I appreciate that NTSB is posting this to TH-cam (rather than or inclusive of the usual source) since it is possible to start and come back to it at the point where the user goes elsewhere and then comes back.
I love that they have the safety briefing prior to the meeting. As a teacher, it would drive me bonkers if we had to do this every meeting. But doing it like three times a school year might be worthwhile.
This 5:58:00 exchange, lasting 3 minutes, tells the story about what went wrong at the factory. Boeing needed to get the unfinished plane removed from the factory floor to ready room for another fuselage to be assembled. A "move crew" closed the door plug so that the plane could be moved outdoors into the elements. A final closure of the door plug by a "door crew" was never completed on the aircraft due to missing paperwork. Just incredible. And no one from the factory has come forward to explain why the paperwork covering the opening of the door plug was never created in this case.
In the NTSB Preliminary Report a photograph was shown, taken by Boeing employees at the time of rivet rework but just prior to interior panel re-installation. This is the photo visibly showing at least 3 of the 4 bolts were missing. A commenter noticed in that photo a zip tie around one of the stop pad assemblies. I think 2nd up from bottom on forward edge. If the Move Crew had to “push” the plug closed, not to actually “close it” but to protect interior from the weather outdoors. It raises a HUGE question I have never heard asked. That question is- If you “push” a plug closed, does it stay closed? Or do the lift springs on the bottom hinges exert enough upwards push to dislodge the stops & upper guide track rollers? Or is gravity enough to keep the plug in closed position even without lock bolts being installed? If the plug does pop open against gravity on its own it might explain why a “Move Crew”might put that zip tie around the stop pad assembly as a temporary measure, assuming someone in charge of installing the bolts would do their job. I’m reminded of different types of mechanical safety features, roughly divided by being either an Active or Passive feature. I’m wondering if the pressure of the lift springs was purposely designed as a passive safety feature? In other words, does it require someone holding plug down in closed position while bolts are installed(or possibly a special tool designed to do so, example- a long punch inserted in a bolt hole that prevents interior panel being installed) In this scenario- if the bolts are not installed the plug pops open on it’s own and flops partially open. Nobody is going to install interior blankets & panels with a plug hanging open 1 foot plus. Maybe they rely on a passive safety feature? If the plug is closed, its bolted, UNLESS someone bypassed that passive safety feature, by putting a zip tie around the stop, to hold plug in closed position. The implication being that the zip tie was the only thing holding plug closed until it let go at 15K feet. A generic example of a passive safety feature could be the spring loaded grip to engage your snowblower impeller. How many people poked snow out of a plugged chute, and chopped up their hand, before those passive devices became mandatory? It might be easier to unplug chute if the impeller is running, it might clear itself with some prodding, so some people bypass the safety feature by using a zip tie to hold lever down. They maybe bypass the safety feature so they can wipe snow off their goggles while guiding machine with one hand, (or maybe push a plane outside in the weather) then they lose a hand unplugging chute.
They try to practice what they preach ~ heard stories of investigators on the highway pulling over and parking multiple times to answer urgent texts, and the Chair once mentioned how much she gets honked at for driving at the speed limit
Then at around 3:15 pointed question was put to the head of the mechanics untion: do you have confidence in the "speak up" systen inside Boeing as described by Ms. Lund? NO.
The spirit rep admitted that "when one raises a hand to report an issue on the production line, an inspecting manager would evaluate DEPENDING ON THE IMPACT... Basically saying in simple words we do not hold production lines even if there is a quality or safety issue. I am surprised that no one there picked up on it. It's right around 2:58 minutes in. The real question should be How many times has Spirit held the line of production in 2023 due to mechanical engineering and machinist complaints of being rushed and being given questionable quality parts. He arrives with no paperwork and no laptop to reference to even though he knows he will be in the hot seat. Arrogance.
5:47:50 lean manufacturing come back to bite you again maybe? A major tenet of lean/six sigma thinking is that having spare hardware, or oversized hardware, is unnecessary because "rework will be a thing of the past" I'm noticing that it takes Spirit 1 day or more to go from the request to rework to accomplishing the rework. On 9/18 this was because they needed to get the rivets from another site. Is it a frequent issue where spare hardware needs to be scrounged up to complete rework? (Yeah I know I'm playing armchair NTSB)
This Lund woman the truly toxic, duplicitous, bureaucrat destroying all that is good, obfuscating, blocking, Using all kinds of jargon and acronyms, but appearing helpful.
Then someone with the Board would probably point to a specific person and tell them to use them. However them having designated people to handle all these points is actually smart, because it bypasses the risk of delay due to the bystander effect, because in an emergency it's unfortunately common for people to delay or even avoid doing all these things because of the assumption that someone else is already calling 911 for example.
intersting that the only problem Mrs. Boeing sees with people working 10+hours 6-7 days a week is with "Quality and safety of the product" . Which for some reason that doesn't affect!? On the other hand what these contractors mainly do is fix mistake that came out of the Spirit factory. So you can see that Boeing employees might be a bit miffed about it. Once Boeing buys Spirit back, they will all be a happy family again with no work condition or quality issues whatsoever.
They don't have a water faucet on the secure side? Bathroom, janitor's closet, boardroom, maybe even a water fountain? Every week I go into the locked side of the county jail, I bring an empty water bottle and fill it from a faucet on the secure side. It doesn't have to be empty. But since it contains nothing they don't have to worry about inspecting it. Have people been in Washington so long that they forgotten how to find, obtain, carry, and consume water; without a commercially pre-filled container?
This hearing gives important lessons in Thinking Quality. It's a bit reassuring that the panels know what they are talking about and not answering "There I've teams for" as Calhoun did. 300k$/yr for each team that he has, making it up to 38M$/yr.? Isn't that the real root cause of the escapes? CEO's not knowing QAM?
The use of the term retaining bolts is somewhat incorrect, as they do not physically hold the plug in position. What they actually do is restrict the movement of the ejection assistance mechanism: the door's spring-loaded to assist anyone needing to remove it in an emergency. Please note my change of language from plug to door, as in the plug configuration, an internal cover makes access to the ejection system impossible. The reason for the variable configuration is to facilitate increased passenger loading: the aircraft is designed to carry loads around the 200-passenger mark, at which point the extra door is legally required.
Isn't there a discrepancy between the 2-8 week on boarding training and the 1,500hr. requirement for CAP's? The latter has no scientific base, was an ad hoc underbelly decision and as if 1,500hr. crop dusting or medivac makes you a better CAP. It is even the contrary... European airlines have no problem with hiring students who even flew never by them self and who worked previously in an area not at all related to flying. (mid career side entrants) An "Arbitur" is required and being a team player for the most. Fighter Pilot is not an automatic ticket to CAP in Europe. (Mission Minded, Risk Acceptance and no CRM) Airlines even stopped active hiring of fighter pilots. The 1,500hr rule didn't touch the factors of the Buffalo Accident at all! The pilots were qualified and the lady was even an instructor. It was pure actionism, kind of we have to do something. Hiring complete fresh green behind the ears students make that the airliner flight schools do not have to unlearn bad habits and the students do flight briefing and risk assesment from the begining on. Not simply take a plane for your sunday ride. I'm always baffled how many misconceptions even aviation enthusiast often have. Being an aviation enthusiast doesn''t predestinate perse.
1:18:00 Boeing Corporate KPI speech...plus her glance away like she KNEW she just gave the corporate KPI speech...girl...I get it...you live for the man.
Would be great to get some more discussion and visibility on how this has actually impacted the people who were on the plane during the explosive decompression
8 week on boarding training for "Pizza Flippers"? Here in Europa a aircraft mechanic has 3yr. technical schooling and depending on the assigned work/ job level part 147 acredited aircraft mechanic schooling training, wether at an in house school either at an extern school, before even being allowed to come within 50ft of an aircraft... The difference between training monkeys and people who have an understanding of what they do and and why they do it a specific way and an understanding of the possible results of not adhering to procedures. At least having some basic notion of scratches in high stress areas, slamming fasteners/bolts in non fitting holes, "pot life" even of metal parts (aging alloys) and so on.... Or for instance feeling and hearing the difference between T2 (faulty/bogus) and T6 Ti (floor-)brackets (Sic). The same for Ti bolts and 12.9 Dacromet Bolts. (perhaps not Boeing but Lockheed Martin F35.)
That’s for a factory floor technician, they are not getting 8 weeks of training and then go do line maintenance on a revenue aircraft, we are talking about non certified labor, these are people how get trained on a sub task, be it drilling and riveting. Interior outfitting, bonding etc. these non certified positions are available at all the aircraft manufacturers.
@@raffiaroyan1118 I was not talking about maintenance at all. IMHO drilling and rivetting are core tasks. And bonding if it concerns structural and skin panels is a core task too. Installing lavatories and gallies too since they can cause severe corrossion and electrical problems. And even non compliant interior work can cause safety items/ issues. Everyone is important for quality and safety. Thinking in "Monkeys" and the "Kings of Mechanics" is fault per definition. Even "Monkeys" cause a great part of FOD. Even the "Monkeys" who vacuum clean the frames cause FOD and I see it as a core task. Thinking of Puppets with regard to quality and safety and not thinking holistic is a great misconception. And are it not the "Interior Monkeys" who determine the percieved quality at the transfer inspection by an customer/airliner? The real quality of an aircraft will emerge in service of coarse. Like in automotive. Gaps are cosmetic but determine the first glance quality impression. The same for body work. The sound of closing a door from a Cryber Fruck destroys the percieved quality regardless wether it is cosmetic or auditive. Even a DACIA sounds "better". And "only" carpet bonding in door areas is a core task too with regard to corrossion.... And in Toyota's view "only carpet bonding" is a "core" task. You can ask Porsche about it.... And being to lazy to replace a blunt drill 15 min. before shift end? Can have great consequences special in an aging alloy!! A notion of that makes the difference between a "monkey" and a mechanic. EVERYONE is important with regard to quality and safety. Even the cafetaria ladies and the cleaning ladies!!
There is a difference between one complaining employee and multiple employees with the same complaint. It’s not that we negate the complaint of one, but we as a society cannot keep going down the path of bending to the outliers. Human nature will never change, many people are never satisfied. Apply rational and reason. Overall the culture within an organization is the most important component to quality, safety, and personal satisfaction. It is not easy to implement and nurture such a positive culture. Unfortunately Boeing has some serious issues to address, I imagine the morale within is busted. I also believe anytime there is a labor union involved, there will always be division within an organization.
I’m not impressed by her. She is too good at explaining away important questions. She speaks like someone who is accountable but has zero authority to make changes. She doesn’t speak like an engineer or a leader.
![BOWKYLION - วิงวอน (ex-change) [Official MV]](http://i.ytimg.com/vi/cLdnZWDaO-w/mqdefault.jpg)
24:49 formalities end
Don't you mean 8:01:06! J/k, these are so stiff.
I appreciate that NTSB is posting this to TH-cam (rather than or inclusive of the usual source) since it is
possible to start and come back to it at the point where the user goes elsewhere and then comes back.
I love that they have the safety briefing prior to the meeting. As a teacher, it would drive me bonkers if we had to do this every meeting. But doing it like three times a school year might be worthwhile.
Agree.
It Highlights there Mission.
This 5:58:00 exchange, lasting 3 minutes, tells the story about what went wrong at the factory. Boeing needed to get the unfinished plane removed from the factory floor to ready room for another fuselage to be assembled. A "move crew" closed the door plug so that the plane could be moved outdoors into the elements. A final closure of the door plug by a "door crew" was never completed on the aircraft due to missing paperwork.
Just incredible. And no one from the factory has come forward to explain why the paperwork covering the opening of the door plug was never created in this case.
In the NTSB Preliminary Report a photograph was shown, taken by Boeing employees at the time of rivet rework but just prior to interior panel re-installation. This is the photo visibly showing at least 3 of the 4 bolts were missing. A commenter noticed in that photo a zip tie around one of the stop pad assemblies. I think 2nd up from bottom on forward edge. If the Move Crew had to “push” the plug closed, not to actually “close it” but to protect interior from the weather outdoors. It raises a HUGE question I have never heard asked.
That question is- If you “push” a plug closed, does it stay closed? Or do the lift springs on the bottom hinges exert enough upwards push to dislodge the stops & upper guide track rollers? Or is gravity enough to keep the plug in closed position even without lock bolts being installed? If the plug does pop open against gravity on its own it might explain why a “Move Crew”might put that zip tie around the stop pad assembly as a temporary measure, assuming someone in charge of installing the bolts would do their job.
I’m reminded of different types of mechanical safety features, roughly divided by being either an Active or Passive feature. I’m wondering if the pressure of the lift springs was purposely designed as a passive safety feature? In other words, does it require someone holding plug down in closed position while bolts are installed(or possibly a special tool designed to do so, example- a long punch inserted in a bolt hole that prevents interior panel being installed) In this scenario- if the bolts are not installed the plug pops open on it’s own and flops partially open. Nobody is going to install interior blankets & panels with a plug hanging open 1 foot plus. Maybe they rely on a passive safety feature? If the plug is closed, its bolted, UNLESS someone bypassed that passive safety feature, by putting a zip tie around the stop, to hold plug in closed position. The implication being that the zip tie was the only thing holding plug closed until it let go at 15K feet.
A generic example of a passive safety feature could be the spring loaded grip to engage your snowblower impeller. How many people poked snow out of a plugged chute, and chopped up their hand, before those passive devices became mandatory? It might be easier to unplug chute if the impeller is running, it might clear itself with some prodding, so some people bypass the safety feature by using a zip tie to hold lever down. They maybe bypass the safety feature so they can wipe snow off their goggles while guiding machine with one hand, (or maybe push a plane outside in the weather) then they lose a hand unplugging chute.
5:41:10 Getting into the meat of what happened to the door plug that led directly to the accident
Typical of NTSB to do an Entire Safety Breif before any Meeting.
Safety 1st
@@timestampz correct.
yes. they always did, thry always do. It feels abit airplany. But imagine some serious accident would happen during an NTSB meeting....
In the event of Washington being taken over by some orange despot kiss you rear goodbye.
They try to practice what they preach ~ heard stories of investigators on the highway pulling over and parking multiple times to answer urgent texts, and the Chair once mentioned how much she gets honked at for driving at the speed limit
That labor dude is landing some solid punches bad
omg its 8 hours for just the first day. Looks like the NTSB is gonna beat the PennCentral WTYP total video length of 9 hours.
C'mon buddy it's a whole agency of autists, not just a podcast of them
In addition, they cut the breaks out of this vid. What a long few days
Then at around 3:15 pointed question was put to the head of the mechanics untion: do you have confidence in the "speak up" systen inside Boeing as described by Ms. Lund? NO.
You're doing the timestamps wrong, homie. its hh:mm:ss, so 3:15:00 for 3 hours 15 minutes. you linked to 3 minutes 15 seconds.
18 days to replace 5 rivets. Jesus christ...
The spirit rep admitted that "when one raises a hand to report an issue on the production line, an inspecting manager would evaluate DEPENDING ON THE IMPACT...
Basically saying in simple words we do not hold production lines even if there is a quality or safety issue.
I am surprised that no one there picked up on it.
It's right around 2:58 minutes in.
The real question should be How many times has Spirit held the line of production in 2023 due to mechanical engineering and machinist complaints of being rushed and being given questionable quality parts.
He arrives with no paperwork and no laptop to reference to even though he knows he will be in the hot seat.
Arrogance.
2 minutes, 58 seconds in is the safety briefing
Having no recieving inspection at all is a bad idea IMHO, wether paper work control or actual inspection. Random sample inspection at least?
5:47:50 lean manufacturing come back to bite you again maybe?
A major tenet of lean/six sigma thinking is that having spare hardware, or oversized hardware, is unnecessary because "rework will be a thing of the past"
I'm noticing that it takes Spirit 1 day or more to go from the request to rework to accomplishing the rework. On 9/18 this was because they needed to get the rivets from another site.
Is it a frequent issue where spare hardware needs to be scrounged up to complete rework?
(Yeah I know I'm playing armchair NTSB)
I've got my popcorn and I'm ready
The Spirit understanding of audit is deficient: it should be a virtual history of each airframe, who did what when.
This Lund woman the truly toxic, duplicitous, bureaucrat destroying all that is good, obfuscating, blocking, Using all kinds of jargon and acronyms, but appearing helpful.
Water can’t pass through security? That’s a new one.
Soooo.... what do we do if Sabrina Woods is the one _having_ the heart fibrillation? Or if Deidra Esters is the one on fire?
Then someone with the Board would probably point to a specific person and tell them to use them. However them having designated people to handle all these points is actually smart, because it bypasses the risk of delay due to the bystander effect, because in an emergency it's unfortunately common for people to delay or even avoid doing all these things because of the assumption that someone else is already calling 911 for example.
That’s life, I guess.
intersting that the only problem Mrs. Boeing sees with people working 10+hours 6-7 days a week is with "Quality and safety of the product" . Which for some reason that doesn't affect!? On the other hand what these contractors mainly do is fix mistake that came out of the Spirit factory. So you can see that Boeing employees might be a bit miffed about it.
Once Boeing buys Spirit back, they will all be a happy family again with no work condition or quality issues whatsoever.
Why overtime at all when running have the capacity........?
7:34:10 and subsequent is pretty chilling.
They don't have a water faucet on the secure side? Bathroom, janitor's closet, boardroom, maybe even a water fountain?
Every week I go into the locked side of the county jail, I bring an empty water bottle and fill it from a faucet on the secure side. It doesn't have to be empty. But since it contains nothing they don't have to worry about inspecting it.
Have people been in Washington so long that they forgotten how to find, obtain, carry, and consume water; without a commercially pre-filled container?
Makes me wonder the way Airbus builds their aircraft.
Hi, Madam Chairman!
This hearing gives important lessons in Thinking Quality. It's a bit reassuring that the panels know what they are talking about and not answering "There I've teams for" as Calhoun did. 300k$/yr for each team that he has, making it up to 38M$/yr.?
Isn't that the real root cause of the escapes? CEO's not knowing QAM?
if it's boeing, i ain't going!
The use of the term retaining bolts is somewhat incorrect, as they do not physically hold the plug in position. What they actually do is restrict the movement of the ejection assistance mechanism: the door's spring-loaded to assist anyone needing to remove it in an emergency. Please note my change of language from plug to door, as in the plug configuration, an internal cover makes access to the ejection system impossible. The reason for the variable configuration is to facilitate increased passenger loading: the aircraft is designed to carry loads around the 200-passenger mark, at which point the extra door is legally required.
1:23:30...BPI? DPI? The audio was not accurate...is it BPI that is audited every 5 years at the min?
Isn't there a discrepancy between the 2-8 week on boarding training and the 1,500hr. requirement for CAP's? The latter has no scientific base, was an ad hoc underbelly decision and as if 1,500hr. crop dusting or medivac makes you a better CAP. It is even the contrary... European airlines have no problem with hiring students who even flew never by them self and who worked previously in an area not at all related to flying. (mid career side entrants) An "Arbitur" is required and being a team player for the most.
Fighter Pilot is not an automatic ticket to CAP in Europe. (Mission Minded, Risk Acceptance and no CRM) Airlines even stopped active hiring of fighter pilots.
The 1,500hr rule didn't touch the factors of the Buffalo Accident at all! The pilots were qualified and the lady was even an instructor.
It was pure actionism, kind of we have to do something.
Hiring complete fresh green behind the ears students make that the airliner flight schools do not have to unlearn bad habits and the students do flight briefing and risk assesment from the begining on. Not simply take a plane for your sunday ride.
I'm always baffled how many misconceptions even aviation enthusiast often have. Being an aviation enthusiast doesn''t predestinate perse.
1:18:00 Boeing Corporate KPI speech...plus her glance away like she KNEW she just gave the corporate KPI speech...girl...I get it...you live for the man.
Taylor George Garcia Elizabeth Lewis Patricia
Smith Brenda Rodriguez Patricia Martin Robert
Walker Carol Martin Cynthia Robinson Gary
Would be great to get some more discussion and visibility on how this has actually impacted the people who were on the plane during the explosive decompression
Mueller Center
8 week on boarding training for "Pizza Flippers"? Here in Europa a aircraft mechanic has 3yr. technical schooling and depending on the assigned work/ job level part 147 acredited aircraft mechanic schooling training, wether at an in house school either at an extern school, before even being allowed to come within 50ft of an aircraft... The difference between training monkeys and people who have an understanding of what they do and and why they do it a specific way and an understanding of the possible results of not adhering to procedures.
At least having some basic notion of scratches in high stress areas, slamming fasteners/bolts in non fitting holes, "pot life" even of metal parts (aging alloys) and so on....
Or for instance feeling and hearing the difference between T2 (faulty/bogus) and T6 Ti (floor-)brackets (Sic). The same for Ti bolts and 12.9 Dacromet Bolts. (perhaps not Boeing but Lockheed Martin F35.)
That’s for a factory floor technician, they are not getting 8 weeks of training and then go do line maintenance on a revenue aircraft, we are talking about non certified labor, these are people how get trained on a sub task, be it drilling and riveting. Interior outfitting, bonding etc. these non certified positions are available at all the aircraft manufacturers.
@@raffiaroyan1118this answers a lot of questions.
@@raffiaroyan1118 I was not talking about maintenance at all.
IMHO drilling and rivetting are core tasks. And bonding if it concerns structural and skin panels is a core task too.
Installing lavatories and gallies too since they can cause severe corrossion and electrical problems.
And even non compliant interior work can cause safety items/ issues.
Everyone is important for quality and safety.
Thinking in "Monkeys" and the "Kings of Mechanics" is fault per definition.
Even "Monkeys" cause a great part of FOD.
Even the "Monkeys" who vacuum clean the frames cause FOD and I see it as a core task.
Thinking of Puppets with regard to quality and safety and not thinking holistic is a great misconception.
And are it not the "Interior Monkeys" who determine the percieved quality at the transfer inspection by an customer/airliner?
The real quality of an aircraft will emerge in service of coarse.
Like in automotive. Gaps are cosmetic but determine the first glance quality impression. The same for body work.
The sound of closing a door from a Cryber Fruck destroys the percieved quality regardless wether it is cosmetic or auditive.
Even a DACIA sounds "better".
And "only" carpet bonding in door areas is a core task too with regard to corrossion....
And in Toyota's view "only carpet bonding" is a "core" task. You can ask Porsche about it....
And being to lazy to replace a blunt drill 15 min. before shift end? Can have great consequences special in an aging alloy!!
A notion of that makes the difference between a "monkey" and a mechanic.
EVERYONE is important with regard to quality and safety. Even the cafetaria ladies and the cleaning ladies!!
White Helen Harris Jessica Davis Michelle
There is a difference between one complaining employee and multiple employees with the same complaint. It’s not that we negate the complaint of one, but we as a society cannot keep going down the path of bending to the outliers. Human nature will never change, many people are never satisfied. Apply rational and reason. Overall the culture within an organization is the most important component to quality, safety, and personal satisfaction. It is not easy to implement and nurture such a positive culture. Unfortunately Boeing has some serious issues to address, I imagine the morale within is busted. I also believe anytime there is a labor union involved, there will always be division within an organization.
Ms. Lund is kind of amazing. I’m so surprised Boeing has someone this competent on their side given their less than competent leadership lately.
I’m not impressed by her. She is too good at explaining away important questions. She speaks like someone who is accountable but has zero authority to make changes. She doesn’t speak like an engineer or a leader.
Worst chair in history. Absolutely useless woman
stay mad, Norfolk Southern Bot Account #756,928
I think she’s quite good
You guys really aren't beating the weird allegations
Not really
you literally only say the same thing every video, why are you so weird about this?
wtf Fed bureaucracy gone wild-smh
Boeing and Spirit bureaucracies running wild.