • And that leads to the grabbing headlines in even the WSJ

        “Boeing 737 MAX 9 Part in Plane Blowout Was Made in Malaysia, Official Says”
        The official quoted is Chair of NTSB promoted in 2021 to that position.

        where the door was made has zip to do with the issue, as does who made the bolts which were not replaced.

        Deflection uber alles

        • Beg to differ a bit here. Made in a LCC (low cost country) shows the intent by leadership to do everything imaginable to increase bonus and profit at the expense of safety…

          • SamW
            It is common as a condition of sale to require the manufacturer to make production offsets to other countries. These are customer driven requirements BA accepts to close the sale. If you were correct in your assertion, and the jury’s out there, BA would have already closed Renton and located the FAL offshore. The fact that BA hasn’t done that really defuses your position.

          • EMB airplanes are built in a “LCC”, but dont have Boeing’s troubles

      • Two hands and a flashlight can’t see that four bolts are missing?? It’s not MY job!

    • ThrowAWay:

      I am having PTWS (Post Traumatic Work Syndrome) , its exactly the sort of thing (usually without the risk of life) I saw.

      One that was truly scary was post Quake Gas Line inspections inside the buildings. They inspected the warehouse area but not where it ran into the office area and was hidden above the ceding (400 some feet to the meter)

      When I brought that up I was beat down. The only good news was after 3 days (it happened on my 3 day weekend) if there had been a line break they would have smelled it all over the facility (the ceiling area is also the return air plenum so it goes into and then through a fan and that smell is intense for a reason)

      What you are writing tracks perfectly with process failures I saw all too often.

      Many of them were actuary people failures, there was a kprocess in place, it was ignored or pencil whipped.

    • Wow!

      @Throwaway: Please contact

      Dominic Gates
      Seattle Times
      (206) 683-5329 cell

    • Hi, my name is Sydney Ember, and I’m a reporter at the New York Times. I’m doing some reporting on Boeing and Spirit AeroSystems and very interested in learning more about this — could you please contact me? My email is sydney.ember@nytimes.com and number is 212-556-4649. Thank you!

    • Contact a lawyer that handles SEC whistleblower cases — for example Jordan A. Thomas (secwhistlebloweradvocate)

      Until people start getting paid/protected for blowing the whistle this type of stuff isn’t going to stop.

    • But you missed the obvious! They can’t throw out Spirit because there’s no other option, and even if there was it’d mean admitting that spinning it off was an intentional decision to lower quality (because you can’t just magically “lower costs” by spinning something off, but you can lower costs by doing a worse job).

    • This also would be a very good time to get to know your union rep, if you’re in a job represented by SPEEA or IAM 751.

    • I can’t speak for Renton, but in Everett the mechanics are not told to use, nor are they trained to use, SAT. All work is to be documented in CMES only. No other (second) system is officially allowed. SAT is never even mentioned in training

    • I have seen similar occurrences in the automotive sector. While it is easy to see how they happen it is appalling that they are allowed to happen.
      My question is: Once the hole is designed to be filled with an emergency exit door (EED), why was the design of/with the door plug panel (DPP) left using the same “ejector springs” rather than being made semi-permanent? Because “the DPP needs to be unsealed for paint” doesn’t seem worth the risk of a billion dollar error…
      By the way, Thanks.

    • Q: Are ALL door plug panels (DPP) and emergency exit doors (EED) ALLWAYS unsealed at Paint and Livery?
      This is a critical question because any inspection of bolts/sealing prior to said unsealing at Paint and Livery is essentially meaningless.
      It is also relevant to ask how many un-sealings and re-sealings the seal is designed (and tested!) to survive before replacement is mandated.

  27. It used to be, “If ain’t Boing, I ain’t going.” Now it’s, “If it’s Boeing, I ain’t going.”

  28. There is another problem here which is in the nature of the IT culture. While I am anything but a fan of John Doerr, the title of his book “Measure What Matters” is spot on, it’s just that he focuses on the financials and nothing else. But, almost nobody in the IT business takes the time to learn enough about the processes the systems they build systems to support work to be able identify the critical process metrics and then make sure that the things they build actually make things better. If they had done that, the SAT system would never have been built in the first place. Any needed metrics and chat tools would have been UI/UX options on CMS.

    You see these kinds of mistakes in every business, but they are particularly grievous in safety critical businesses such as system design work that supports infrastructure (that includes Boeing) and healthcare. If one were to have a contest between how off-target the Boeing production management systems are with EPIC, the big healthcare system that so many providers rely upon, it would probably be a dead heat. Virtually nobody in IT measures what matters because they typically haven’t so much as a clue as to how the processes they are supporting actually work.

    Learning how processes work takes a lot of time and direct observation. Typically in IT, they use the non-excuse that what they build is done against customer requirements. That way, they can always blame the customer for their shoddy work. Sadly, a whole lot of IT customers have bought into this nonsense. Building to a customer requirements documents is a scam, pure and simple. This kind of work should never ever be done that way. And, if they were using valid metrics they would know this.

    • RTF:

      That really resonates. Though my experience is with what was supposed to be functioning software.

      In one case we spent 3 years peeling the Onion and in the end the decision was made to re-write the whole controls software set (it had a lot in common with MCAS without the risk of life)

      I know one guy who was consulted on a system wide software system that failed horribly and repeatedly. He was the first IT guy who understood how you build those systems and track changes so you can back track.

      Again the only recourse was to write it all new. The Data collected could be saved but none of the processes.

      The Onion was not the only time an entire system was deficient. Everyone of those had major issues, I was not a programmer but I knew how the systems were supposed to work and could explain to a decent programmer when we finally got one what was not working.

    • > But, almost nobody in the IT business takes the time to learn enough about the processes the systems they build systems to support work

      Wait, you think management gave IT a choice?

    • Consider that plans often regress to measuring what is easy. (Google McNamara Fallacy)

    • The reality is that Boeing would come to a halt anyway as they need the FAA sign off (and are not going to get it regardless)

      Throwaway (I am going to accept who he is) hits all the valid points I would expect to see and be mucked up with an by as its not just a tech problem its a process problem).

      Batting back and forth who was to blame for what is a managers main job. I can see the whole thing the way he laid it out.

    • One side is determined to throw a wrench into the economy to hurt the other side in the upcoming election. People with jobs, who need to keep the bills paid? Who cares.

  29. One of my real world examples was one of the guys I worked with asking why a bolt was not in place on a Split Case Fire Pump (those have all sorts of approvals and tests as they are life safety items for Sprinkler Systems – falls under National Fire Protection System standards – fire pumps I believe are Part 25)) – 8 or 10 bolts and two were missing.

    My first reaction was, that is a forcing bolt hole (to lift the cap off the pump if you are gong tow work on it). But it was, huh, no threads in the cap, close look, we are missing a bolt.

    Call to the mfg, how come these pumps (6) all are missing a bolt?

    They can’t be! Yea they are, where are the bolts? Well if they used those spots to lift the pump then they are in a bad with the pump.


    So I forced them to send me the bolts. Said bolts were grade 5 which is pretty cheesy level for something like that (sort of like head bolts on an engine).

    Ok, what is the right torque.

    We don’t have a torque spec!

    This is an NFPA approved by, inspected by Factory Mutual (now FM Global of course, something like Raytheon is RTX).

    FM insisted we could not even replace rubber heating hoses unless it was the OEM mfg supplied ones (safety group fought them to a draw)

    But a missing bolt? No big deal. Were they concerned, not at all.

    You have a whole paper system in place and don’t care its failing? Yep.

  30. The following addresses things like EICAS that has come up. It in no way excuses what happened to Alaska Airlines aircraft, that was NOT a trade off but a failure of the Aircraft mfg and certification system that should never occur.


    We don’t stop traveling in cars regardless of how dangerous it is. Most of us had to or have to get to work, grocery shopping, med appointments, banking etc.

    We have had an increasing level of safety since the 50s, first with seat belts, then air bags, followed by more air bags, anti lock brakes and some systems I find iffy to downright dangerous (lane assist and its various forms of constant beeping, auto driving)

    The Airbags should work, they are proven safety systems (my brother owes his life to them) but that is different than if we should drive at all and risk from others on the road.

    Aircraft like Cars and their seat belts/air bags should be built right and if not, corrected.

    But a knee jerk reaction for more stuff is not even close to being a benefit and as has been brought up repeatedly with EICAS, put it in some models and not in others of not only the MAX but the NG that pilots would be moving back and forth in is an unnecessary and totally unproven in reducing risk.

    • so why have other manufacturers to conform to these “unnecessary” features?

      In other domains ( shipping, transport) you may have to swap out engines to conform to current emissions rules and upgrade other features to conform to changed current requirements.

      But Boeing can work with paleolithic features for a new type under the protection of grandfathering applied with the widest brush ever.

      Here automobiles, HGV have to conform to current rules at delivery.

    • “We don’t stop traveling in cars regardless of how dangerous it is.”

      What happened to the Chevy Corvair? Just asking.

    • 737 was basically designed in the 60s
      And thanks to grandfather, its safety features are still 60s vintage
      remember the CORVAIR
      Do not be surprised if the fuselage is not so strong….
      But it is around 2 tons lighter than if it was designed around 80s safety rules (as the A320)
      lighter means cheaper, and saves fuel… But certainly it also means less safety.
      How long shall we keep these dangerous grandfather rules?

      • And how many structural failures on 737 due to flight loads ? and what is the percentage ?

        Suggest you slow down re ‘structural’ and similar comments

        BTW other than being a bit windy- the 737 that lost the window-door – plug could have flown for hours as far as structural ( dont know if the door hit the tailplane which could have dingged it ) but no reports seem to mention that so far and no obvious comments/problems from the crew.

        • It’s not about standard load. There were multiple incidents where a 737 broken into 3 pieces in a crash landing, while the 320 stayed in one piece in similar situations.

          • PLEASE list dates – location and basic details for all- and the match re similar .

            Thank you

          • Tuan.
            Crash dynamics are exceptionally unpredictable and post impact performance means little. Just look at the A340 scrapped at the factory aftee it broke into pieces after taxiing into a JBD. It wasnt anywhere near flying speed and it broke apart…… And it met current regs…. Im missing your point

          • Missing something?

            you are weazling around his point.

            this is about crash resilience in excessive sink rate accidents
            or hitting a berm or slope on landing.
            The A340-600 crashed into a solid obstacle while moving forward. Nothing in the cert requirements touches on that.

            funny google for “a320 crash broken fuselage” and you get up front a range of 737 broken up fuselage instances shown.

          • Uwe said “funny google for “a320 crash broken fuselage” and you get up front a range of 737 broken up fuselage instances shown.”

            I suspect Tuan is/has punked the system- I use duck duck go and got many many photos of a320 crashes


            never heard of ‘ funny google ‘

            images for 737 crash broken fuselage show a lot of the train derailment photos and some 737 crash stuff

          • Some instance 737 broken in crash landing:
            China Eastern Flight 5735
            Lion Air Flight 904
            Turkish Airlines Flight 1951
            Pegasus Airlines Flight 2193
            I’m not sure if I can find “A320 in similar situation”, I’ve never seen a broken A320 in crash landing. It always stay intact.

      • Flying Frog.

        At the risk of pissing you off, I may suggest you are late to the game asking how long we will keep
        These so called dangerous grandfathering game.
        FIRST Grandfathering as you call it, had nothing to do with MCAS. That was new to the MAX, not a carryover from the NG.
        SECOND. The Congressional Air Safety Act passed a few years ago ended the practice of Certification by Commonality and is the bulk of the driving force behind the Max7 Max10 and 777x cert timeline delays as they are all being done under the new rules. Also of note is that there are few, if any, structural changes to the -7 or -10 fuselage relative to the -8 and 9 indicating that all of them also meet whatever you find lacking in safety as they meet the congressionally updated rules.

        I know its hard, but try to complain about actual facts, it looks far better on you

        • @Scott Correa:

          MCAS had a *lot* to do with grandftathering! The system itself wasn’t grandfathered in, but its existence was a result of squeezing newer, bigger engines into a space limited by the original engine and landing gear… its application was through adapting grandfathered systems and it’s erroneous behaviour resulted from (poor) attempts to maintain grandfathered control and crew interaction/training.

          Wuthout grandfathering, the aircraft would have had to be redesigned with taller landing gear (so no imbalance and need for MCAS), MCAS could have been explicitly added as a new systems module, there would have been changes to the interface to allow crew to properly interact with it and there would have been additional training for crew to work with it.

          • Someone…….
            Here we go…….
            The engines weren’t grandfathered, which is why they TEST FLEW the entire flight envelope for stab and control and performance proof. They found a high alpha spot where they didn’t meet required stickforce gradients. They patched it. So far that works fine. The patch itself was fine, the inability of the Boeing to look its reaction to bad data inputs/failure modes was the issue (A single channel pitch data source is beyond belief). Neither crash was the fault of the program, per se, both were unanticipated/horrific engineered outcomes of the programs response to bad single channel pitch data inputs. It was absolutely inexcusable that the engineers didn’t see it, and people should go to prison for that, but there was no grandfathering involved at all. If they had grandfathered the aircraft, they wouldn’t have flown the entire envelope for stab and control and MCAS would have never been created. You need to understand this a bit better and be able to parse cert by commonality VS new structure requiring new cert. There were no Grandfathered systems in stab and control, the entire stab and control system was tested to the current existing standards. The fact that the vast bulk of the flight control system already met current S&C standards and was reusable is not an indicator that they were grandfathered (certified by commonality) as the entire system was reflown to verify conformity to current standards. I know it can be confusing, but that’s the way it went down……

            We can discuss the training aspect later, especially when MCAS had no off switch and was not crew addressable, and it still isn’t.

          • @Scott

            I said the system wasn’t grandfathered but was the result of maintaining other grandfathered choices. This is inarguably the case.

            I agree I blurred the line between the strict definition of certification grandfathering and “making fundamental changes while deliberately stretching definitions of existing certification as far as possible to fit those changes” – but these are two sides of the same coin.

        • @Scott Correa

          The 737 MAX 7 and 10 are not certified under new rules, they have a waiver:


          “Dec. 20 [2022] —Congressional leaders reached agreement early Tuesday morning on an end-of-year government spending bill that includes an amendment to give Boeing the clearance it needs to get its 737 MAX 7 and MAX 10 jets certified without further changes.

          The amendment ensures a deadline included in legislation passed in 2020 does not apply to the MAX 7 and MAX 10 models that have yet to enter service.”

          • Eldakka
            The devil is in the details. The exemption you are citing was specifically addressing cockpit alerting/EICAS. This narrow ruling did little to reduce the certification requirements of having to fly the entire stability and control profiles or a lot of otjer things identified on the Major change and minor change forms submitted with the cert package. While it is nice to grab headline titles and think you can explain away very complex subjects with a couple sentences, it just doesnt work that way in the real world. Did you even read your referenced article, it clearly spoke to the EICAS deadline alone……. Anyhow its a good point to clarify, thanks for bringing it up.

      • in crashes the fuselage easily comes apart at the pickle fork positions just ahead and aft of the wingbox. This is a killer. even for Boeing personel.
        You never see such faults on the higher certified g load designs.

        • There are lots of photos of broken-up 737s as Uwe describes on the web- if one cares to look.

          • For Scott Hamilton- unfortunately it looks like we have a few trolls and maybe its time to restart this thread or close it.

            A320 versus 737 crash issues are WAY too far off subject

    • Yea all those stories start popping up that have nothing to do with the the MAX issue (they are probably NG or so called Classics)

      Most governments can’t keep their commercial aircraft working.

      Farm it out to Delta and you would get good results.

  31. The door plug issue can clearly be checked quickly and bolts tightened (or installed?!). The real issue is what else is waiting to be discovered. Maybe nothing but there is no easy way to know.

    • I fully agree, I don’t blame the FAA for what they are doing as it gets data needed.

      Its likely a major help to have those inspections and compare it to the records – there may be an indicator per Throwaway per above, but gives a cross check.

      FAA has no reason to trust Boeing (or the NTSB) and this is a way to hit them with a 2 x 4.

      Obviously there are a lot of quality controls not working.

      The biggest aspect in my mind is unless there is integrity in the processes, you have to ensure that people are not afraid to do their jobs.

      I am totally appalled, like others I had thought Boeing was slowly getting back to stability and its nuts that you have airlines trying to inspect work – if that is needed then its more of a downward spiral and Airlines are not setup to maintain their own aircraft and inspect Boeing (you might as well shift over to Airbus)

      Keep in mind you have to get those bolts that are missing as well as the nuts, washers and cotter key to each location a MAX-9 is grounded at as well as complete reports and documentation by the Airlines of what was found. Add in a qualified mechanic and inspector.

      • Airline representative on site during build was the norm from after WWII until recently. They followed their aircrafts and helped with clarifying their options like on BFE “Buyer furnished material” with any delivery and quality issues. I find it helpful as they later can help their own heavy maintenance during its disassembly/reassembly/rigging of their aircrafts if the airline sends the right type of engineering people and not some complaining MBA’s “Not the whiners again…”

      • Trans.
        First, BA has absolutely no excuse for an aircraft being delivered in tbe state it was.
        Second, Nobody is talking about the fact that the FAA having revoked Boeings ODA is the current owner of the 737 Production Certificate Surveilance mission. Perhaps the FAA is also asking themselves HOW DID WE MISS THIS. I can see a legitimate questioning of the FAA processes that contributed to this QA escape… Inspecting for missing bolts is simple and shouldnt take long for thr FAA to release the MOC for the EAD Note. I think the regulator is inspecting himself here as he played a big role in the last couple years of CofA signoffs for deliverys…..

        • Scott C:

          Agreed no excuse and I hope none was remotely implied.

          I do see it as multiple failures of the build process, having inspectors report to FAA would help, not solve the problems.

          When you have a total failure of a Blank install, then you have a massive failure up and down Boeing Management.

    • “Maybe nothing but there is no easy way to know.”

      Take a couple of stored MAX frames ( a -9 preferably? )
      and do a complete teardown. ( “E-Check” :-= )

      compare to the specs.
      Jot down all discrepancies.
      Both. those versus specs and those versus “sane”

      Write a report. 🙂
      Prick your ears to hear the skies falling.

  32. ” For those of you who checked “good swimmer” on our pre-flight questionnaire, instead of a flotation device under your seat, you will find a torque wrench and socket set. We will be coming down the aisle shortly with soft drinks and bags of assorted nuts……and bolts.”

    • Tnx link good article. I don’t think Calhoun (who took over from Muilenburg who certainly didn’t appreciate engineering warnings) has adequate capability to revise or cause to revise the unacceptable holes in process and QA systems that Boeing uses (multiple on different products, different plants). Their use complicates training so more stuff goes wrong than normal and then complicates checking and inspecting the essential and necessary things. Outsourcing complicates it further. He’s had several incidents followed by promises but more faults keep coming. Where is the final inspection? Its of course completely unacceptable for a plane to be released with loose or missing bolts and so many other issues that are now found when airlines are looking deeper. All these flight and safety affecting issues should have been found before delivery! There should be a list of the vitals thoroughly checked before fit-out and the acceptance flight. But a good process and QA system ensures minimal rework well before that. Old adage – find the problem at source cost $1, find it upon completion cost $1000, customer finds it cost reputation, trust and too many $ to count. Calhoun is costing Boeing its reputation just as badly as Muilenburg did and he has to go.

  33. from bloomberg ‘” “That Spirit divestiture was a huge mistake,” said Jeffrey Sonnenfeld, senior associate dean for leadership studies at the Yale School of Management. “Boeing should have bought it back at any price, even now. You have to wonder if Boeing leadership is still stuck with their heads in the clouds and planes on the ground.”

    RE heads – Yep – heads ARE stuck – but in a different location- modern technology seems to allow that even with golden posterior covers firmly in place.

    • Keeping in mind the treasury is gutted paying all those perks, stock buy back, dividends, aka full steam ahead.

      The dilema is you have to borrow the money and you are leveraged to the hilt with nothing for it.

      There may still be a deal in the works but we will only know when its announced.

      • Also…

        What do you do with all the Spirit work that’s done for Airbus? Embraer?

        • Frank P:

          Assessment would take in depth analysis, but as I understand it, the Boeing mfg for the MAX is in the former Boeing assembly plant.
          It may not be all Boeing but probably most of it and you could pull just that Boeing Portion MAX assembly (well and some NG to) and sell it back to Boeing (maybe Gift it?)

          How profitable are the 787 Nose and other Boeing work (and where in the complex) as well as the various Airbus (East Coast and Northern Ireland aka A350 and A220 work).

          Oddly, other than the pressure bulkhead caught up in the shim debacle, you don’t hear issues with the 787 nose. That would be a separate operation even if its in part of the 737 fuselage factory.

          MAX/NG fuselage back under Boeing is not going to fix all the p[problem but it does get it all under one management structure that can then address failures in quality control without negotiating with another company.

          Like my prediction for the Green Bay Dallas Game, I did not forecast a win, but I did put it before the game that it was possible and not a slam dunk for Dallas if they p[played down to their capability and Green Bay played up to theirs.

          Boeing has precedent for taking stuff back aka Charleston and Chance Vought as well as the Common Leonorado and Chance Vought assembly plant next door.

          They also took back some 747 outsourced work towards the end of the -8 program when (again I think CV) decided to get out of the dead end business for that work.

  34. FT: Boeing’s financial targets must ‘take a back seat’ in focus on safety, says big customer

  35. ” Great, but my focus is less on the executive team ….”
    translation- You guys are home free- lets find the Janitor who forgot -unless ( they them ) are part of the DEI cadre. Then we need to talk Should only take a year or so..

      • And the ‘ chair ‘ actually said “Boeing 737 MAX 9 Part in Plane Blowout Was Made in Malaysia, Official Says ‘ which made a WSJ headline.

        By that time the door was found, and at least two facts were obvious
        Door was intact Bolts had either failed or not in stalled. So how and where the door was mad by whom had ZIP to do with anything unless major parts like brackets had never been installed which would have been obvious during pressure test ( hi blow ) -perhaps a missing seal ??

        ” look look a shiny object made by a furriner- that must be the problem “

        • Yes, that’s an obvious (with xenophobic overtones) distraction…

          • The proper tag is “rabid jingoism”.

            Haneda crash was reported as “Airbus A350 cashes fire”
            that it was caused by a collision was only mentioned in the last sentence. It is niceties like these that exposes some nations character.

        • Some of the comments that have come out are indeed deflection.

          That I can tell you is that the bolts did not fail, there would have been ripping and tearing if bolts had been there, if one bolt had been there you would have had that.

          Clearly from a forensics view, there were no bolts in place, not one. A clean ejection of the door once it rattled loose and had the right pressure applied.

          And while all parts should be inspected, Malaysia making that door blank is irrelevant from the perspective of this failure.

          They have both the aircraft and the door ejected from – they really do not need the door, its just a check mark.

          Seeing the condition of the tracks the door ejects along is all that is needed.

          Yea you can check the door as a quality check of its build and if you find issues you address them, but it being made in Malaysia is irrelevant.

          Its should be subject to and fully controlled by Boeing checks as well as its core documentation. Each door will have that.

          The way this is going there are likely other gaping holes in the Boeing system and failure to inspect outside components (and document) could be there.

          Having done my share of post failure checks, its clear that there were no bolts in place.

          • Agree with TransWorld with a very small possible but improbable addition. It Is possible for all the bolts to have been put in place but never secured with nut and cotterpin- so bumps on landing etc could have allowed them to slip out. Note that I said improbable since even then for all four bolts to slip out stretches any statistical analysis into a different dimension/universe. Even so-the baseline goes back to kulture, multiple failure of ‘ system and sly definitions of words such as replace-remove- install and even so right at Boeings feet. Hopefully the eventual FAA report will be printed on 30 grit sandpaper pages so that it can be inserted in appropriate orifices.

            That the chair of NTSB yapped about door being made in Malaysia borders on incompetence , stupidity or most likely a deliberate attempt to deflect and join the good ole boy gang.

          • I have not been impressed with the top NTSB person.

            Some of it is opportunism. The big deal about the re-write of the cockpit voice recorder was in the same vein. Its an issue, it should be addressed, but in this case, irrelevant to the outcome or the investigation. The pilots in my mind fully excused for having dealt with a very different situation than a more usual loss of pressure.

            My belief on the bolts goes with Bubba2, but some more aspect to it. If any bolts had been in place, several of them would have been done right, yes I can see a slip up on one, though again, the post install inspection and sign off is for that purpose, to catch a drop.

            I believe Throwaways account. It was a complete drop and his supporting information explains how that could happen.

            Its just incredible good fortune that we did not loose an aircraft. Luck is not a strategy though that is what Boeing management has reduced the production process to.

  36. Haha

    -> “Feb. 11, 2015: I don’t see a 60% market share for Airbus, single-aisle airplanes, says Randy Tinseth, VP Marketing, before the PNAAlliance . He referred to Richard Aboulafia’s prediction that Airbus will have a 60% single-aisle market share through 2024.

    -> “Well, guess what: 2023 ended with
    Airbus having a 58% share vs Boeing of the A320-737 sector. Add A220-300 and you’re at 60%. 2024 may make it worse for $BA.


    • It’s been a long time that Mr. Tinseth produced any of his prissy commentary. Where did they bury him?

  37. excellent article in Seattle Times by Talton


    Boeing’s challenges can’t be fixed without a culture change
    Jan. 19, 2024 at 6:00 am Updated Jan. 19, 2024 at 6:00 am

    ” The Boeing Problem won’t be resolved until real consequences are visited personally on the top executives and the directors. A return to the culture of engineering excellence and reduction of subcontracting may be too much to ask from a company so invested in this business model. But it needs to happen, or more deadly incidents will occur. “

    • Humpty Dumpty sat on a wall.
      Humpty Dumpty had a great fall.
      All the king’s horses and all the king’s men
      Couldn’t put Humpty together again.

      • Very insightful.

        Its also wrong. Organizations have been fixed before, its a matter of will and that is an open aspect right now.

        • nothing against a faulty opinion 🙂
          There is some other lore around about singing horses.

          Starkly visible issues with the way Boeing was gutted and potemkinized go back for 2 decades if not more. PR project SonicCruiser and its visibly elegant morph into the “Dreamliner” afaics. Cudos, really perfect PR.

          The process though invisible at the time must have started earlier.
          _IMU it reaches back beyond the McD merger._

    • Its well written but its been covered in depth including here and rather than beat the issue to death, what we need are solutions.

      A number have been presented here, without a fix the hand wringing is wasted.

      The FAA should mandate a full production stop and review the entire program (again) its not design issue, its an execution failure.

      If the FAA does what it should Boeing will fire Calhoun and his group and try again. Calhoun clearly was not the answer from the start, he was and is part of the problem.

      • Agree with transworld even though hell is still hot. But unfortunately Shareholders cannot fire the board- and can anyone name a board member(s) who will commit seppiku (sp)?
        For those doubters –
        https://www.law.cornell.edu/cfr/text/17/240.14a-8 in part
        ” i) Question 9: If I have complied with the procedural requirements, on what other bases may a company rely to exclude my proposal? (1) Improper under state law: If the proposal is not a proper subject for action by shareholders under the laws of the jurisdiction of the company’s organization; ”

        ” (6) Absence of power/authority: If the company would lack the power or authority to implement the proposal;

        (7) Management functions: If the proposal deals with a matter relating to the company’s ordinary business operations;

        (8) Director elections: If the proposal:

        (i) Would disqualify a nominee who is standing for election;

        (ii) Would remove a director from office before his or her term expired;

        (iii) Questions the competence, business judgment, or character of one or more nominees or directors;

        (iv) Seeks to include a specific individual in the company’s proxy materials for election to the board of directors; or

        (v) Otherwise could affect the outcome of the upcoming election of directors.

        (9) Conflicts with company’s proposal: If the proposal directly conflicts with one of the company’s own proposals to be submitted to shareholders at the same meeting; .””

        And time to submit such a proposal has long since passed.

        • And that is truly the rub.

          Its purely a technicality that the shareholders can hold a company accountable.

          Many are instantiations as well as mutual funds and none of those are going to engage in a fix it campaign.

          If the Board gets tired enough of it they will move to fix it, but that does not happen often.

    • -> ‘ Throughout last year’s series of quality lapses and production setbacks, Pilarksi — who is personally close to many top executives and engineers within Boeing — remained one of the industry figures most staunchly positive about the company.

      In an interview, he said the Alaska Flight 1282 debacle was the last straw for him and many inside Boeing. […]

      “There’s a high probability Dave Calhoun will not survive long as CEO,” Pilarski said Friday.’

      • -> ‘ Calhoun “told the world, we’re not thinking about the future until we fix what we are doing now,” Pilarski said. “It turns out, he doesn’t know how to fix the present.”

        • I hope Boing doesn’t get rid of Mister Calhoun only to
          replace him with that MBA-woman: nothing would
          change but the PR.

      • -> “In stark contrast, Airbus CEO Guillaume Faury and the company’s new Commercial Airplanes CEO Christian Scherer held a news conference on Jan. 11 in Toulouse, France, to tout the company’s 2023 performance.
        The Airbus executives exuded confidence, took questions easily, and spoke of accelerating production and plans for new planes in the 2030s. For the Airbus leadership, clearly the present looks very good and all eyes are on the future. […]

        Using market pricing data from Pilarski’s firm, Avitas, The Seattle Times estimates the dollar value of the 2023 commercial jet orders at $153 billion for Airbus and $115 billion for Boeing.

        The jet deliveries from Airbus are estimated to be worth about $48 billion compared to about $39 billion for Boeing.

        • Pedro, I’m not sure that I understand this.

          Dollar value (Revenue based on market pricing) is $153 & $115 billion, respectively.

          Deliveries (margin?) are worth $48 & $39 billion?

          Typically, history has show us around a 10% margin (give or take) on a yearly basis. Boeings 2018 bumper crop year was 13% based on $60 billion in revenue and ~$8 billion in margin.

          A few points either way and you’re in the ball park.

          In 2022 Airbus (commercial) had some 41 billion euros and 4.6 billion in adjusted earnings.


          I know these are not your words. What do you make of this?

          • $153 & $115 billion are the value of orders received by AB and BA respectively in 2023 as estimated by the Seattle Times.
            The other dollar figures are the estimated revenue/value of commercial aircraft delivered in 2023 for respective companies.

        • Wrong time sequence – how many days a decade might result in a number less than 10 but greater than 1 . And at least one visit would be with a factory manager who could explain with show and tell the pointy end with windshield was the front and the rose petals on the floor were in honor of his presence – but the photo op with safety glasses, hard hat, and boeing jacket would be carefully staged and the riveting and bucking bar crew would be quiet.

          • Maybe a new board of directors would direct Calhoun to move his desk/office from home to the shop floor…that would be “culture change”

          • In reply to Dave P re new board. Shareholders cannot fire a Board member or insist he/she/they leave before their time/term is up, and even then very difficult.

          • “.. desk/office from home to the shop floor ..”

            never had contact. .. but..
            How is this handled in the “Best of Breed” Japanese domain?

            I know about relatively flat hierarchies.

            That used to be the case for owner managed entities in Germany too. this changes under “brought in” management and over time.

  38. “… They are getting killed.”

    The passive “getting killed” is faulty terminology.

    it is “Suicide by Greed” what takes effect now.

  39. What we have here is a failure to communicate – that is until the platinum plating on the boards parachutes reaches the sell by date.

    • Christ on a Crutch. They’re hopeless.

      “Lobbying and Better PR will Save Us!”

    • When the seattle times runs an article by andy P (used to be for WSJ ) the effulent is hitting the turbine for sure for sure


      Boeing’s manufacturing, ethical lapses go back decades
      Jan. 22, 2024 at 2:19 pm

      “By Andy Pasztor
      Special to The Seattle Times
      Probes of the recent Boeing 737 MAX cabin blowout must expand far beyond safety practices and manufacturing controls. Investigators should scrutinize persistent company failures over the past four decades to become more transparent and law-abiding.. …

      And he missed a few items even so . .

      • Mr. Pasztor must be patently wrong
        as 4 decades reaches back beyond the MacD merger. :-=)

        But it perfectly fits my regularly derided view of all things Boeing.

  40. Same old stuff … different decade – different millennium …

    “Down There at Boeing”
    (To the tune “Down in the Valley”)

    Down there at Boeing,
    Things are real bleak.
    Seems that the red ink,
    Has sprung a big leak.

    Slogans and dictums,
    From the Executive realm,
    They mention cutbacks,
    Watch stock prices swell.

    While out in the fact’ry,
    Our “brothers-in-arms”,
    Are stamping out wildfires,
    Just saving the farm.

    Despite their heroics,
    The backlog grows large,
    Their last vacation,
    Was when Frank was in charge.

    Junior’s in school now,
    Sally’s been sad,
    Both were in diapers,
    When last they saw dad.

    Morale takes a nose-dive,
    Boeing responds:
    “Let’s reduce bennies”,
    Still the line rumbles on.

    The workers hum strike songs,
    And hope someone hears,
    While their bosses whistle,
    With thumbs in their ears.

    “Sell, sell more airplanes”,
    Comes a cry from the smoke.
    “Ramp up production”,
    The factory chokes.

    Out on the tarmac,
    Planes held for parts;
    Hear the men grumble,
    “This is FUBAR!”

    “DCAC* will save us”,
    Some say with no clue,
    The fact’ry needs help now,
    Not 2002.

    Our brothers in Long Beach,
    Are very confused;
    Thought “Boeing will save us”,
    Now ask “who will save you?”

    When this is behind us,
    I hope we know well,
    We all work together,
    Or we all go to hell.

    The moral to this story,
    Is important to note:
    Mechanics build airplanes,
    Executives don’t.

    *Pronounced “DEE-KAK”, not to be confused with Ipecac, but has had the same effect on Boeing.

    Original Lyrics (circa 1998) by B.A. Songs (Parody songs for the Boeing Slave)

  41. Boeing Aerospace QA from ’77-’88 – I never worked in Airplanes. One of my first reads on joining the company in what was called Procurement QA, was Boeing Corporate Policy 5H1 “Quality Assurance”.

    In a nutshell, 5H1 said the responsibility for product quality rested not with Quality Assurance, but with Engineering for design quality, Manufacturing (which includes the planning guys who interpret drawings and specs to write the build orders followed by the IAM mechanics) is responsible for product quality, and Purchasing (was called Materiel in my day) was responsible for the quality of procured goods. Quality Assurance simply verified – and even that was in cooperation with Engineering, Manufacturing and Materiel to conduct risk assessments, incorporate inspection points in manufacturing and procurement planning, etc. As best I can recall, to maintain the independence and objectivity of Quality Assurance, 5H1 also specified QA would report at the VP/President level, though functionally often reported to Manufacturing. I exited QA midway in my 20 year career because as often as cost and schedules butted heads with product quality, cost and schedules prevailed. I don’t know if Airplanes has the same, but many Aerospace contracts with the DoD and NASA had incentive awards and thus the pressure to meet schedule was at times intolerable as a QA auditor (FAI/FCA/PCA). The glowing words of 5H1 were never more than words, in my experience. It was then I first heard and often used the word BOHICA.

    Consistent with 5H1, I always wondered why Quality Assurance wasn’t renamed Product Assurance, since by policy any quality problem was the fault of either engineering, manufacturing, or materiel. How is it in 2024 Quality Assurance is cited for a “quality escape” and not manufacturing / manufacturing planning? In defense of my Quality Assurance brothers, it ought be termed a “verification” escape of a manufacturing quality error – least ways – if corporate policy 5H1 were still around. Hard for me to imagine the corporate policy has survived for 50 years. I suspect after the merger in ’97 it was obsoleted in the culture wars that followed – and precipitated my volunteering for layoff in ’99. The proverbial handwriting was on the wall even then.

    • Engineering management responsibility is exactly the thing that journalists aren’t getting. The specific part of QA that is failing is preventive action, known to engineering managers as risk management. Lip service isn’t sufficient – it is a resource intensive process that everyone contributes to. Potential catastrophic failures aren’t allowed to be pencil whipped by subcontractors. The door should have been designed to fail inwards, bolts should have been designed to fail slowly and evidently, the door should be readily accessible for in-service verification inspection, the bolts should have been serialized and tracked, or a combination of these risk mitigation actions should have been mandated.

  42. Be sure to put in yours resume as a expert design engineer, long range expert analysis, andsuper manager who has determined that bolt failure and poor door -plug design is the basic problem. Who knew ??

  43. Anybody know (with pictures) what the “Exit Door” version of the plug looks like?
    What does operation of the optional exit door look like? Does it “open” just like the plug, hanging on the bottom (spring loaded) attachments? If so, how are passengers to actually exit over the still attached panel???
    My suspicion is that there is a different plug, with an actual exit door, that can be installed in the same opening in fuselages in the “sardine can” seating configuration. Same hole in ALL fuselages, some get plugs with actual doors, some get “dead” plugs.
    Either way, before the interior trim is installed, ANY DAMN TIME IT IS BEING INSTALLED, HIDING THE ATTACHMENT SYSTEMS, the procedure should DAMN WELL CALL FOR CERTIFICATION THAT THE BOLTS ARE IN PLACE WITH CASTELLATED NUTS AND COTTER PINS IN PLACE. It’s not that difficult, unless you’re under pressure to get the planes out.

  44. RE exit door version. I recall reading months ago a description as to how the real “Exit Door ” version works. cant find it now. BCut as a ‘ door ” the four bolts are replaced with a solenoid acutator pins such that after takeoff the pin stays or is held in place and while on the ground they ( pins ) can be removed via a handle- lever actuator

    When the door is used- ejected- it pulls out an emergency air/gas powered slide and then is no longer attached but on the ground and hopefully out of the way. I’m sure someone here can find the details and correct me iff needed.

    • Thanks Bubba2! Some of my assumptions are plainly wrong. But I’d still love to see any documentation you might stumble back across.
      Check me on these new assumptions:
      1) In the emergency exit door (EED) configuration, operation of the door lever, WHILE ON THE GROUND, results in ejection of the EED panel and deployment of the emergency escape slide (EES), (packaged along the bottom edge of the EED but attached inside the plane) Yes/No?
      2) In flight, the EED is prevented from doing anything because a switch (in the cockpit?) keeps retaining pins (in place of the bolts) in their holes which keeps the EED in place Yes/No?
      3) The retaining pins, when allowed by the switch, are all simultaneously pulled out by the operation of the door lever Yes/No?
      4) The large washers on the top ends of the bottom spring ejector mounts appear to keep the door plug panel (DPP) from being ejected (or separating from the plane when open). Washers this large would NOT be used in the EED configuration Yes/No?
      5) The springs are compressed when either the DPP or the EED is installed. Is design intent that they push the panel up until the first of the four bolts/pins (It could be any one of them) makes contact to stop it? Or is design intent that the panel “hang” precariously in the hole, spring loaded, just waiting to be pushed out?
      Why spring load the DPP for ejection?
      Is it ever actually necessary (rather than simply expedient) to open/remove the DPP, other than for a seal problem?

  45. OK -I REALLY hope someone with specific-detailed- knowledge of the details will jump in to correct or embellish MY understanding of the ” plug” and EED -but here goes. AFIK

    1) Correct
    2) partly right- dont know if it is a switch or some sensor combination with maybe a switch backup and panel light combo.
    3) Manual Handle-lever does release-slide out pins- designed so it works on ground but not at ” altitude ” and or ” speed ”
    4) Dont think so- AFIK panel completely separates when ” opened” or more accurately ” removed “- “ejected ”
    5) The springs assist in raising the panel a few inches when pins ‘ pulled’ – ” removed” thus requiring minimum force-strength to raise panel-plug enough to clear dozen ” stops” /”pads” and push it out or perhaps trigger a gas powered ejector to assist in ejection and triggereing slide
    Why spring load ejection? – simplest- most reliable method of storing force-energy to always work over 20 years or so. No gages-no expiration- just remove some kind of latch and it expands. Gets the preload when door installed. Which raises the question- how did they compress the spring and keep it compressed as they ‘ re- installed the plug so that it did not simply eject. ? perhaps another friction- holding device as part of the manual release is in play. ??

    I doubt it is normally ever necessary to remove the DPP but during a routine maintenance check ( C or D ) it is required to verify bolts- pins are in place

    Now waiting for someone who KNOWS the system to correct me or verify my basic understanding.

  46. A bit more- AFIK normally before interior installation- each ‘ completed’ body undergoes what is called ‘ HIGH BLOW ‘ which pumps compressed air into the fuselage to simulate approx 90,000 feet- about one and 1/2 to twice the max altitude capability of the plane. they do this to check for leaks etc.

    Thats about a 14-15 psi internal pressure.
    Which then raises a question – the NTSB report says the plug was removed to fix rivets in frame and also a damaged seal. seems to me IF spirit had not installed the 4 bolts, then the pressure test might have been enough to push the panel out enough to let plug move enough to cause a leak and damage the seals.

    So if the bolts were never installed- then the fubar dual ‘ paperwork’ system would not track that. So Boeing had no reason-paperwork to replace bolts that they did not have to remove.

    So when they replaced the panel- simply pushikng it down against the springs would allow the ‘ top edge’ to go flush with the skin, and absent any internal pressure it would stay there for a while. and the rest is history !!

    • So the High Blow te$t is performed at Boeing Renton on sealed fuselages prior to interior trim. How are test results reported? “No Leaks Noted”? or perhaps “Door plug blew out”? Is there a specific leak-down rate measured that cannot be exceeded?
      Could it be performed again as the last step before release-to-customer?
      One crazy concept I thought of was a large vacuum cup sucking away the installed panel from outside the plane. Check for sealing with audio probes on the inside. This would also give an unsecured panel a chance to blow out in testing rather than in service. The test rig could be moved to any point along the assembly process in the plant where it would be located.
      But paint (and livery) also come in to the picture. How many open-and-reseal cycles is the SEAL designed to survive?

      On spring ejection: My question was specific to the door plug panel (DPP) and does not apply to the emergency exit door (EED). It seems a good system to get the EED out of the way in an emergency, and I expect it is designed to work with no stored energy assist other than the springs. But the DPP never needs to be ejected… Why give the DPP springs? Lift assist for the few times it might be unsealed doesn’t seem a good enough reason… And a slightly different retention system for ONLY the DPP could include securely bolting the DPP in place, (like Huck Bolted through 6 of the 12 pads).
      It appears that there are already big washers in the DPP retention system that would have to be smaller in the EED ejection system.

      Then there’s the question of why critically balance the upper DPP tracks on the fuselage roller pins? It is only the EEP that NEEDS to be critically balanced, with the tracks taking the spring load, so the pins can be pulled out before bumping the EEP for ejection. This does NOT apply to the DPP. It could be bolted (Hucked?) in place.

      It would seem that the quest for a common system for both options didn’t diverge into separate tracks for the separate functions at quite the right place.

      BTW, being curious as to your experience base that has provided so much great information I thought I’d share mine. I am a retired mechanical engineer. “I have spent my career acquiring a skill set that makes me a nightmare for…” many designers and design managers. I’ve supported part, tool, and process designs for multiple Big 3 automakers with a concentration in doors and swing panels. (Think systems providing gap and flush, around 4 doors, a hood and a liftgate, at a rate of one car every minute or so…) I’ve also supported interior trim programs and even did a year at a supplier of bulkheads, lavatories, and trim for major airlines. Sometimes I ask the right questions. (And thank you!)

  47. Mike- I am also mech engineer and worked in Aerospace for almost 40 years with over 30 years at Boeing and also was( now retired ) a PE. Most of my work at boeing was in manufacturing and tooling and fastening , along with some testing of parts on saturn 5, system test-reporting on Minuteman – and a few specialized rocket engnes- propellant. Worked on specifically 767 777 2707 and b2 composite. – And yes a lot of tooling concepts used werre birthed in automotive. I’ve witnessed as a non participant HI blow on 767 and as a non participant on wing test of 767 and 777 plus developing a unique fastening method and specialized tooling for fatigue improvement and certain drilling tools.

    I Suggest that most of your questiions could be better answered by a search of public information such as FAA-NTSB and Boeing documents plus a few websites devoted to airplane manufacturing.

    That being said -my obsersvations of HIgh Blow years ago on 767 are probably not too much different for 737

    At that time-80’s- leaks were detected by wrapping fuselage joints join areas with plastic and leaks would either ballon plastic or more often shred it depending on size.
    A lot of old Boeing documents and magazines are available on the Boeing site and even some videos like wing test of 777, etc.

    I am still in comm with a few recent workers who spent most time on 737 before retireing- and at times before retireing had one on one with a few real managers, executives, and vp. But Its NOT about me

    have to go know

    • Thanks Bubba2! I could tell the info you’ve been providing was for real (No challenge there!).
      I’ll look for some more documents but it’s still a large search grid for me. Can you narrow it down with a few links perhaps? I so appreciate the close focus you provide.
      Automotive: We make it work every minute. Aerospace: You make it work without fail.

  48. RE 737 at renton – everett does their thing a bit different
    one of the best is


    sometimes https://www.pprune.org has good info depending on where you look






    Sometimes on those sites one can dig a bit deeper and of course the seattle times has some pretty good info

      • Not at all- happy to be able to direct you or anyone to reasonably credible sites

        BTW the

        is one of the best I’ve found- it was updated from a previous on the same issue.

        And one of my favorites a bit off the 737 issue is the 777 wing test- the last program I worked on before retireing

        Wing failed at predicted point within a few inches and above requirements by a few percent. Wuz there and went to quiick look presentation about 1/2 hour after


        Have a nice evening :))))

        • Hi Bubba2,
          I am a freelance journalist and author. A major global magazine asked me to develop a feature on what’s gone wrong at Boeing–obviously plenty. You wrote: I am still in comm with a few recent workers who spent most time on 737 before retireing- and at times before retireing had one on one with a few real managers, executives, and vp.
          What you have laid out in your comments are too technical for my audience. I am trying to reach people who have worked on the 737 assembly floor who can explain the path that led (or would lead) to the retention bolts in the door plug failing to get replaced and how that was overlooked in quality/safety management. I can interview people anonymously or on background. Please reach out to me via email: marc.wortman@sbcglobal.net. Go to my website to see my career credentials. marcwortmanbooks.com Thanks, Marc

          • Marc again. I’ve heard rumors that a young person on the assembly line got fired for failing to put the retention bolts on. Would love to hear from anybody with direct knowledge about what happened. Anonymously or on background. e: marc.wortman@sbcglobal.net

          • RE simple current issue re door/plug and ‘ quality escapes Scott Hamiltons answer and direction /link is much closer to the current and partial past issues than I could ever provide. If you look at some on my previous posts ‘above’ you can get a much clearwer picture. While I am long retired and know in ‘ general ‘ terms how Boeing used to/ be/work- at the same time you and other media must realize that since DOJ/FBI has indicated possible criminal action what has been published here and elsewhere is about as close an outsider /insider can get pending completion of investigation and/or trial ( both civil and criminal.)

  49. It seems to me that a modern 767 replacement would be a very good fit for Airbus- bringing them close to “checkmate”, if they aren’t there already.

    Something bigger’s going on though, I think.

  50. Time to break out the slide rules- to err is human- to really foul up takes a computer plus a graduate bean counter- juste another ‘ quality escape ”

    SPEEA members benefit
    Boeing acknowledges EIP error; some to get more money, none taken back

    Boeing notified SPEEA it had provided Employee Incentive Plan (EIP) bonuses based on misclassified business units for potentially thousands of Boeing workers.

    The company mistakenly paid some employees the Corporate (CORP) EIP bonus instead of the bonus applicable to the business unit they supported in 2023. As a result, impacted workers supporting Boeing Commercial Airplanes (BCA) and Boeing Defense Systems (BDS) were overpaid. SPEEA members working for Boeing Global Services were underpaid by more than 30%.

    SPEEA filed an information request with Boeing after a number of members reported concerns about a potential error in their EIP payouts. Some had been informed by their management that overpayments would be taken back out of three upcoming paychecks.

    On March 28, Boeing told SPEEA it will make SPEEA members whole if they were underpaid and will not take back money that was overpaid. “We appreciate Boeing fixing this and ensuring that nobody was harmed by the error,” said Ray Goforth, SPEEA executive director.

    The 2023 performance year’s EIP formula should have paid bonuses between 3.6% and 5.95% of an individual’s eligible earnings, based on the performance of the business unit to which they are assigned.

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