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Former engineer here. There is nothing more frustrating than dealing with a company leadership team that’s hell bent on getting the product out the door and doesn’t want to hear about quality problems. I don’t know who said it originally but it’s impossible to make people understand something when their livelihood depends on them not understanding it. I’ve never worked in aviation but I’m guessing this is what was happening at Boeing.
I think we are getting into an age where leaders of technology companies should have both an economics and technical background of sufficient level to become leaders in these type of companies. Look at all the Elon Musk companies, they shine because their leader and board have both backgrounds and they are up against companies with board members with only an economic/organizational background.
I worked in aviation for several decades. The last 'influencer' that safety-oriented folks like engineers, mechanics and pilots always had to sway the management to see things there way was the FAA/(oversight authority). Recent moves to 'pass this responsibility) to company themselves is the worst form of leaving 'the wolves in charge of the sheep!'
What i really like about this channel is that he waits for official reports and facts before telling the story. So many others release speculations and guesswork just to get clicks. Keep up the good work
@@MentourPilot not sure why you feel the need to make your thumbnails so fucking dramatic, there was no explosion on this flight and yet you show one on the completely wrong side of the aircraft in this thumbnail, also the door that pops off is somehow in front of the aircraft? this dude is becoming a typical TH-camr, which we all hate. Stop being a drama queen.
The company I work for has a process called Stop Work, where ANYONE detecting a material problem in a product can halt production within a week, and until all the manufacturing and design engineers agree there is no longer a problem. This keeps us from shipping dangerous errors or stuff that will be rejected and scrapped. I believe we got the idea from Toyota. I'm shocked an airplane manufacturer does not operate in a similar fashion.
Boeing used to operate similarly (prior to the McDonnell Douglas merger really) and on multiple occasions actually halted production based on feedback from engineers and test pilots, which drove up the cost (hence why they no longer allow this) but insured a quality product. Ultimately the financialization of Boeing after the merger completely uprooted this culture of open communication and reporting, and unfortunately the regulators over in the FAA are primed to dote on Boeing no matter what.
Boing has a process that's intended to achieve about the same. They would enter line items into a system and unless they were cleared, the plane wouldn't pass final inspection. That system would have caught the issue, but for "door has been opened" it required "check that door has been closed", while for "door has been removed" it had "make sure door is bolted in". And naturally, someone signed off on "door has been closed"...it had been closed afterall...
Sounds like Toyota's "Jidoka" system. Stop the line, Assess the 7 Whys. Why is this the way it is? Why is that allowed to be the way it is? Why? Why? Why? Why? Why? Tracing a problem to it's very beginning. Filling every hole in the swiss cheese. THEN permitting the assembly line to continue.
How is it possible that one guy with a full-time job and being a pilot and evidently being married and having a couple kids can put out this kind of quality work? This is the type of work that TV networks used to do. And it probably took dozens of people. Great graphics, quality, sound, data, charts and video. And more importantly, the Mentour Is able to add his own insight and perspective. Totally entertaining and educational. Absolutely top-notch work! Thank you very much!
I guess it makes it even better when you consider that every video he makes is another lesson learned for him personally and, while I’m sure he is a wonderful pilot already, this only makes him better. Always good to see pilots look into these things and learn from them, even if the scenario is handled perfectly by the crew.
I see these super suck up comments way too much. I’m sure Mentour has a team of editors and graphics guys who make this stuff while he narrates and edits the script? Mentour is a pilot and a trainer, would be too much work to do this channel alone.
@@Svabreoddly this is how I feel with my own career. I've been a senior Nurse in the UK for 14 years, I watch "horror story" videos and learn from other people's eff ups!! I know it's not quite the same and some things are so far fetched that they almost seem impossible but my biggest take away has been how many "small, avoidable" things soon add up to one disaster!! Although I don't often learn something I didn't already know, it's taught me "what NOT to do" in a lot of situations and I think that's probably just as vital! We can always learn and improve and ego has no place when lives are at stake!
The production values are so insane. The simulation preparation and filming adds so much. The motion graphics also make things really easy to understand.
I can only imagine what would've happen if the door plug would hit the stabilizer or the fin. And things would be much more sinister if those seats were occupied and the passengers haven't fastened
For me, though, it's the music he has playing during the dialogue track that is extremely distracting to paying attention. I want to listen to him, not any music. So, please, Petter, I ask you, please refrain from playing any music while you are speaking. It is not as backgroundy as one might think. Thanks.
Hi Petter, I’m the son of a former Indian Air Force fighter pilot. My father always used to tell his stories about flying the Mig21. As a kid I loved listening to those. He unfortunately passed away 2 years ago due to Covid-19. In some way you way of story telling (and looks too)remind me of my father - and I love watching these aviation accident stories - and - its sort of cathartic - I just feel close to many father watching them. Thanks for everything you do and such great quality video made with highest professional standards. Regards.
Your father sounds like he was a wonderful man, Dr. Gupta. I see that you’re a pediatric oncologist, and coincidentally, my dad is a retired pediatric oncologist who studied medicine in his native Andhra Pradesh before moving here to the U.S. in the late 1960s. It takes a special person to do that kind of work; your father must have been very proud of you. May he rest in peace. 🙏🏽
I gotta say, it sure is crazy how many weird things happen to Portland International Airport. An off-duty pilot trying to shut down the engines. A door plug flying off the fuselage. A mysterious man jumping out with a parachute. Sounds like Portland is living up to its unofficial motto of "Keep Portland Weird."
Coming from a QC background, this really is quite shocking. The idea of having multiple logs for nonconformances, some of them in private channels is a huge company wide failure
Exactly. Workers and production Management under time pressure will absolutely choose the process that can be completed with less documentation and fewer inspections.
@@18robsmith This is not the reason and if you understand how doors works its completely OK. Problem is, that this piece arent door, this is plug. So for plug there is nothing like “open”, its always “disasembly” (I dont remember proper word from procedure). Somebody screw this.
I am a consultant specializing in quality assurance and Failure Mode and Effects Analysis (FMEA), primarily within the automotive industry. The fact that the process did not require a check for the proper installation of these bolts after the reassembly of the door plug is simply bewildering to me. Frankly, this is scary.
My husband and I are both former Boeing employees. During assembly on the factory floor parts, ie. fasteners, Are carefully monitored and must be accounted for. If you are performing a job that requires 20 rivets you get 20 rivets and that’s it. There are no parts bins with extra fasteners. This is done to control FOD and also to verify if the job was done correctly if you have an extra fastener in your hand after completing your tasks something is wrong. So what we are wondering is where are the four bolts that did not get reinstalled?
My guess, the person who found them after the fact threw them away to avoid blame. Is that a management problem?, work environment maybe, bad employee?
@@billdeibner7105 not likely, they wouldn't have anything to lose by calling attention to it... no mechanic is going to pitch certified hardware into a bin... the bolts should be traceable and likely have already been found in the parts store inventory, and the records of their movement should help reveal what happened...
RIP JOHN BARNETT whose wife says he was DEFINITELY NOT SUICIDAL. I hope MENTOUR keeps safe and also does a BIO on the late whistleblower who dedicated 30 years of his life to BOEING. Such INGRATES!
The above comment ⬆️ has *absolutely nothing* to do with whatever grievance politics and/or anti-DEI 🤬 you've been hearing on Earth 2. Mentour Pilot did an excellent job recounting this air incident...
Maybe a future recommendation will be for ATC personnel to say as a last instruction after the aircraft is parked, "please pull your CVR breaker". Of course this will be only after dealing with a crew that has declared an emergency.
Hey, I was a caterer for this flight! My partner and I catered the flight once it got into its gate and later that day, on another truck we saw it back at its gate missing its door - spoke with the flight attendants involved and got to see the aircraft we had just catered missing a door. I love this channel and I can’t believe I’m getting to see this covered here, it’s very exciting!!
@@malebetegrrr5793 No shit really? As a Certified Aircraft mechanic With a Degree in Aviation maintenance Technologies from the National Aviation Academy in Clearwater FL 4.0 GPA. The BOLTS have to be INSTALLED to work. Even the slide mounting bolts were loose and no safety wire or safety cable installed.
@@farangerOh really ? Don't we discuss about how to use bolts properly ? I have some degrees in Engineering (but I am French, sorry), I never ever show it when discussing about bolts. I never will discuss a mechanics engineer about if a bolt should be secured, by what mean, etc ... it is his domain, no mine. But it should have been a thing to be observed by Boeing.
27:03 What I love about what you do is that you give a first-hand pilot’s perspective on everything you talk about. And this „It would be good if they told us that” part is a great example 😂
Captain Mentour, I don't know much about airplanes but I love watching your channel in the background while I work. Your manner of speaking is very soothing, the content is informative without being intimidating, and your compassion for your fellow human being's ill fate (regardless of whether they erred or did everything correctly) is inspiring and comforting. Thank you for providing this high-quality content to us for free. You make the world a better place.
Ad a former aerospace worker, my whole family is aero workers and engineers, we wll cry bitter tears to see how bad its got. I personally have made a million QA stamps on new and reman assemblies, 30 years and no field failures was the gold standard goal! Cheaper not usually better. Get a clue aerospace industry! Thanks for the report ❤❤
@@chipset2900In GMP you'd have a checklist signed off by a different worker. But if it is denied there is any work done (that's why the door was opened rather than removed) no checklist is needed and the work goes FASTER.
My wife had no problem flying, I have really high anxiety and just the thought of having to fly gives me the body sweats. Watching your videos for over a year have helped me become more informed of the aviation industry as well as slowly replacing my baseless anxiety and with intellectual confidence to fly for the first time.
I would heartily recommend British Airways' book Flying with Confidence too- you get a technical breakdown of the aircraft and the physics of flight, alongside the psychology of fear and ways to overcome it. Along with Mentour Pilot, it helped me after my fear developed (extreme turbulence on my first solo trip abroad).
im the same, will sit for weeks before watching air crash investigation The last line is always, after the investigation, several recommendations were made which has made flying safer for everyone ever since.
"I have really high anxiety and just the thought of having to fly gives me the body sweats. " As the late Spike Milligan commented: Flying isn't dangerous. Crashing, that's dangerous.
@@TheRealWindlePoons haaa had a similar argument with my wife when I bought my first motorcycle 😂 I said honey it ain’t the bike that’ll kill me, it’s the sudden stop. Needless to say she did not like that joke and the bike was sold 🤣
In the late 1960s, I flew from New Delhi to Kathmandu on a Royal Air Nepal DC/3 with no passenger door and was in the rear seat near and opposite the missing door. There was a crate of chickens in the very rear of the aircraft. Very memorable fresh air flight.
A friend of mine who is very glad he retired from Spirit long before these quality issues cropped up, said that part of the problem is that Spirit had a lot of lay offs due to Covid shut downs and that they didn't get many of those experienced people back. Now they are trying build aircraft as fast as ever with less experienced personnel. This is just one of the issues that they are dealing with. Now inspectors will be EVERYWHERE checking paperwork ramping up the stress level on everyone.
In other words they fired their competent expensive technicians who did not get vaccinated and replaced them with unskilled minority labour to improve their ESG rating.
@@mandowarrior123"They had a lot of layoffs due to COVID shutdowns." Can you read? That was BEFORE vaccines, in the shutdown phase. Did you just try to find a post to reply to where you could bemoan "unskilled minority labor" for your own reasons?
@@hannahp1108 except Spirit did mandate vaccines, and did change it's hiring criteria, boasting of their 'skilled diverse' hirings over 'traditionally qualified.' Wouldn't hurt you to look it up would it? Also look up 'minority' while you are at it, I'm not confident you're aware of its meaning. Implying I have learning difficulties is not only rude but harmful to vulnerable members of our community that struggle with comprehension.
This flying door plug has attracted an unbelievable amount of news coverage and "specialist opinions"., Many stories being premature, not completely correct, often incomplete and predominantly time-wasters. Thank you Petter, for bringing us within 2 months of the incident the full story. with understandable technical details, superb graphics, analyzing human error snd all covered within spell-binding narration. This video was all the world needed, as always: unsurpassed!
hmm, not sure I'd agree with that, the internet community very quickly zeroed in on the issues, which are again confirmed by the info in this video... Petter has added some key info from the Boeing internal communications that weren't known before...
This one was pretty quick to diagnose because they didn't have to hunt through and reconstruct a ton of debris to make sense of it. Door plug pops out, chances are that there's something that kept it from staying in place, in either design or installation. You find the fallen plug, notice it's missing some bolts and there's no sign of those bolts ever being there during flight... AHA!
Initially I thought "not another door plug video", but quickly I realized that this is actually telling the whole story with new details that were not explained before. As an engineer I recognize so many patterns here and am almost in disbelief that this is an airplane manufacturer.
" I realized that this is actually telling the whole story with new details that were not explained before. " === The details have all been explained before, just *not in one place* . This is why I keep watching this channel.
As a software engineer it was clear to me that Boeing was a fatally sick organisation when the first flight test of Starliner (their very delayed new space capsule) suffered multiple unrelated software failures on the happy path (the everything-as-expected situation, not some hard-to-foresee edge case). That can only have happened if they never even once ran an integration test before flying it. Engineers as a subspecies are first and foremost motivated to turn ideas into things that actually work. The more audacious and ambitious those ideas are, the more motivated they are to make it happen. Aerospace engineering is pretty much the most extreme example of this - you can be absolutely sure that every engineer on the project (software or otherwise) would be deeply invested in the success of the mission, and keenly aware of the insane difficulty of the optimisation problem that needs to be solved to make space hardware work - they would be kept up at night worrying that they'd missed something, no way would they just omit the most basic testing if they had any say in the matter. Engineers perceive any impediment to achieving their goal (making the thing, and making it well) as a threat, which often includes management (either because the management makes actual bad decisions, or withholds information from the engineering teams so that their necessary decisions don't make sense). To have a failures like those on the first flight test of Starliner, you have to have built such a toxic work culture for so long that your engineering teams and management are in all-out war with each other. With the power imbalance, that means that engineering always loses. In that environment, your best engineers leave, and any who stay have to distance themselves emotionally from the success of the project. At that point the only way you recover is to gut both management and engineering and rebuild with competent people who understand what went wrong and are committed to the structural and cultural changes necessary to avoid it happening again. Good luck getting that right in a company as large and sick as Boeing, where the side effect of losing the institutional knowledge that would entail would set back anything they're working on by many years.
This is the first video I have seen on Alaska flight 1282. I wasn’t interested in any previous ones and I’ve been waiting for this because I knew this channel is the gold standard for aviation news. I am not a pilot, nor am I involved in the industry (besides as a passenger), but I can tell a serious communicator whenever I see one. Thanks a lot Petter. You always shine a bright light into these events.
Huge props for the enormous amount of 3D modelling you did for this episode Dominic! Even the Boeing and Spirit factories!! Great 2D graphics explaining the door plug assembly too.
The fact that this was not a specific MAX design flaw, but a general quality control problem, is even scarier for anybody depending on Boeing, because ANY Boeing aeroplane can be and is affected by the way they make their junk in general!
There's a bit more to it. It is far from all Boeing planes which has these plugs. From what I can understand, it's a relatively new thing. You won't find them on 747's, 777's older 737's etc. Not sure Airbus even has any. The scary part here is, that it tells us a lot about the working environment and culture at Boeing, and that affects ALL planes going out. It is as terrifying to learn that they did not replace the rivets which were supposed to have been replaced for example. Also note that Spirit is still Boeing, and it is the responsibility of Boeing to make sure Spirit does its job properly. It is also a problem that Boeing disregards issues, and thus demands the production to be ramped up so deliveries continue on schedule.
Airbus does have door plugs. Just a guess, but an a321 neo probably has them because of passenger configurations. Bigger planes are less affected by this, because they’ll just have a door there because of passenger count. It’s these large 737s that are right on the edge of passenger count for exits, which is really just the max 9 and 10, as well as a 900ng
@@thomasneal9291 No. Boeing is very much in charge of its final quality control. Don't you understand that a big part of this problem stems from the pressure Boeing not only puts their own employees under, but also those of its subsidiaries? Boeing's business transactions with Spirit, accounts for more than 90% of Spirit's contracts at this stage. And what little work Spirit has done for Airbus, has not shown to be a problem, because the rush at any cost does not run rampant at Airbus. Boeing is run exactly like McDonnell-Douglas was ran, and it did not work, and it was all about "just get it out the door" as fast as possible, no matter what. We are dealing with a company that literally moved a fuselage across the road from the assembly plant and back, just so they could claim it had been delivered. That is what GE and McDonnell-Douglas did, and that is the culture which is running amok at Boeing now. What you see here is the results, just like they were with older GE Aviation products, the MD DC-10 and so forth.
With over 30 years of aviation maintenance experience (& still on going), these pilots did a great job! Hands down they were handed a serious crap situation and knocked it out of the park. God bless them
Another excellent video! As an ex Boeing engineer, I was aware of issues concerning senior management and I quit back in 2009. Considering recent events I am not likely to fly on another Boeing aircraft, no matter the type. I don’t expect to see any meaningful change in culture there in my lifetime (I’m 73).
Boeing seems to have developed a habit of “forgetting” to tell pilots about various features of their planes. Kind of makes you wonder what other surprises they have in store.
8:56 I worked at Hewlett Packard in the days when quality took priority. Stopping the entire assembly line when there was a quality problem was accepted as the correct thing to do.
Nah - whistle-blower is the phrase to look for. Easier and cheaper are simply reality at every large company. Compensate whistle-blowers richly with an insurer based reward scheme and you will see decent safety records restored PDQ. Think about it - if you had the opportunity to turn squealer and get what amounts to a rich pension automatically - no corner cutter would be safe. Both shuttles and the astronaut crews would be alive today. And "US" products would actually have US engineering drawings instead of some bogus Chinese cad drawings with no revision block data.
@@jeffmilroy9345 We used to joke about Boeing doing everything FASTER, QUICKER, CHEAPER, BETTER. It finally happened that the McDonnell - Douglas leadership team reached their desired goal with almost deadly consequences.
Thanks Petter - really great description of this event. As a retired, very high time pilot with plenty of time in command on 737s (and other Boeings), I can not pick a single hole in your excellent presentation. Outstanding job! 👍
12:26 Do what I do: take the nut & bolt out, move the work piece, replace the nut & bolt in its original holes so the work piece can't be replaced until the next shift (or future me) has to deal with & handle those fasteners.
As an allmost engineer (i did not finish my course) the manager deciding to choose for "Just opening the plug so it can retain an SAT and no further action will be needed" must have never had any engineer training, because in that case he would have heard of murphy's law and would have chosen for a path with an integral final check-up on the work (CMES if i write it correctly). I hate when people do stuff like this. I must say i am very glad injuries where just few and minor! I am an upholstery guy mostly for flight cases and on friday i got distracted and missed a few steps in finishing 4 boxes. But i always lay out my work so i had two pieces left over and that got me thinking about my distractions and i took those 4 boxes back into my workplace for check up and i got them finished eventually. Someone should have taped those 4 bolts to the door plug to remind them and other workers that they needed to be fitted again. And since it is aviation and lives we talk about, this work should be written down as needing extra inspection effort. What i am saying is workers should train themselves to help with oversight of job completion and especially when things become more responsible management should pitch in and give workers back-ups, just because murphy's law will always be a thing and mistakes will be made.
The problem is that so many company directors are deciding to save money by either out-sourcing by separating different divisions into individual entities within the corporation, or out-sourcing while shutting down their own divisions, or simply forcing workers onto workplace-agreement contracts (or a combination of these). As the parent company then dictates how much a contract is worth, the off-shoot is forced to hire the cheapest sub-contractors they can find, meaning skill-levels & standards drop! Here in Australia, Qantas board-members (especially the outgoing CEO), have made a killing in bonuses & shares, despite the airline's reputation & value taking a nose-dive! The result is of course that the bosses expect the workers to loyal & hard working, but all the while paying less, with no pay for holidays or sick-days! The old saying is; "If you're only willing to pay peanuts, then you'll just get monkeys!"
Nah i understand why he would do it, its faster and probably easier to fix with less delay. Doesn't necessarily have to do anything with putting it in the system. The problem was that there wa snot the correct checklist to be done afte changing the seal. Normally that should have been correctly stated in a work order. That is also normally atleast in Airbus the standard procedure where a non conformity then also needs to be signed off by quality control
Per Boeing processes there should have been a removal written to open the door plug in CMES and attached to the Non Conformance Record addressing the bad rivets. There also should have been removals written on the wall panel, stow bins, and whatever else had to come out to access the plug. But Boeing has been unable to produce any removal records whatsoever. Boeing is in violation of its own processes and FAA requirements. Probably some low level manager was pushing to speed things up.
I don't agree with workers should train themselves to help with oversight in this industry. I do agree with this IF it's completely independent of the workplace expectations but as a general rule no. The inspections, instructions and quality control should be the ultimate factor in these situations. The workers doing the actual fitting work WILL miss something eventually if there is no process to check (specifically a dedicated person to inspect the work). Saying it's the mechanics job to do quality control means they will be lax with inspections. Which in other industries is not a big deal and makes sense but not when a simple mistake can absolutely kill people.
These pilots and cabin crew should be given an award, and the passengers reaction should be used an example for people on how to behave in an emergency. Wonderful story.
It’s a miracle that no one was sucked outside through the hole. I don’t fly often but I’ll think twice before flying on a Boeing. There are too many issues like this, it’s scary.
Where do get the time to make these videos, researching facts, do your job as pilot/ instructor, family commitments, leisure time, and probably a whole bunch of other stuff we dont even know of. And then you present this in such a calm and entertaining manner. All i can say is a simple Thank you.
Current Engineer (and pilot) here. I’ve worked with multiple aerospace companies and I cannot stress this enough, it’s (almost) always the process, not the people. The tech forgot to put the bolts back because it was not in the process. It took me many years to accept this. I oversaw at least 200 leap 1b GE engine builds. Everything was in a kit. No parts were ever left over. Nothing left un torqued. The process was bulletproof. Sure we had problems but the process caught them before they ever made it to the plane. For this example (disassembly of a finished component) all the details would be re-kitted and isolated from production details. Easy. No exploding door. It pains me as an engineer to see this.
Thanks once again Petter, for yet another crystal clear, logical, unbiased, factual and very instructional video. Brilliant! This incident takes me back to a military flight between Balad AFB and Basra in Iraq in an RAF C130. With a tightly packed load of PAX in full combats and body armour, warm, tired and nodding off in the cruise (it was about 0300Z) when in a flash ....all hell broke loose! Instantly, the hold (cabin) filled with dirt, dust, debris, toenail clippings and insulation material - which made it impossible to see anything or breathe. As the now depressurised Herc went into a steep dive, the only way to breathe in this thick muck was to do so through the sleeve material of my combat jacket, whilst hanging on tightly to the seat webbing. Being in a war zone, I thought we had been hit, but there was no panic and I remember how silent everyone was. Wallop, bounce, rumble... incredibly abrupt and rough landing heaven knows where. Engines shut down, the loadmaster opened the ramp and everyone piled out...into the swirling dust. Sorry, l'm rambling a bit, but anyway: it turned out that the young soldier sitting immediately in front of the port mid fuselage emergency exit door had stood up for a stretch, but in doing so had managed to catch the yellow / black door release handle on the webbing on his back, and .... wooosh! So if this happens to you, then in the absence of oxygen masks, breathe through the nice thick material of your combat clothing. Stay well, stay safe, and as they say on the London underground: "Stay clear of the doors please!" and "Mind the gap."
Truly one of your very best vids!!! Sharing the insider details from Boeing and Spirit, along with your outstanding point by point walk through of the airborne event is really impressive. Keep doing what you do!
I sure have heard about Alaska 1282 and the missing bolts but I really enjoyed the unusual level of detail that you give in this story. I understand the incident more fully. I have never regretted subscribing to both your channels from which I have garnered immense knowledge about aviation. Thank you very much, from Nairobi, Kenya.
Another example of why you're the best at this Petter. Excellent analysis. I'm a layman but I was incensed that Alaska had been aware of pressurization issues and didn't ground this plane. I concluded that the very fact they limited the plane to overland routes was indicative of negligence since they must've known there was a significant potential of catastrophic failure. You've offered a different perspective which I appreciate. That said, perhaps my view on Alaska has to do at least in part because of their history of cutting corners. Great video as always and keep up the great content. I'm from Ann Arbor Michigan and would enjoy it if you could do a video on NW flight 255 in 1987.
Excellent detail on this situation with the door. Thank you for the detail. Amazing how you collect and present in an understandable way this critical situation.
I've been aviation maintenance in the military and an engineer in product manufacturing. This seems unacceptable on so many levels. Every maintenance action should have another person very it was done correctly. There should never be any part of a manufacturing process quality can be ignored.
And the people at each station on the line should verify that the previous step was done correctly. No way that wall panel should have been installed without the crew checking to make sure nothing looked funny. Touch each bolt -- the same way I was taught to touch each bartack on the MOLLE webbing before sewing the panel in place.
Thats how we work in software development even with non-critical components or small tools for personal use only. I was taught that this is engineering gold standard. Apparently enough people don't hold up to standards
@@pdoge "I was taught that this is engineering gold standard." Absolutely. The real engineering motto for this situation is: "Cheap, quick, good. Pick any two."
@TheRealWindlePoons While this situation MAY have involved Manufacturing Engineering, that is not the motto for ANY situation. It was invented by people who don't have a clue what engineering is all about. Proper engineering requires the balancing of many factors including cost, manufacturing efficiency and quality. Pick two is the excuse of the incompetent.
10:28 Painting over bad rivets should be prison time for anyone involved. The handling of records is bad (and probably the biggest reason the incident happened), but DELIBERATELY faking a repair is disgusting.
You don’t know that it was intentional faking. If the write up wasn’t very clear it’s totally possible that they repaired the wrong rivets and painted those ones while touching everything up afterwards. It’s VERY difficult to write up a repair on a handful of items when there are thousands of the same item in the vicinity.
@@gpaull2 Except there isn't. It's very clearly stated that it was the rivets on the plug "door". Do you know how many plugs were on the aircraft? ONE. And they opened up the plug to paint over the rivets, the exact plug they were supposed to fix and painted over the exact rivets they were supposed to fix, and you think that it wasn't clearly written down what they were supposed to fix huh? So much for that "theory" that has absolutely no logic behind it and is just some bs you thought up in two seconds. And oh, records are so hard to handle huh? I have a feeling you've never had to keep records before. it's not hard to handle, it might be cumbersome, but it's not that hard to figure out. Not only did they paint over the shit they were supposed to repair and act like it was fixed, but they broke the sealing around the plug and said NOTHING until they had to. Whether you believe the painting was intentional or not, they knew they broke the seal and INTENTIONALLY said nothing. Despicable, idk why you people try to defend it, probably because you don't even know what you're talking about or paid any attention to the video.
Absolutely superb video from Petter. Explained the technical side so it was fully understandable by both expert and non expert alike. And with superb graphics. If only my lecturers at Uni had been as good and clear as Petter!
Just want to say that I have watched a number of your videos, and although I was trained as an engineer Aviation has never been particularly interesting to me, preferring to use my problem-solving skills in the IT/Tech busness area, your presentation and explanation of issues as in this video is brilliant. This is a 40 minute video that did not have me feeling itchy to click away after 10 minutes which many TH-cam videos do. Keep up the good work, you have an excellent balance of detail and overview and a great understanding that if the story is not interesting and logical, no amount of fancy graphics or effects will save it. Look forward to the next one.
Wow. This channel is just amazing! I've had this on my playlist for some time but it was recently that I saw a full video and couldn't stop. Petter, your level of detail in explanation and your obvious experience, just makes this channel pure GOLD. My new favorite channel on TH-cam and I'm gonna have others watch as well. Thank you.
While I was flying B-73's, I also only had to use The Manual Pressurization Control ONCE! I have nearly 30,000 Total Operational Hours & about 10,000 hours in The B-73. You're right, "Emergency Decompressions" are something that we Practiced Extensively in Simulators. My one time use of The Manual Pressurization Control was probably due to an Electronic Sensor Malfunction, & I never flew that Particular Aircraft again. I made the proper Entries In The Maintenance Log & notified The Company. Also, after The Post 9-11 Bullet Proof Fortified Cockpit Doors were installed, NO ONE EVER TOLD ME THAT IN A DECOMPRESSION SITUATION, THAT THOSE DOORS WERE DESIGNED TO OPEN. THAT WOULD HAVE SEVERELY FREAKED ME OUT! As you said, That Would've Been Some Very Nice Information To Have!!! Before I was Typed in The 73's, I previously flew DC-9's, MD-80's, 83's, 88's & 90's. I never had a Pressurization Issue In That Type. Most of my over 40 years flight Experience was in Those Aircrafts. Sure, I've made Emergency & Pan Pan Landings, almost all were Medical In Nature, With A Handful Due To Faulty Equipment Readings. It's good that you & others are posting these Videos Online to help prepare The Flying Public for what they might expect in the event of such Emergencies! Fortunately, this is not an everyday occurrence! The chances of this ever happening on your flight is extremely low! HAPPY FLYING!
My family flew cross country last week and I made sure we were flying in Airbus airplanes. The Boeing executives should be ashamed of themselves for sacrificing safety for profits and higher bonuses. The entire Max management needs to be fired and even more severe punishment for Spirit, the manufacturer of the fuselages. I will NOT be flying in any Boeing Max planes for at least the next couple of years. This channel is great and I wait anxiously for each new video!!!
0:22 All because someone forgot to do something. Well not quite... If they had merely forgotten to fit the 4 locking bolts then the door would have failed on its first flight. It probably wouldn't have even got as far as it's first flight without being discovered, as they no doubt perform a full 8psi (or higher) differential pressurisation test on the ground and even if the door plug didn't fail then (which it probably would) there would be a noticeable air leak as the door will be significantly lifted by the assist springs. The reason it passed the initial pressure test and then didn't fail until it had done 150+ flights is that they didn't merely omit the four locking bolts, they actually added a white plastic zip tie, which was holding the door plug closed. Why isn't that mentioned by NTSB? At 12:18, in the "after closure" Boeing progress photo, on the (forward) right hand side of the door, the second up from the bottom, pair of door & frame lugs, have a white plastic zip tie clamping the door lug pin & frame lug pad firmly together. (This photo is figure 16 in the NTSB preliminary report). The zip tie held, keeping the 12 pairs of lugs aligned, until a bumpy landing broke it, or made it finally slip off one of the lugs. Without that zip tie, the lift assist springs will lift the door to the point where all of the 12 pairs of lug pins/pads are pretty much disengaged and only the very bottom part of the upper guide tracks are engaged with the guide rollers. That part of the guide tracks was never designed to hold the cabin air pressure and it finally broke at 15,000 ft, the first flight after the zip tie broke. (After 150+ flights). It's a shame that the lift assist springs didn't lift a tiny bit more, because then the guide tracks would have fully disengaged from the guide rollers when the zip tie broke on landing. The door would have then fallen open to 15° where it's wire lanyards would hold it. Hopefully a door plug open 15° would be noticed on the next pre-flight walk around. Failing that there would be serious wind noise on takeoff, deformation of the interior panel, no pressurisation and an interesting view for anyone looking out through that "window". Note: a zip tie is also known as a hose tie, cable tie, zap-straps or tie wrap.
Thanks for forwarding this observation! The explanation has needed a basic cause, the missing bolts and the culture that let it happen, and a proximate cause that allowed the plane to operate normally for those 150+ flights.
Good catch. Thanks. Human errors do happen but this one failed in many respects. Should there be a job card developed and followed? And of course some supervisor to inspect and sign off when the job was completed. Especially this plug now becomes a part of the structure! Personally I feel that structural parts should be "permanently" held in position, either by weldings or fasteners. In this case, can those lugs be used? Say threaded so bolts can be used to hold the plug in position.
So - the team that inspected that exterior wall and the team that installed the interior wall panels just didn't notice the zip tie? They just said, "That's not my department?"
@RyanK-100 Isn't that the reason that any of this happened? There isn't a team inspecting the work done to open/close the door plug because it's considered to be as trivial a task as opening/closing the L1 main cabin entry door, that's done on every flight. Nobody noticed 4 critical locking bolts were missing, that you might very reasonably expect the most trivial glancing inspection to check for. So it's no surprise that a zip tie isn't noticed. Is the person refitting the insulation & interior panel, the same "grade" of person who was reworking rivets & door seal? Is it "their place" to look at what an airframe grade person has been doing with a door plug? The insulation is draped over the top of a seat headrest. Perhaps just held by trapping the end of the insulation in the seat tray on the back of that seat. Just release it and the insulation is instantly draped over the door, covering the zip tie and the empty locking bolt holes forever. (Or at least until Bob finds the door in his back yard). The zip tie is the entire reason that passengers lives were put at risk. So that's a very important part of the investigation that isn't being mentioned by NTSB, even though they published the photo. If it had been both no locking bolts AND no zip tie, then the door plug would have failed a ground based 8+psi pressure test, either due to leakage or blowout. In the unlikely event of it getting to the first test flight (without passengers) then it would have failed then. It would never have got to fly with passengers, putting their lives at risk. It's only the zip tie that escalated things to the level where passengers lives were at risk. Everyone is believing that the springs don't immediately lift the door to almost full extent, just because that belief is needed to support the narrative that the door can stay in place for 150+ flights with no locking bolts (and no zip tie) and that's what people have been believing for weeks. The belief that the springs barely support the weight of the door becomes fact in their minds. Any photo of the door open, shows the hinge guides at the top of the hinge tubes. (I can see 2 fairly important reasons why the springs would be designed to lift the door like this). Because the springs will lift the door, the zip tie is needed to hold the door closed for the progress photo. It's the zip tie firmly clamping that door lug pin to a frame lug pad that is holding the door in the down/closed position for the photo. (Person who fitted the zip tie obviously expected to have the lock bolts available shortly and to be fitting them. They weren't thinking a zip tie is ample for flight, in place of 4 locking bolts!)
I'm sorry, three successive posts on the same video may seem excessive, but I've yet to see anyone else with factory experience comment on the fact that the people who installed the wall panel didn't check the work that was done ahead of them to ensure that it was right. I was always required to look over each item in my hand before sewing the next step and hand back anything that wasn't right. They'd done the job before, they KNEW what the plug SHOULD have looked like -- how did they not realize that something "looked funny"? Why didn't they call an inspector before they continued? Why weren't they trained to touch each of the CRITICAL bolts before covering them up the same way I was trained to count bartacks on the MOLLE webbing before sewing the seam that would make adding a missing one impossible? QC isn't something that happens once at the end, it's something that every single person on the line needs to do on every single item, large or small.
I think the issue there is these are not the same people who regularly install panels over the plug, and would not know what to look for...most criticism is there were no QC/QA people who would be versed on what to look for....
@@wokewokerman5280 If they weren't trained to look for flaws in the previous operation on the line then they weren't qualified to do the job. There's just no excuse for it. Boeing shouldn't be accepting these defective fuselages into their facility. I know from experience that a factor that accepts defective product from vendors guarantees that defects will get worse and worse and worse. The parachute plant I worked in had that issue and it continued until they put their foot down and sent the stuff back at the vendor's expense. It cost us overtime and stress in the short term making up the shortfalls, but saved us a lot more in the long term.
As a non-pilot, I appreciate your initial deep dive into the details. This fleshes out context and understanding. And, as a professional radio broadcaster and voiceover talent, your delivery of these details and the production value of your video are superb!
You got to give credit to all the simulator training that pilots have go through periodically. It is quite realistic and it really helps them stay as current and proficient as possible on different emergency scenarios.
Fascinating stuff. One thing I find a bit crazy is that in this day and age of terabytes of data storage that the CVR in a brand new aircraft is still limited to just two hours of recording before being overwritten. Nevertheless, it’s obvious the crew did a fantastic job in this incident sand I hope they will get the recognition they deserve.
" The older analog units use one-quarter inch magnetic tape as a storage medium and the newer ones use digital technology and memory chips." - source: NTSB - Cockpit Voice Recorders (CVR) and Flight Data Recorders (FDR) I was going to guess they still used tape (for valid reasons), but after a quick search, it appears that newer planes do use digital systems. So I'm with you in not understanding the automatic overwrite. Audio can add up pretty quick in data. 16 bit wav files is around 650MB for an hour of audio. Pretty much a gig for 24bit. But memory is hardly scarce resource, so I'm with you wondering why that limit is still the standard. It wouldn't be a problem to have a CVR/FDR for every entire flight, from gate to gate. I would think this would also provide all kinds of data to improve airplane systems, CRM, etc.
Congratulations for such an amazing analysis, explanations, and graphics. Love your channel you are such a PRO! Thank you for bringing this and other content to us.
I love that the footage of the assembly process, courtesy of Boeing, at 8:58 clearly shows while moving the fuselage that a cart is left in the way and is just pushed along by the aircraft undergoing assembly. A simple thing but it speaks loudly for the safety culture at Boeing. No one did a walk around before moving a very large, very expensive item?
RIP Whistleblower, worked years towards a goal, then when he finally is close to that goal "deciding" that its not worth it and ""commiting "" """suicide"""
Your videos are absolutely the best! Top-notch, both in production and analysis. A far cry from back in the day when I used to read the “crosscheck” magazine from Pan Am
So why was the whistle blower that was due to take the stand at a trial this week, assassinated the other day? He actually told friends that if he had an untimely death, that it would not be suicide. Posted this on 15th March and this untimely event happened after this video was posted on TH-cam
..Reminds me of the same mentality as the Challenger faut pas.. Where the board of Directors over rode the advice of it's Engineers and launched anyhow.. The Achilles heel of such primary focus on rate of return over riding front line engineers...
@@darronwolf7731 For sure... In my company, I actually put seasoned (read: old, been there done that quality street smarts) techs with veto power to force meaningful reviews of the engineers production designs. Some weren't happy, but I was, and it was my company..
It honestly was a miracle no one was sitting in those seats, thank whatever sky deity you praise or praise the luck of the draw that no one lost their lives in this incident.
Mistakes happen. The important thing here is to learn to prevent them from happening again. It's amazing that nobody got seriously hurt or killed, and the crew did their job. It's also a miracle that the stabiliser was not damaged from the departing safety door into the heavens. As always, it is very well explained as always. Slainte, Petter ❤
Following that death, we've just had ANOTHER 737 Max 8 land with a panel missing. March 15 Rogue Valley International, Medford, Oregon. Only discovered after landing post-flight walk-around.
I find, by far, these productions of Mentor Pilot are ‘EXTREMELY EXCEPTIONAL’. The knowledge as well as the insight are second to none. This episode does not acquit Boeing from any wrongdoing, but exposes the fact that there is more going on that needs to be scrutinized. But let’s not fool ourselves, Boeing is a huge vessel of the American military and together with the United States government will go to any length to protect their brand.
Watching this video two weeks later is wild because in just the last two weeks, not only have there been many more Boeing safety incidents, but that whistleblower was found dead in his car. I also saw an article from 2022 about how Boeing threatened to not release these planes at all unless they could be exempt from safety standards.
As always, a well researched and fascinating report. I live along the flight path and have flown out of PDX many times. Grateful that there were so few injuries. Kudos to all involved on that flight! Thanks Peter and Team.
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Ok
Yes
I'm so confused by the way you mix trustworthy, indepth technical content with an obvious scam ad
The springs may be left in, so the door plug doesn't rattle or make other noises, as the plane pressurizes or de-pressurizes?
"There's plenty of bolts in this aircraft. What's a few bolts here or there among friends?"
Former engineer here. There is nothing more frustrating than dealing with a company leadership team that’s hell bent on getting the product out the door and doesn’t want to hear about quality problems. I don’t know who said it originally but it’s impossible to make people understand something when their livelihood depends on them not understanding it. I’ve never worked in aviation but I’m guessing this is what was happening at Boeing.
Yep, I understand what you mean
I think we are getting into an age where leaders of technology companies should have both an economics and technical background of sufficient level to become leaders in these type of companies. Look at all the Elon Musk companies, they shine because their leader and board have both backgrounds and they are up against companies with board members with only an economic/organizational background.
IS happening. Not was happening. Boeing still hasn't fixed their safety culture. 😠
I worked in aviation for several decades. The last 'influencer' that safety-oriented folks like engineers, mechanics and pilots always had to sway the management to see things there way was the FAA/(oversight authority). Recent moves to 'pass this responsibility) to company themselves is the worst form of leaving 'the wolves in charge of the sheep!'
haste makes waste
What i really like about this channel is that he waits for official reports and facts before telling the story. So many others release speculations and guesswork just to get clicks.
Keep up the good work
Thank you for stating this. This is exactly our ethos when it comes to these incidents. Awesome!
@@MentourPilotKeep at it
@@MentourPilot tack, det betyder mycket när det kommer från dig. Fly safe and keep up your awesome work.
@@MentourPilot not sure why you feel the need to make your thumbnails so fucking dramatic, there was no explosion on this flight and yet you show one on the completely wrong side of the aircraft in this thumbnail, also the door that pops off is somehow in front of the aircraft? this dude is becoming a typical TH-camr, which we all hate. Stop being a drama queen.
But the facts about the error came from a whistleblower not any official report.
The company I work for has a process called Stop Work, where ANYONE detecting a material problem in a product can halt production within a week, and until all the manufacturing and design engineers agree there is no longer a problem. This keeps us from shipping dangerous errors or stuff that will be rejected and scrapped. I believe we got the idea from Toyota. I'm shocked an airplane manufacturer does not operate in a similar fashion.
Boeing used to operate similarly (prior to the McDonnell Douglas merger really) and on multiple occasions actually halted production based on feedback from engineers and test pilots, which drove up the cost (hence why they no longer allow this) but insured a quality product. Ultimately the financialization of Boeing after the merger completely uprooted this culture of open communication and reporting, and unfortunately the regulators over in the FAA are primed to dote on Boeing no matter what.
@prikas4313 Another nail to add to the many other nails on the coffin that holds Douglas's reputation.
Boing has a process that's intended to achieve about the same. They would enter line items into a system and unless they were cleared, the plane wouldn't pass final inspection.
That system would have caught the issue, but for "door has been opened" it required "check that door has been closed", while for "door has been removed" it had "make sure door is bolted in". And naturally, someone signed off on "door has been closed"...it had been closed afterall...
Sounds like Toyota's "Jidoka" system.
Stop the line,
Assess the 7 Whys.
Why is this the way it is?
Why is that allowed to be the way it is?
Why?
Why?
Why?
Why?
Why?
Tracing a problem to it's very beginning. Filling every hole in the swiss cheese.
THEN permitting the assembly line to continue.
@@prikas4313 its just about $$$ - we, the pax are expendable - cost of doing business - FAA >not even ganna bother...
How is it possible that one guy with a full-time job and being a pilot and evidently being married and having a couple kids can put out this kind of quality work? This is the type of work that TV networks used to do. And it probably took dozens of people. Great graphics, quality, sound, data, charts and video. And more importantly, the Mentour Is able to add his own insight and perspective. Totally entertaining and educational. Absolutely top-notch work! Thank you very much!
I guess it makes it even better when you consider that every video he makes is another lesson learned for him personally and, while I’m sure he is a wonderful pilot already, this only makes him better. Always good to see pilots look into these things and learn from them, even if the scenario is handled perfectly by the crew.
It’s the accent.
He will have a team doing this as he’s that big a channel
I see these super suck up comments way too much.
I’m sure Mentour has a team of editors and graphics guys who make this stuff while he narrates and edits the script?
Mentour is a pilot and a trainer, would be too much work to do this channel alone.
@@Svabreoddly this is how I feel with my own career. I've been a senior Nurse in the UK for 14 years, I watch "horror story" videos and learn from other people's eff ups!! I know it's not quite the same and some things are so far fetched that they almost seem impossible but my biggest take away has been how many "small, avoidable" things soon add up to one disaster!! Although I don't often learn something I didn't already know, it's taught me "what NOT to do" in a lot of situations and I think that's probably just as vital!
We can always learn and improve and ego has no place when lives are at stake!
The production values are so insane. The simulation preparation and filming adds so much. The motion graphics also make things really easy to understand.
Glad you liked it
I can only imagine what would've happen if the door plug would hit the stabilizer or the fin. And things would be much more sinister if those seats were occupied and the passengers haven't fastened
@@ofacid3439 what's the problem - you never done a HALO jump?...
Right
For me, though, it's the music he has playing during the dialogue track that is extremely distracting to paying attention. I want to listen to him, not any music. So, please, Petter, I ask you, please refrain from playing any music while you are speaking. It is not as backgroundy as one might think. Thanks.
Hi Petter, I’m the son of a former Indian Air Force fighter pilot. My father always used to tell his stories about flying the Mig21. As a kid I loved listening to those. He unfortunately passed away 2 years ago due to Covid-19. In some way you way of story telling (and looks too)remind me of my father - and I love watching these aviation accident stories - and - its sort of cathartic - I just feel close to many father watching them. Thanks for everything you do and such great quality video made with highest professional standards. Regards.
Sorry for your loss
Condolences. I've lost friends and family to Covid.
Your father sounds like he was a wonderful man, Dr. Gupta. I see that you’re a pediatric oncologist, and coincidentally, my dad is a retired pediatric oncologist who studied medicine in his native Andhra Pradesh before moving here to the U.S. in the late 1960s. It takes a special person to do that kind of work; your father must have been very proud of you. May he rest in peace. 🙏🏽
Did your father also stop for commercial breaks?
@@Manowarmx3 Wow. You’re kind of a garbage person, aren’t you?
I gotta say, it sure is crazy how many weird things happen to Portland International Airport. An off-duty pilot trying to shut down the engines. A door plug flying off the fuselage. A mysterious man jumping out with a parachute. Sounds like Portland is living up to its unofficial motto of "Keep Portland Weird."
That’s true!
It must be our carpet.
😂 Gotta love Portland, tho'! ❤
Portland can't even come up with their own motto - they stole it from Austin. KEEP AUSTIN WEIRD has been around FAR longer.
Portland is an absolute liberal shit hole.
As a former aircraft mechanic i found incredible how those mechanics ends up with a bunch of parts left on the bench without realizing the mishapp
As a former employee of Spirit Aerosystems I could tell you stories! LOL Things are seldom as they are suppose to be.
@@rossdmccWe got time lol.
@@rossdmcc I'm listening 🎧!
@@rossdmcc please, elaborate...
They dont care and half ass the job
Coming from a QC background, this really is quite shocking. The idea of having multiple logs for nonconformances, some of them in private channels is a huge company wide failure
Not only that two processes exist for the putting the plug back in place -one "critical" and the other "less-critical".
Exactly. Workers and production Management under time pressure will absolutely choose the process that can be completed with less documentation and fewer inspections.
@@18robsmith This is not the reason and if you understand how doors works its completely OK. Problem is, that this piece arent door, this is plug. So for plug there is nothing like “open”, its always “disasembly” (I dont remember proper word from procedure). Somebody screw this.
Fortunately his explanation isn’t accurate
@@ivansemanco6976this right here is the real answer.
I am a consultant specializing in quality assurance and Failure Mode and Effects Analysis (FMEA), primarily within the automotive industry. The fact that the process did not require a check for the proper installation of these bolts after the reassembly of the door plug is simply bewildering to me. Frankly, this is scary.
Airbus is making boeing look silly ...clearly a bean counter decision
Playing by gallery.
@@alexanderreith6043 Look on current Boeing logo....
U see it, it's MDD logo. Bean counter culture comes from there
My husband and I are both former Boeing employees. During assembly on the factory floor parts, ie. fasteners, Are carefully monitored and must be accounted for. If you are performing a job that requires 20 rivets you get 20 rivets and that’s it. There are no parts bins with extra fasteners. This is done to control FOD and also to verify if the job was done correctly if you have an extra fastener in your hand after completing your tasks something is wrong. So what we are wondering is where are the four bolts that did not get reinstalled?
I'll bet some suit in Chicago decided that counting the exact number of parts took too much time and then eliminated that step in the process.
I wonder the same thing. 4 bolts and associated nuts and washers would be left over after the job. Where did they go?
My guess, the person who found them after the fact threw them away to avoid blame. Is that a management problem?, work environment maybe, bad employee?
Math word problem of the year 😂
@@billdeibner7105 not likely, they wouldn't have anything to lose by calling attention to it... no mechanic is going to pitch certified hardware into a bin...
the bolts should be traceable and likely have already been found in the parts store inventory, and the records of their movement should help reveal what happened...
Careful dude, it's starting to look like Boeing REALLY don't like criticism.
Stay safe.
RIP JOHN BARNETT whose wife says he was DEFINITELY NOT SUICIDAL.
I hope MENTOUR keeps safe and also does a BIO on the late whistleblower who dedicated 30 years of his life to BOEING. Such INGRATES!
@@Jddoes3Dmy guy he's a 737 pilot
@@MsElke11 Barnett himself said: "If anything happens, I'm not suicidal."
Bullshit. Stop with these conspiracy theories.
@@JanR1995 Another whistleblower just happens to commit suicide.
You must be one of those coincidence theorists I keep hearing about.
"When the Cabin Door closes, another one opens!" - Boeing
😆😆😆😆
😂
Touchè! Boeing plays GOD, much to the chagrin of passengers.
😂😭
Brilliant 😂
You've set a new standard of quality for reports like this.. very impressive, well done.
Thank you! We do what we can to be as accurate as we can.
The above comment ⬆️ has *absolutely nothing* to do with whatever grievance politics and/or anti-DEI 🤬 you've been hearing on Earth 2. Mentour Pilot did an excellent job recounting this air incident...
😀 Except fot the pilots wearing their sunglasses on all flights, even in the middle of the night😃
@@DabNaggit WTF ???
The fact their only mistake was not pulling the circuit breaker can be forgiven I think, they got everyone down on the ground safely, great piloting
You think that was a mistake? Ha! It was intentional 😂
@@mangos2888 why? They had nothing to hide
Forgiven by everyone but the NTSB who will undoubtedly make mention of that mis-step in the final report ... - i still say.. Bravo Crew...
Maybe a future recommendation will be for ATC personnel to say as a last instruction after the aircraft is parked, "please pull your CVR breaker". Of course this will be only after dealing with a crew that has declared an emergency.
@@jimwebb9328 while the crew ought to remember, anything can be forgotten in a delayed panic.
Petter reading a bedtime story:
"Hansel and Gretel were walking peacefully through the woods... but that was all about to change...."
...when the Fire Nation attacked....
sorry wrong story
The witch coming in for a landing on her broomstick lining up with runway 02
"And they had bread in their bags, which is going to become very important in what is about to happen. Remember that."
😂😂😂
They were hit by a boeing door
Hey, I was a caterer for this flight! My partner and I catered the flight once it got into its gate and later that day, on another truck we saw it back at its gate missing its door - spoke with the flight attendants involved and got to see the aircraft we had just catered missing a door. I love this channel and I can’t believe I’m getting to see this covered here, it’s very exciting!!
They probably moved the food onto a different plane. 😅
@@mediocreman2 Didn't the flying sandwiches just fly out the hole?
What did you do to the door? Might have been a loose pretzel.
Somebody thought it was a piece of cake?
@@mediocreman2😂🤣 No doubt!
As a non Boeing engineer, I appreciate bolts.
Thank you all for the hard work every one put into all these bolts.
Bolts hold our world together. Literally.
The bolts have to be PROPERLY INSTALLED to work. 😢
@@farangerBolts are made for one purpose, I think it is not to be put just alone ... for the weight.
@@malebetegrrr5793 No shit really?
As a Certified Aircraft mechanic With a Degree in Aviation maintenance Technologies from the National Aviation Academy in Clearwater FL 4.0 GPA.
The BOLTS have to be INSTALLED to work.
Even the slide mounting bolts were loose and no safety wire or safety cable installed.
@@farangerOh really ? Don't we discuss about how to use bolts properly ?
I have some degrees in Engineering (but I am French, sorry), I never ever show it when discussing about bolts.
I never will discuss a mechanics engineer about if a bolt should be secured, by what mean, etc ... it is his domain, no mine. But it should have been a thing to be observed by Boeing.
27:03 What I love about what you do is that you give a first-hand pilot’s perspective on everything you talk about. And this „It would be good if they told us that” part is a great example 😂
Captain Mentour, I don't know much about airplanes but I love watching your channel in the background while I work. Your manner of speaking is very soothing, the content is informative without being intimidating, and your compassion for your fellow human being's ill fate (regardless of whether they erred or did everything correctly) is inspiring and comforting. Thank you for providing this high-quality content to us for free. You make the world a better place.
Ad a former aerospace worker, my whole family is aero workers and engineers, we wll cry bitter tears to see how bad its got. I personally have made a million QA stamps on new and reman assemblies, 30 years and no field failures was the gold standard goal! Cheaper not usually better. Get a clue aerospace industry! Thanks for the report ❤❤
Engineer here. That no quality control was performed after what was obviously a critical repair, is beyond belief.
Could be Planner error (not likely). Inspection is always called out after structure installation. Depends if it was production, or rework planning.
@@chipset2900In GMP you'd have a checklist signed off by a different worker.
But if it is denied there is any work done (that's why the door was opened rather than removed) no checklist is needed and the work goes FASTER.
My wife had no problem flying, I have really high anxiety and just the thought of having to fly gives me the body sweats. Watching your videos for over a year have helped me become more informed of the aviation industry as well as slowly replacing my baseless anxiety and with intellectual confidence to fly for the first time.
I would heartily recommend British Airways' book Flying with Confidence too- you get a technical breakdown of the aircraft and the physics of flight, alongside the psychology of fear and ways to overcome it. Along with Mentour Pilot, it helped me after my fear developed (extreme turbulence on my first solo trip abroad).
im the same, will sit for weeks before watching air crash investigation
The last line is always, after the investigation, several recommendations were made which has made flying safer for everyone ever since.
"I have really high anxiety and just the thought of having to fly gives me the body sweats. "
As the late Spike Milligan commented:
Flying isn't dangerous. Crashing, that's dangerous.
@@TheRealWindlePoons reminds me when Clarkson said speed doesnt kill you, its the sudden stopping that does it
@@TheRealWindlePoons haaa had a similar argument with my wife when I bought my first motorcycle 😂 I said honey it ain’t the bike that’ll kill me, it’s the sudden stop. Needless to say she did not like that joke and the bike was sold 🤣
In the late 1960s, I flew from New Delhi to Kathmandu on a Royal Air Nepal DC/3 with no passenger door and was in the rear seat near and opposite the missing door. There was a crate of chickens in the very rear of the aircraft. Very memorable fresh air flight.
A friend of mine who is very glad he retired from Spirit long before these quality issues cropped up, said that part of the problem is that Spirit had a lot of lay offs due to Covid shut downs and that they didn't get many of those experienced people back. Now they are trying build aircraft as fast as ever with less experienced personnel. This is just one of the issues that they are dealing with. Now inspectors will be EVERYWHERE checking paperwork ramping up the stress level on everyone.
In other words they fired their competent expensive technicians who did not get vaccinated and replaced them with unskilled minority labour to improve their ESG rating.
@@mandowarrior123"They had a lot of layoffs due to COVID shutdowns." Can you read? That was BEFORE vaccines, in the shutdown phase. Did you just try to find a post to reply to where you could bemoan "unskilled minority labor" for your own reasons?
@@hannahp1108 except Spirit did mandate vaccines, and did change it's hiring criteria, boasting of their 'skilled diverse' hirings over 'traditionally qualified.' Wouldn't hurt you to look it up would it? Also look up 'minority' while you are at it, I'm not confident you're aware of its meaning.
Implying I have learning difficulties is not only rude but harmful to vulnerable members of our community that struggle with comprehension.
@@mandowarrior123 diversity hires 😂😂😂
Greedy CEOs can't be at fault, it must have been those vaccines am I right bro.
This flying door plug has attracted an unbelievable amount of news coverage and "specialist opinions"., Many stories being premature, not completely correct, often incomplete and predominantly time-wasters. Thank you Petter, for bringing us within 2 months of the incident the full story. with understandable technical details, superb graphics, analyzing human error snd all covered within spell-binding narration. This video was all the world needed, as always: unsurpassed!
I was actually waiting for Petter to provide a video on this.
hmm, not sure I'd agree with that, the internet community very quickly zeroed in on the issues, which are again confirmed by the info in this video... Petter has added some key info from the Boeing internal communications that weren't known before...
@@PRH123 Yep, not seen a single out of range claim other than "door opened".
Exactly, this is an incredibly well made account of this incident, and from a fanatical aviation steward that is utterly appreciated...
This one was pretty quick to diagnose because they didn't have to hunt through and reconstruct a ton of debris to make sense of it. Door plug pops out, chances are that there's something that kept it from staying in place, in either design or installation. You find the fallen plug, notice it's missing some bolts and there's no sign of those bolts ever being there during flight... AHA!
Initially I thought "not another door plug video", but quickly I realized that this is actually telling the whole story with new details that were not explained before. As an engineer I recognize so many patterns here and am almost in disbelief that this is an airplane manufacturer.
" I realized that this is actually telling the whole story with new details that were not explained before. "
===
The details have all been explained before, just *not in one place* . This is why I keep watching this channel.
As a software engineer it was clear to me that Boeing was a fatally sick organisation when the first flight test of Starliner (their very delayed new space capsule) suffered multiple unrelated software failures on the happy path (the everything-as-expected situation, not some hard-to-foresee edge case). That can only have happened if they never even once ran an integration test before flying it. Engineers as a subspecies are first and foremost motivated to turn ideas into things that actually work. The more audacious and ambitious those ideas are, the more motivated they are to make it happen. Aerospace engineering is pretty much the most extreme example of this - you can be absolutely sure that every engineer on the project (software or otherwise) would be deeply invested in the success of the mission, and keenly aware of the insane difficulty of the optimisation problem that needs to be solved to make space hardware work - they would be kept up at night worrying that they'd missed something, no way would they just omit the most basic testing if they had any say in the matter.
Engineers perceive any impediment to achieving their goal (making the thing, and making it well) as a threat, which often includes management (either because the management makes actual bad decisions, or withholds information from the engineering teams so that their necessary decisions don't make sense). To have a failures like those on the first flight test of Starliner, you have to have built such a toxic work culture for so long that your engineering teams and management are in all-out war with each other. With the power imbalance, that means that engineering always loses. In that environment, your best engineers leave, and any who stay have to distance themselves emotionally from the success of the project.
At that point the only way you recover is to gut both management and engineering and rebuild with competent people who understand what went wrong and are committed to the structural and cultural changes necessary to avoid it happening again. Good luck getting that right in a company as large and sick as Boeing, where the side effect of losing the institutional knowledge that would entail would set back anything they're working on by many years.
This is the first video I have seen on Alaska flight 1282. I wasn’t interested in any previous ones and I’ve been waiting for this because I knew this channel is the gold standard for aviation news. I am not a pilot, nor am I involved in the industry (besides as a passenger), but I can tell a serious communicator whenever I see one. Thanks a lot Petter. You always shine a bright light into these events.
Huge props for the enormous amount of 3D modelling you did for this episode Dominic! Even the Boeing and Spirit factories!! Great 2D graphics explaining the door plug assembly too.
Yes. I recognized the renton factory exterior really well done. N
The 3D graphics really stood out. Loved the pushback truck girl :D
Microsoft flight simulator 2020 and PMDG 737
The "models" are just Microsoft Flight Simulator.
@@connorranz9746 Not the PMDG one.
“Darth Vader running a marathon” is the funniest line I heard today
i came down here looking for this comment
Of course it sounded more like Darth Wader.😅
I will have the AI produce this image for me immediately...
The fact that this was not a specific MAX design flaw, but a general quality control problem, is even scarier for anybody depending on Boeing, because ANY Boeing aeroplane can be and is affected by the way they make their junk in general!
It seems that the problem was within Spirit which is even scarier because it means all Boeing aircraft *and* some other brands, too.
There's a bit more to it. It is far from all Boeing planes which has these plugs. From what I can understand, it's a relatively new thing. You won't find them on 747's, 777's older 737's etc. Not sure Airbus even has any. The scary part here is, that it tells us a lot about the working environment and culture at Boeing, and that affects ALL planes going out. It is as terrifying to learn that they did not replace the rivets which were supposed to have been replaced for example.
Also note that Spirit is still Boeing, and it is the responsibility of Boeing to make sure Spirit does its job properly. It is also a problem that Boeing disregards issues, and thus demands the production to be ramped up so deliveries continue on schedule.
@@AB-80Xno... it tells us a lot about the culture at SPIRIT, not Boeing.
Airbus does have door plugs. Just a guess, but an a321 neo probably has them because of passenger configurations.
Bigger planes are less affected by this, because they’ll just have a door there because of passenger count. It’s these large 737s that are right on the edge of passenger count for exits, which is really just the max 9 and 10, as well as a 900ng
@@thomasneal9291
No. Boeing is very much in charge of its final quality control. Don't you understand that a big part of this problem stems from the pressure Boeing not only puts their own employees under, but also those of its subsidiaries?
Boeing's business transactions with Spirit, accounts for more than 90% of Spirit's contracts at this stage. And what little work Spirit has done for Airbus, has not shown to be a problem, because the rush at any cost does not run rampant at Airbus. Boeing is run exactly like McDonnell-Douglas was ran, and it did not work, and it was all about "just get it out the door" as fast as possible, no matter what. We are dealing with a company that literally moved a fuselage across the road from the assembly plant and back, just so they could claim it had been delivered. That is what GE and McDonnell-Douglas did, and that is the culture which is running amok at Boeing now. What you see here is the results, just like they were with older GE Aviation products, the MD DC-10 and so forth.
With over 30 years of aviation maintenance experience (& still on going), these pilots did a great job! Hands down they were handed a serious crap situation and knocked it out of the park.
God bless them
Another excellent video! As an ex Boeing engineer, I was aware of issues concerning senior management and I quit back in 2009. Considering recent events I am not likely to fly on another Boeing aircraft, no matter the type. I don’t expect to see any meaningful change in culture there in my lifetime (I’m 73).
Hm. I'd still feel fairly comfortable on a good ol'e 747 or 737-300 etc. The 747 is still a nice cigar with a fairly good track record.
Wait, you quit when? Are you a time traveler? (Joking of course)
@@andon_RT
I guess there's a secret project Boeing hasn't disclosed😀
@@andon_RT my bad. I quit in 2009 🙄
I love flying but I'm not getting on a Max.
The most incredible part of this whole story is how the door didn't hit the plane's elevator.
True
facts
There’s an elevator?? How tall is this plane
For legal reasons this is a joke
Edit: thanks for all the likes guys! It means a lot
I think that the most incredible part of it is how that door survived a drop of about 10000ft or so and stayed intact the whole way down
I imagine its shape caused it to feather on its way down.
Boeing seems to have developed a habit of “forgetting” to tell pilots about various features of their planes. Kind of makes you wonder what other surprises they have in store.
Yeah like MCAS?
Yeah like MCAS?
8:56 I worked at Hewlett Packard in the days when quality took priority. Stopping the entire assembly line when there was a quality problem was accepted as the correct thing to do.
I heard two words - "easier, and cheaper". And that explains absolutely everything.
Nah - whistle-blower is the phrase to look for. Easier and cheaper are simply reality at every large company. Compensate whistle-blowers richly with an insurer based reward scheme and you will see decent safety records restored PDQ. Think about it - if you had the opportunity to turn squealer and get what amounts to a rich pension automatically - no corner cutter would be safe. Both shuttles and the astronaut crews would be alive today. And "US" products would actually have US engineering drawings instead of some bogus Chinese cad drawings with no revision block data.
@@jeffmilroy9345
We used to joke about Boeing doing everything FASTER, QUICKER, CHEAPER, BETTER. It finally happened that the McDonnell - Douglas leadership team reached their desired goal with almost deadly consequences.
@@mrc8683 Well at least Sully gave a harsh, public criticism.
Thanks Petter - really great description of this event. As a retired, very high time pilot with plenty of time in command on 737s (and other Boeings), I can not pick a single hole in your excellent presentation. Outstanding job! 👍
12:26 Do what I do: take the nut & bolt out, move the work piece, replace the nut & bolt in its original holes so the work piece can't be replaced until the next shift (or future me) has to deal with & handle those fasteners.
You're fired for not moving the product out the door fast enough.
You're all fired for talking about it!
Thanks for the amazing videos you put together! I’ve learned so much and the high quality of your work shines through every time!
As an allmost engineer (i did not finish my course) the manager deciding to choose for "Just opening the plug so it can retain an SAT and no further action will be needed" must have never had any engineer training, because in that case he would have heard of murphy's law and would have chosen for a path with an integral final check-up on the work (CMES if i write it correctly).
I hate when people do stuff like this.
I must say i am very glad injuries where just few and minor!
I am an upholstery guy mostly for flight cases and on friday i got distracted and missed a few steps in finishing 4 boxes. But i always lay out my work so i had two pieces left over and that got me thinking about my distractions and i took those 4 boxes back into my workplace for check up and i got them finished eventually.
Someone should have taped those 4 bolts to the door plug to remind them and other workers that they needed to be fitted again.
And since it is aviation and lives we talk about, this work should be written down as needing extra inspection effort.
What i am saying is workers should train themselves to help with oversight of job completion and especially when things become more responsible management should pitch in and give workers back-ups, just because murphy's law will always be a thing and mistakes will be made.
The problem is that so many company directors are deciding to save money by either out-sourcing by separating different divisions into individual entities within the corporation, or out-sourcing while shutting down their own divisions, or simply forcing workers onto workplace-agreement contracts (or a combination of these). As the parent company then dictates how much a contract is worth, the off-shoot is forced to hire the cheapest sub-contractors they can find, meaning skill-levels & standards drop!
Here in Australia, Qantas board-members (especially the outgoing CEO), have made a killing in bonuses & shares, despite the airline's reputation & value taking a nose-dive!
The result is of course that the bosses expect the workers to loyal & hard working, but all the while paying less, with no pay for holidays or sick-days!
The old saying is; "If you're only willing to pay peanuts, then you'll just get monkeys!"
Nah i understand why he would do it, its faster and probably easier to fix with less delay. Doesn't necessarily have to do anything with putting it in the system. The problem was that there wa snot the correct checklist to be done afte changing the seal. Normally that should have been correctly stated in a work order. That is also normally atleast in Airbus the standard procedure where a non conformity then also needs to be signed off by quality control
Per Boeing processes there should have been a removal written to open the door plug in CMES and attached to the Non Conformance Record addressing the bad rivets. There also should have been removals written on the wall panel, stow bins, and whatever else had to come out to access the plug. But Boeing has been unable to produce any removal records whatsoever. Boeing is in violation of its own processes and FAA requirements. Probably some low level manager was pushing to speed things up.
I don't agree with workers should train themselves to help with oversight in this industry.
I do agree with this IF it's completely independent of the workplace expectations but as a general rule no.
The inspections, instructions and quality control should be the ultimate factor in these situations.
The workers doing the actual fitting work WILL miss something eventually if there is no process to check (specifically a dedicated person to inspect the work).
Saying it's the mechanics job to do quality control means they will be lax with inspections.
Which in other industries is not a big deal and makes sense but not when a simple mistake can absolutely kill people.
22:55 the quality of this channel is incredible
Thanks for your effort in producing this!
These pilots and cabin crew should be given an award, and the passengers reaction should be used an example for people on how to behave in an emergency. Wonderful story.
It’s a miracle that no one was sucked outside through the hole. I don’t fly often but I’ll think twice before flying on a Boeing. There are too many issues like this, it’s scary.
As one of the biggest fans of this channel I look forward to a great story
#1
Where do get the time to make these videos, researching facts, do your job as pilot/ instructor, family commitments, leisure time, and probably a whole bunch of other stuff we dont even know of.
And then you present this in such a calm and entertaining manner.
All i can say is a simple Thank you.
Current Engineer (and pilot) here. I’ve worked with multiple aerospace companies and I cannot stress this enough, it’s (almost) always the process, not the people. The tech forgot to put the bolts back because it was not in the process. It took me many years to accept this. I oversaw at least 200 leap 1b GE engine builds. Everything was in a kit. No parts were ever left over. Nothing left un torqued. The process was bulletproof. Sure we had problems but the process caught them before they ever made it to the plane. For this example (disassembly of a finished component) all the details would be re-kitted and isolated from production details. Easy. No exploding door. It pains me as an engineer to see this.
Thanks once again Petter, for yet another crystal clear, logical, unbiased, factual and very instructional video. Brilliant! This incident takes me back to a military flight between Balad AFB and Basra in Iraq in an RAF C130. With a tightly packed load of PAX in full combats and body armour, warm, tired and nodding off in the cruise (it was about 0300Z) when in a flash ....all hell broke loose! Instantly, the hold (cabin) filled with dirt, dust, debris, toenail clippings and insulation material - which made it impossible to see anything or breathe. As the now depressurised Herc went into a steep dive, the only way to breathe in this thick muck was to do so through the sleeve material of my combat jacket, whilst hanging on tightly to the seat webbing. Being in a war zone, I thought we had been hit, but there was no panic and I remember how silent everyone was. Wallop, bounce, rumble... incredibly abrupt and rough landing heaven knows where. Engines shut down, the loadmaster opened the ramp and everyone piled out...into the swirling dust. Sorry, l'm rambling a bit, but anyway: it turned out that the young soldier sitting immediately in front of the port mid fuselage emergency exit door had stood up for a stretch, but in doing so had managed to catch the yellow / black door release handle on the webbing on his back, and .... wooosh! So if this happens to you, then in the absence of oxygen masks, breathe through the nice thick material of your combat clothing. Stay well, stay safe, and as they say on the London underground: "Stay clear of the doors please!" and "Mind the gap."
Truly one of your very best vids!!! Sharing the insider details from Boeing and Spirit, along with your outstanding point by point walk through of the airborne event is really impressive. Keep doing what you do!
I sure have heard about Alaska 1282 and the missing bolts but I really enjoyed the unusual level of detail that you give in this story. I understand the incident more fully. I have never regretted subscribing to both your channels from which I have garnered immense knowledge about aviation. Thank you very much, from Nairobi, Kenya.
What a way to explain the incident.
Your expertise and professionalism are beyond incredible.I love your channel, thanks for what you do here
I spoke directly to someone who works for the company. The inspection team who double checks the work was basically nullified.
What do you mean by nullified?
@@reason8958 fired. let go. downsized. involuntarily retired... you get the picture.
This is by far the best aviation channel out there, so great to see the videos back again.
Another example of why you're the best at this Petter. Excellent analysis.
I'm a layman but I was incensed that Alaska had been aware of pressurization issues and didn't ground this plane. I concluded that the very fact they limited the plane to overland routes was indicative of negligence since they must've known there was a significant potential of catastrophic failure.
You've offered a different perspective which I appreciate. That said, perhaps my view on Alaska has to do at least in part because of their history of cutting corners.
Great video as always and keep up the great content.
I'm from Ann Arbor Michigan and would enjoy it if you could do a video on NW flight 255 in 1987.
Excellent detail on this situation with the door. Thank you for the detail. Amazing how you collect and present in an understandable way this critical situation.
I've been aviation maintenance in the military and an engineer in product manufacturing. This seems unacceptable on so many levels. Every maintenance action should have another person very it was done correctly. There should never be any part of a manufacturing process quality can be ignored.
And the people at each station on the line should verify that the previous step was done correctly.
No way that wall panel should have been installed without the crew checking to make sure nothing looked funny.
Touch each bolt -- the same way I was taught to touch each bartack on the MOLLE webbing before sewing the panel in place.
Thats how we work in software development even with non-critical components or small tools for personal use only. I was taught that this is engineering gold standard. Apparently enough people don't hold up to standards
@@pdoge "I was taught that this is engineering gold standard."
Absolutely. The real engineering motto for this situation is: "Cheap, quick, good. Pick any two."
@TheRealWindlePoons While this situation MAY have involved Manufacturing Engineering, that is not the motto for ANY situation. It was invented by people who don't have a clue what engineering is all about. Proper engineering requires the balancing of many factors including cost, manufacturing efficiency and quality. Pick two is the excuse of the incompetent.
@@pdoge Damn I want to work where you work because that is not standard in our industry.
10:28 Painting over bad rivets should be prison time for anyone involved. The handling of records is bad (and probably the biggest reason the incident happened), but DELIBERATELY faking a repair is disgusting.
You don’t know that it was intentional faking. If the write up wasn’t very clear it’s totally possible that they repaired the wrong rivets and painted those ones while touching everything up afterwards. It’s VERY difficult to write up a repair on a handful of items when there are thousands of the same item in the vicinity.
@@gpaull2 Except there isn't. It's very clearly stated that it was the rivets on the plug "door". Do you know how many plugs were on the aircraft? ONE. And they opened up the plug to paint over the rivets, the exact plug they were supposed to fix and painted over the exact rivets they were supposed to fix, and you think that it wasn't clearly written down what they were supposed to fix huh? So much for that "theory" that has absolutely no logic behind it and is just some bs you thought up in two seconds. And oh, records are so hard to handle huh? I have a feeling you've never had to keep records before. it's not hard to handle, it might be cumbersome, but it's not that hard to figure out. Not only did they paint over the shit they were supposed to repair and act like it was fixed, but they broke the sealing around the plug and said NOTHING until they had to. Whether you believe the painting was intentional or not, they knew they broke the seal and INTENTIONALLY said nothing. Despicable, idk why you people try to defend it, probably because you don't even know what you're talking about or paid any attention to the video.
@@Kratos-eg7ezFor your own health, perhaps you shouldn't get so worked up about Internet comments. Stress isn't good for you.
@@elliotgillum eh, it's not like I'm stressed about it, I just like shitting on dumb people with dumb opinions.
@@elliotgillumHe made a very good point
Absolutely superb video from Petter. Explained the technical side so it was fully understandable by both expert and non expert alike. And with superb graphics. If only my lecturers at Uni had been as good and clear as Petter!
Glad it was helpful! 💕💕
good description of the event with good detail. Much appreciated.
First class and professional video. This is the first time I have understood clearly what happened on flight 1282.
39:36 you were so right. Thank you.
Thanks Petter, an excellent report. Well explained and backed up with exceptional graphics / video sequences.
Just want to say that I have watched a number of your videos, and although I was trained as an engineer Aviation has never been particularly interesting to me, preferring to use my problem-solving skills in the IT/Tech busness area, your presentation and explanation of issues as in this video is brilliant. This is a 40 minute video that did not have me feeling itchy to click away after 10 minutes which many TH-cam videos do. Keep up the good work, you have an excellent balance of detail and overview and a great understanding that if the story is not interesting and logical, no amount of fancy graphics or effects will save it. Look forward to the next one.
Wow. This channel is just amazing! I've had this on my playlist for some time but it was recently that I saw a full video and couldn't stop. Petter, your level of detail in explanation and your obvious experience, just makes this channel pure GOLD. My new favorite channel on TH-cam and I'm gonna have others watch as well. Thank you.
While I was flying B-73's, I also only had to use The Manual Pressurization Control ONCE! I have nearly 30,000 Total Operational Hours & about 10,000 hours in The B-73. You're right, "Emergency Decompressions" are something that we Practiced Extensively in Simulators. My one time use of The Manual Pressurization Control was probably due to an Electronic Sensor Malfunction, & I never flew that Particular Aircraft again. I made the proper Entries In The Maintenance Log & notified The Company.
Also, after The Post 9-11 Bullet Proof Fortified Cockpit Doors were installed, NO ONE EVER TOLD ME THAT IN A DECOMPRESSION SITUATION, THAT THOSE DOORS WERE DESIGNED TO OPEN. THAT WOULD HAVE SEVERELY FREAKED ME OUT! As you said, That Would've Been Some Very Nice Information To Have!!!
Before I was Typed in The 73's, I previously flew DC-9's, MD-80's, 83's, 88's & 90's. I never had a Pressurization Issue In That Type.
Most of my over 40 years flight Experience was in Those Aircrafts. Sure, I've made Emergency & Pan Pan Landings, almost all were Medical In Nature, With A Handful Due To Faulty Equipment Readings.
It's good that you & others are posting these Videos Online to help prepare The Flying Public for what they might expect in the event of such Emergencies!
Fortunately, this is not an everyday occurrence! The chances of this ever happening on your flight is extremely low!
HAPPY FLYING!
My family flew cross country last week and I made sure we were flying in Airbus airplanes. The Boeing executives should be ashamed of themselves for sacrificing safety for profits and higher bonuses. The entire Max management needs to be fired and even more severe punishment for Spirit, the manufacturer of the fuselages. I will NOT be flying in any Boeing Max planes for at least the next couple of years. This channel is great and I wait anxiously for each new video!!!
Yes, all those McDonald Douglas scammers need to go -- right up to Calhoun and he can take a few of the board members with him on his way out.
Fantastic and superbly detailed report. Well done! 🎉😊
1. Respirate
2. Aviate
3. Navigate
4. Communicate
Aviate, aviate, aviate. That's what we're taught in Brazil.
Perspirate. 🎉
i don't know how Darth Vader sounds when he runs for a marathon🤣
Picture it
he sounds the same as he does when he's walking only a lot lot faster
0:22 All because someone forgot to do something. Well not quite...
If they had merely forgotten to fit the 4 locking bolts then the door would have failed on its first flight. It probably wouldn't have even got as far as it's first flight without being discovered, as they no doubt perform a full 8psi (or higher) differential pressurisation test on the ground and even if the door plug didn't fail then (which it probably would) there would be a noticeable air leak as the door will be significantly lifted by the assist springs.
The reason it passed the initial pressure test and then didn't fail until it had done 150+ flights is that they didn't merely omit the four locking bolts, they actually added a white plastic zip tie, which was holding the door plug closed. Why isn't that mentioned by NTSB?
At 12:18, in the "after closure" Boeing progress photo, on the (forward) right hand side of the door, the second up from the bottom, pair of door & frame lugs, have a white plastic zip tie clamping the door lug pin & frame lug pad firmly together. (This photo is figure 16 in the NTSB preliminary report).
The zip tie held, keeping the 12 pairs of lugs aligned, until a bumpy landing broke it, or made it finally slip off one of the lugs. Without that zip tie, the lift assist springs will lift the door to the point where all of the 12 pairs of lug pins/pads are pretty much disengaged and only the very bottom part of the upper guide tracks are engaged with the guide rollers.
That part of the guide tracks was never designed to hold the cabin air pressure and it finally broke at 15,000 ft, the first flight after the zip tie broke. (After 150+ flights).
It's a shame that the lift assist springs didn't lift a tiny bit more, because then the guide tracks would have fully disengaged from the guide rollers when the zip tie broke on landing. The door would have then fallen open to 15° where it's wire lanyards would hold it. Hopefully a door plug open 15° would be noticed on the next pre-flight walk around. Failing that there would be serious wind noise on takeoff, deformation of the interior panel, no pressurisation and an interesting view for anyone looking out through that "window".
Note: a zip tie is also known as a hose tie, cable tie, zap-straps or tie wrap.
Thanks for forwarding this observation! The explanation has needed a basic cause, the missing bolts and the culture that let it happen, and a proximate cause that allowed the plane to operate normally for those 150+ flights.
Good catch. Thanks.
Human errors do happen but this one failed in many respects. Should there be a job card developed and followed? And of course some supervisor to inspect and sign off when the job was completed. Especially this plug now becomes a part of the structure! Personally I feel that structural parts should be "permanently" held in position, either by weldings or fasteners. In this case, can those lugs be used? Say threaded so bolts can be used to hold the plug in position.
So - the team that inspected that exterior wall and the team that installed the interior wall panels just didn't notice the zip tie? They just said, "That's not my department?"
@RyanK-100 Isn't that the reason that any of this happened? There isn't a team inspecting the work done to open/close the door plug because it's considered to be as trivial a task as opening/closing the L1 main cabin entry door, that's done on every flight. Nobody noticed 4 critical locking bolts were missing, that you might very reasonably expect the most trivial glancing inspection to check for. So it's no surprise that a zip tie isn't noticed.
Is the person refitting the insulation & interior panel, the same "grade" of person who was reworking rivets & door seal? Is it "their place" to look at what an airframe grade person has been doing with a door plug?
The insulation is draped over the top of a seat headrest. Perhaps just held by trapping the end of the insulation in the seat tray on the back of that seat. Just release it and the insulation is instantly draped over the door, covering the zip tie and the empty locking bolt holes forever. (Or at least until Bob finds the door in his back yard).
The zip tie is the entire reason that passengers lives were put at risk. So that's a very important part of the investigation that isn't being mentioned by NTSB, even though they published the photo.
If it had been both no locking bolts AND no zip tie, then the door plug would have failed a ground based 8+psi pressure test, either due to leakage or blowout. In the unlikely event of it getting to the first test flight (without passengers) then it would have failed then. It would never have got to fly with passengers, putting their lives at risk. It's only the zip tie that escalated things to the level where passengers lives were at risk.
Everyone is believing that the springs don't immediately lift the door to almost full extent, just because that belief is needed to support the narrative that the door can stay in place for 150+ flights with no locking bolts (and no zip tie) and that's what people have been believing for weeks. The belief that the springs barely support the weight of the door becomes fact in their minds. Any photo of the door open, shows the hinge guides at the top of the hinge tubes. (I can see 2 fairly important reasons why the springs would be designed to lift the door like this).
Because the springs will lift the door, the zip tie is needed to hold the door closed for the progress photo. It's the zip tie firmly clamping that door lug pin to a frame lug pad that is holding the door in the down/closed position for the photo. (Person who fitted the zip tie obviously expected to have the lock bolts available shortly and to be fitting them. They weren't thinking a zip tie is ample for flight, in place of 4 locking bolts!)
@@RyanK-100they tried painting over it the first time ffs. Zip ties was the clever one of the bunch.
Hello from Canada 👋 🇨🇦. Your videos are so well explained and uncomplicated. Definitely binge worthy. Thank you! ✈️
I'm sorry, three successive posts on the same video may seem excessive, but I've yet to see anyone else with factory experience comment on the fact that the people who installed the wall panel didn't check the work that was done ahead of them to ensure that it was right.
I was always required to look over each item in my hand before sewing the next step and hand back anything that wasn't right.
They'd done the job before, they KNEW what the plug SHOULD have looked like -- how did they not realize that something "looked funny"? Why didn't they call an inspector before they continued?
Why weren't they trained to touch each of the CRITICAL bolts before covering them up the same way I was trained to count bartacks on the MOLLE webbing before sewing the seam that would make adding a missing one impossible?
QC isn't something that happens once at the end, it's something that every single person on the line needs to do on every single item, large or small.
I think the issue there is these are not the same people who regularly install panels over the plug, and would not know what to look for...most criticism is there were no QC/QA people who would be versed on what to look for....
@@wokewokerman5280 If they weren't trained to look for flaws in the previous operation on the line then they weren't qualified to do the job. There's just no excuse for it.
Boeing shouldn't be accepting these defective fuselages into their facility. I know from experience that a factor that accepts defective product from vendors guarantees that defects will get worse and worse and worse.
The parachute plant I worked in had that issue and it continued until they put their foot down and sent the stuff back at the vendor's expense.
It cost us overtime and stress in the short term making up the shortfalls, but saved us a lot more in the long term.
24:05 : everybody gangsta until Delta P comes into play
delta P will get ya, every time!
As a non-pilot, I appreciate your initial deep dive into the details. This fleshes out context and understanding. And, as a professional radio broadcaster and voiceover talent, your delivery of these details and the production value of your video are superb!
Was this captain an instructor by any chance because it seems he did everything perfectly for this kind of emergency
I think it was a lady
It was a lady, not sure if she is an instructor. You should go take the time to listen to the atc audio. She is an absolute unit of aviation.
Yes, she is an excellent pilot who remained calm and professional throughout.
You got to give credit to all the simulator training that pilots have go through periodically. It is quite realistic and it really helps them stay as current and proficient as possible on different emergency scenarios.
@@GVSolo not for this event
Fascinating stuff. One thing I find a bit crazy is that in this day and age of terabytes of data storage that the CVR in a brand new aircraft is still limited to just two hours of recording before being overwritten. Nevertheless, it’s obvious the crew did a fantastic job in this incident sand I hope they will get the recognition they deserve.
" The older analog units use one-quarter inch magnetic tape as a storage medium and the newer ones use digital technology and memory chips." - source: NTSB - Cockpit Voice Recorders (CVR) and Flight Data Recorders (FDR)
I was going to guess they still used tape (for valid reasons), but after a quick search, it appears that newer planes do use digital systems. So I'm with you in not understanding the automatic overwrite. Audio can add up pretty quick in data. 16 bit wav files is around 650MB for an hour of audio. Pretty much a gig for 24bit. But memory is hardly scarce resource, so I'm with you wondering why that limit is still the standard. It wouldn't be a problem to have a CVR/FDR for every entire flight, from gate to gate.
I would think this would also provide all kinds of data to improve airplane systems, CRM, etc.
Excellent explaination of what had happened. Cleares out a lot of speculation and addresses the route cause of the problem.
The real root cause is management. W.Edwards Demming always blamed management for quality .
Congratulations for such an amazing analysis, explanations, and graphics. Love your channel you are such a PRO! Thank you for bringing this and other content to us.
I absolutely love the effort and quality you and your team put into every video. Best aviation channel on TH-cam....bar none. Bravo!
Without disclosing how, I can say your concise stage of events and overall accuracy is both impressive and highly commendable - excellent video.
meanwhile the CEO of Boeing just gave himself a 45% salary increase to 32.8 million dollars a year .... Crooks in suites
I love how you keep every video so well structured and interesting to watch like a thriller movie! Well done Peter!
I love that the footage of the assembly process, courtesy of Boeing, at 8:58 clearly shows while moving the fuselage that a cart is left in the way and is just pushed along by the aircraft undergoing assembly. A simple thing but it speaks loudly for the safety culture at Boeing. No one did a walk around before moving a very large, very expensive item?
I’m so surprised you noticed such a quick clip haha
RIP Whistleblower, worked years towards a goal, then when he finally is close to that goal "deciding" that its not worth it and ""commiting "" """suicide"""
Omigosh. Those iPhones that survived the fall.
Terminal velocity at play.
Your videos are absolutely the best! Top-notch, both in production and analysis. A far cry from back in the day when I used to read the “crosscheck” magazine from Pan Am
Boeing has lost the trust of its customers.
So why was the whistle blower that was due to take the stand at a trial this week, assassinated the other day? He actually told friends that if he had an untimely death, that it would not be suicide. Posted this on 15th March and this untimely event happened after this video was posted on TH-cam
..Reminds me of the same mentality as the Challenger faut pas.. Where the board of Directors over rode the advice of it's Engineers and launched anyhow.. The Achilles heel of such primary focus on rate of return over riding front line engineers...
…..and the engineers over-riding the advice of technicians.
@@darronwolf7731 For sure... In my company, I actually put seasoned (read: old, been there done that quality street smarts) techs with veto power to force meaningful reviews of the engineers production designs. Some weren't happy, but I was, and it was my company..
It honestly was a miracle no one was sitting in those seats, thank whatever sky deity you praise or praise the luck of the draw that no one lost their lives in this incident.
Mistakes happen. The important thing here is to learn to prevent them from happening again. It's amazing that nobody got seriously hurt or killed, and the crew did their job. It's also a miracle that the stabiliser was not damaged from the departing safety door into the heavens. As always, it is very well explained as always. Slainte, Petter ❤
Mentor throwing shade at Boeing made my day! XD
Following that death, we've just had ANOTHER 737 Max 8 land with a panel missing. March 15 Rogue Valley International, Medford, Oregon. Only discovered after landing post-flight walk-around.
I find, by far, these productions of Mentor Pilot are ‘EXTREMELY EXCEPTIONAL’. The knowledge as well as the insight are second to none. This episode does not acquit Boeing from any wrongdoing, but exposes the fact that there is more going on that needs to be scrutinized. But let’s not fool ourselves, Boeing is a huge vessel of the American military and together with the United States government will go to any length to protect their brand.
Watching this video two weeks later is wild because in just the last two weeks, not only have there been many more Boeing safety incidents, but that whistleblower was found dead in his car. I also saw an article from 2022 about how Boeing threatened to not release these planes at all unless they could be exempt from safety standards.
If it's Boeing i aint going
Any comments about the death of the whistle blower?
As always, a well researched and fascinating report. I live along the flight path and have flown out of PDX many times. Grateful that there were so few injuries. Kudos to all involved on that flight! Thanks Peter and Team.