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- เผยแพร่เมื่อ 10 ก.ย. 2024
- The National Transportation Safety Board (NTSB) held an investigative hearing open to the public in the NTSB Boardroom on August 6-7. During the hearing, the NTSB gathered sworn testimonies about the Jan. 5, 2024, Alaska Airlines Flight 1282. It is a fact-finding step in the safety investigation and the testimonies will become part of the public record.
The accident occurred Jan. 5, when a left mid exit door plug departed the airplane, operated as Alaska Airlines Flight 1282, at an altitude of about 16,000 feet shortly after departing Portland, Oregon, on a flight destined for Ontario, California. Following the loss of the door plug, which led to a rapid decompression, the flight crew returned to Portland where the airplane landed safely. Of the 171 passengers and six crewmembers onboard, eight reported minor injuries.
www.ntsb.gov/n...
Body language speaks volumes. I want to see Lloyd Catlin (IAM rep) in frame when all questions to the Boeing Management are answered by them. The BS corporate speak is just completely unreal. I work in a machine shop environment as a manufacturing engineer in an ISO/AS 9100 environment for a billion dollar company (not related to this issue at all), but started my career as a machinist and have a good idea how these big corporate profit driven decisions get made. You can tell that Boeing is just going thru the steps as these issues have been going on for a decade or more and aren't addressed nor fixed. Mr. Catlin hit the nail on the head when he talked about the fact that this wasn't an issue before the McDonald Douglas merger. Lots of documentaries out there about the negative effect that had on employees/quality/etc. This company needs a huge corporate culture shift back to where it was, something I don't see happening.
Somewhat illustrative that a union man has more notion of QA, SMS and Risk Mitigation than a CEO who has a team for everything? Even for walking the factory floor?
things always look kind of different from an office. Especially when the office is on the other side of the continent.
16+ hours over 2 days. I was hoping to see on the screen the photo known as exhibit #16 from the NTSB preliminary report. That’s the one taken by Boeing or Spirit employees back in September just prior to reinstallation of insulation & interior panels that infamously shows the bolts were NOT installed. That photo does show what appears to be a white ZIP TIE secured around the second from bottom stop pad / pin assembly on forward edge of opening. The preliminary report seems gone from the NTSB site, but that photo #16 showing that zip tie can still be found on several popular aviation channels where the prelim report was being discussed.
During day one we heard speculation that the “Move Crew” may have pushed the plug closed, not in an attempt to actually firmly close & secure it but rather just to close the opening to allow the plane to be pushed outside in the weather. Which brings up another question I’ve had since the prelim came out, and I’ve never heard anyone from Boeing or NTSB ask the following question- What effect do the lift springs have on plug when it’s in the closed position? Some say the springs are simply buffer stops to keep plug from banging at bottom of travel. Others suggest the springs will actively lift the plug against gravity to the point where the stops & upper guides release (or nearly so). If the latter is the case, then maybe someone had a good reason for putting that zip tie around the stop pad?
Can anyone confirm NTSB is aware of that zip tie & asking questions about how & why it got there?
Keyboard warrior discussions suggest the lift springs, acting on a plug with the 4 bolts missing, might exert enough upwards pressure to flop it open on its own, or maybe during taxi rolling over tarmac irregularities. A passive safety device maybe? Overridden by a zip tie? That broke 3-1/2 months later at 16,000 ft?
“During day one we heard speculation that the Move Crew may have pushed the plug closed, not in an attempt to actually firmly close & secure it but rather just to close the opening to allow the plane to be pushed outside in the weather.”
This was the way that Boeing first portrayed the incident but later on the NTSB refuted that narrative and Boeing was forced to concur that that did not cause the quality escape. The incident of the “move crew” partially closing the door plug occurred the DAY BEFORE the rivets were replaced (because of work that could not be performed due to the scaffolding supporting the plug was in the way). So Boeing actually has no information from interviews as to WHO closed the door plug AFTER the fix. So one can guess at who (and which group) is PHYSICALLY RESPONSIBLE for pushing it close. Boeing seems to believe they know who is responsible for not generating the proper paperwork to open the plug (which would have flagged the need for a closure inspection). These people probably are those that have been transferred to the “BOEING CAGE PRISON”. Also curiously the manager of this door crew has been on an extended medical leave and has not been interviewed.
Conclusion: Quality is about people. EVERYONE should understand the QMS.
Buiding planes like Toyota builds cars? At Toyota even the coffee lady has the authority to halt the line so to speak.
And even Toyota had severe glitches at plants with no or partially japanese management. (South Africa, Mexico and US)
The difference between lip confessions and living Toyota's TQMC.
Could the bolts for the plug have been placed in a bag and zip tied to the door/plug instead of being put in inventory? The bolts would be readily available and it would visible that the bolts hadn’t been installed.
2:54:32 isn’t confidence by repetition to slow when there could be safety concerns in the near term that are not reported due to lack of trust in a company made system that is “confidential”? It is so obvious that this type of systems would be untrustworthy from employee perspective, which means Boeing is knowingly using a system which reduces safety reporting and ultimately makes all of the planes they make more likely to to be unsafe.
Is the Tequila Brand also part of the type design in the VC-25 program?
11:08 - Post introductions, going over the agenda and getting started. (Though I don't know why you want to skip the amazing safety briefing.)
At some point they are going to have to ask themselves, is a 5 minute safety briefing less safe because everyone tunes out?
There's no way in an emergency I'd remember everything they said to do.
A little mustard after the meal: MCAS Risk Assesment: Occurence Low > Hazard Severe > Possibility of Corrective Action High > Risk Acceptable.
A sound FMEA incorperating Human Factors would have tackled that..(?) A kind of SMS. The startling effect was well known as human factor and the assumption of 5 sec. reaction time was BS.... And not knowing of the MCAS even enforces the startling effect. But it works in the background. Yeah! Avionics/FD/FMC/FADEC/INU/Auto Throttle do it a for a great part too! The latter for sure at an Airbus with non moving throttles. So a BS argument too.
And wouldn't a sound FMEA have tackled the cowl overheating too? FMEA can support requirements management/ assignment/ deployement very well....
Even brain storming with "dumb" questions. Invite the coffee lady for brain storming too. "When I forget to temper/ shut off the stove at home.......". It is not all rocket science but common sense too. There are no "dumb" questions.
And is anti icing system overheating not a common phenomen? Wether it are wing ducts either cowling cones?
With regards to human factors: realize what startling effects common phenomena as pitot tube icing and deviating attitude indicators/ speed indicators can cause.
Whoop! Whoop! Overspeed!! Rudder Ratio! Whoop! Whoop! Stall! Stall!! And sometimes doing nothing but lowering the nose and hand throttling in accordance with "normal" values/positions for the FL/Weight and IAS and maybe falling back to GPRS speed with a safety margin of 140kts (Jet Stream) for tail wind (under speed) or up wind (over speed) is often the best solution.
For sure in the middle of nowhere above the ocean or even in the tropical conversion zone (were conditions can change within 2 min.) where one have less information about the atmosphere regarding to super cooled droplets/ temperature/humidity/up drafts/ down drafts/ wind shear.
So going to a lower flight level could even enforce the phenomene. (?) At Air France 447, the pilot who basicly messed up hadn't icing pitot tubes training for nearly 2 yr.
An advantage of a lower FL can be leaving the Coffin Edge. In the case of AF447, not deviating the thunder storm/lighting cell was sub optimal too. (?)
Having a good situational awarenes even in a queit automated flight phase with regards to wind/EPR and N1/N2 is a good thing when an "abnormality" occurs.
Regarding MCAS, there was no assumption of a 5 second reaction time. No quick reaction was necessary. In the 2 accidents, minutes passed between the activation of MCAS and the crash. The problem was how the pilots reacted, not how quickly they reacted.
@@ignorance72 IMHO Mullahberg did mention the use of outdated human factor standards comprising the 5 seconds.
But only using a deterministic risicograph and not probalistic FTA/FMEA/Monte Carlo is BS IMHO.
In "my" riscograph i left out the factor of "Possibility of recognizing the Danger"
Occurence Low > Hazard Severe > Possibility to recognize the Danger High > Possibility of Corrective Action High/Redundancy High > Risk Acceptable
I Forget English , I don't speak it since 1988 oh my God ;((