Boeing 737 missing door report

The fact that the design relies on someone remembering to fit 4 bolts makes it unsafe in my view.

it might surprise you to learn that the engines are held on with less bolts, as are many of the control surfaces.  Bolts are fine when fitted correctly.

According to this, a whistleblower said that Boeing removed the door plug for repairs, but the bolts weren’t refitted. Boeing had been aggressively trying to cut costs and safety inspections suffered. The problem is much deeper than just an assembly line worker forgetting to fit some bolts, it’s a deeper problem with corporate culture.

https://finance.yahoo.com/news/boeing-broke-down-inside-series-110000958.html

The rub is that Boeing’s quality shortcomings—and heavy dependence on a far-flung network of suppliers—are recurring and deep-seated. The problem isn’t merely that one worker on one assembly line failed to install a door screw. It was that managerial decisions, made over a period that spanned more than 20 years and four CEOs, gradually weakened a once vaunted system of quality control and troubleshooting on the factory floor, leaving gaps that have allowed sundry defects to slip through. Many weren’t related to airline safety but caused long delays; others had major and tragic consequences. “The seeds of these quality problems were planted a long time ago. These problems were hidden for years, then they exploded,” says a former top executive at a Boeing supplier.

Yep, even Ryanair have mentioned Boeing quality:

https://www.theguardian.com/business/2024/feb/26/ryanair-aircraft-problems-could-push-summer-fares-up-boeing

“He said that the airline had discovered “silly, small things” during inspections of recent aircraft deliveries. He said they would lift floorboards and find a rag or a spanner under them. “It’s indicative of a poor approach to quality control on the line in Wichita or Seattle and Boeing need to fix it.”

Pot/kettle..

Ryanair are many things, and I hate them with a passion, but they are pretty hot on their maintenance.

Ryanair are many things, and I hate them with a passion, but they are pretty hot on their maintenance.

Not sure how they compare with other budget carriers but they work their planes hard. Most seem to be flown from 6am til about 11pm or so; 2hr flight, super quick turnaround, back up again. I’ve just come back from Prague with Ryanair and the aircraft that flew us (which was only a month old) had already done London – Katowice – London that morning, then London – Prague – London and then it was scheduled for London – Rome – London straight after that.

Not sure if there would have been time to do another short-haul running into the night.

Bare in mind airports charge the operator a LOT for every min a plane is on the tarmac.. so usually its a quick clean through the cabin, bit of fuel and off they go again.

It also make a lot of sense for planes to do a ’round robin’ so, I dunno for example, london – malaga – Ibiza – back to london, or whatever.

I imagine it’s very much like HGV lorries, they barely touch the ground unless it’s scheduled maintenence or if there’s a problem, or the crew runs out of working hours.

I did a fair bit of work in logistics back in my younger years, and the site manager where I worked often said that the companies losing a lot of money when lorries (or tractor units more specifically) are sat in the yard, mostly they pull in, drop a trailer, refuel, grab a new pre-loaded trailer, new driver and off they go again within 30mins if things are working properly.

Margins are so tight they can’t be competetive on price if the vehicle fleet is parked up for too long.

All comes back to money I guess..

there’s a bucket of (unused) fixings somewhere that nobody flagged as an issue

Just to give an example, a part i used to own on a *car* used 6 bolts (out of about 10 of that type used on the whole car) but another bolt (same thread, different flange) will fit, they use about 40 of those on two or three consecutive stations. Someone had been using the wrong bolt because “it looked better”.

It was flagged after less than 200 cars due to a restocking issue.

Caused a minor recall, got two guys sacked and one on a final written warning. (The sacking was for trying to override the restock issue, several times.)

That was only a heat shield.

I read this earlier today, it’s very telling about the situation Boeing has got itself into, and just how dangerous it is.
https://www.politico.com/news/magazine/2024/02/26/former-boeing-employee-speaks-out-00142948

That’s really scarey… I’d trust an old school engineer over a cooperate media sound bite any day of the week!

When booking a short haul flight as a pleb though, how does one know what plane it it will be? is it even possible? I’d sooner pay more if it meant avoiding the MAX line…

@mert I’m willing to bet that it wasn’t JLR. 😉

One of the Apollo moon landing astronauts (Alan Shepherd?) famously answered a question with ” I’m on a rocket built by the lowest quote

All airlines keep their jets busy. They are actually much happier powered up and flying than left sitting powered down and cold.

@mert I’m willing to bet that it wasn’t JLR. 😉

Ouch… It was actually. But nearly 20 years ago now.

When booking a short haul flight as a pleb though, how does one know what plane it it will be? is it even possible? I’d sooner pay more if it meant avoiding the MAX line…

Skyscanner will show you what you’re likely flying in. These things are rare in Europe currently. Only Ryanair in the UK I believe and not this variant but there’s plenty other reasons not to go on Ryanair.

Tui Norwegian and Icelandair fly the MAX too. The version with the dodgy door plugs is i believe US specific. From a pilots view, the MAX is fine now. The problem was that the pilots weren’t aware of the issue/drill required.

The version with the dodgy door plugs is i believe US specific.

The door plugs weren’t dodgy, they just weren’t fitted correctly (the locating bolts weren’t fitted).  The door plugs are there to close off an extra door that is needed in some seating configurations so they are fitted on Max 9 and 737-900 aircraft with a specific seating configuration. It’s specific to the seating configuration, not specific to the U.S.

The problem was that the pilots weren’t aware of the issue/drill required

Speaking as someone working in aerospace, I’m quite hard over on the idea that the problem was actually that Boeing catastrophically cocked up the MCAS system right from the start, and nothing at all to do with the pilots.

Although you might argue that trying to stuff on two really oversized engines in double quick time, in order to get something to market before Airbus got there first, was the root cause.

Maybe I’m thinking about the wrong 737 MAX problem though, maybe the drill you’re thinking of is some kind of corrective action to take when a large hole surprisingly appears in the fuselage?

The problem was that the pilots weren’t aware of the issue/drill required

AIUI, Boeing tried to cheap out on modernizing the 737. They wanted the Max versions to not require recertification of pilots so they tried to use software to prevent pilots from exceeding the safe flight envelope of the newer versions, whereas the older versions didn’t require that. That, apparently, was controlled by a single angle of attack sensor, so when that malfunctioned, the aircraft would nose down to prevent what it believed was excessive nose up. In order to prevent the aircraft crashing, the pilots would have to identify the problem and disable the system. That’s a hell of a lot to ask of pilots if it isn’t part of their training, which it wouldn’t be if pilots trained on the older versions were certified to fly the Max.

I’m not certain of the all the technical details, that’s just what I remember from reading about the investigation, but building an aircraft that flies itself into the ground if a single sensor fails and then blaming pilots for not knowing how to stop the aircraft from auto-crashing isn’t what a responsible company does.

From a pilots view, the MAX is fine now.

Maybe from a pilot’s point of view but not from this particular passenger’s.

I wouldn’t like to be on a flight where the pilots discovered a new ‘issue’ with the MAX.

Not clear to me how the cultural issues described at Boeing are only impacting these later 737 derivatives, or were they not designing and building other stuff in the last 5 years? Although I get that the two crashes were down to trying to upgrade an old design within operating cost imposed parameters.

Building a plane doesn’t depend on anyone remembering anything, you have checklists/flowcharts, you have doublechecks

Quite, and as I understand it, part of the issue here was that the door plug was treated as having been “opened” and not “removed”. Had it been recorded as having been removed, it would have triggered an inspection process to confirm that it had been re-fitted correctly. The problem is that there is no difference between “opening” and “removing” the door plug: either way, the bolts have to be removed.

In any event, chucking more bolts at it isn’t going to fix anything. There were already four times as many as needed.

Not clear to me how the cultural issues described at Boeing are only impacting these later 737 derivatives, or were they not designing and building other stuff in the last 5 years? Although I get that the two crashes were down to trying to upgrade an old design within operating cost imposed parameters.

Well, indeed… issues may have manifested with certain variants of 737, and they all look to be QC/procedural/documentation failings at manufacture level rather than airlines or pilots/crew/maintenence teams not doing the job properly post-sale.

So the only logical question to ask now, is…where else is the manufacturer cutting corners? It seems to be a systemic lack of oversight and following of proceedure in order to keep costs down, so common sense would dictate there may well be more issues with other types of aircraft that have yet to manifest themselves in the form of new and unpredictable catastrophic failiures.

It’s not exacly confidence inspiring.

where else is the manufacturer cutting corners?

As corporate culture shifted at this point, perhaps all things undertaken since the MD merge reverse-takeover, have gradually become infected by a cost-cutting-profit-prioritising kind of approach.

https://www.imdb.com/title/tt11893274/

I’m not certain of the all the technical details

MCAS worked by activating the trim for a period of time (IIRC 10 seconds).

Boeing’s argument was that should it malfunction, pilots would treat it as a Trim Runaway, disable the trim system, and then they would be able to manually adjust the trim (remember the 737 is that archaic the flight deck controls are still mechanically connected to the control surfaces).

However as the Trim only ran for a short period of time, it likely confused the pilots, as it wasn’t a conventional runaway, which would have ran continually. Instead it ran for a period of time, stopped, and if MCAS still thought the plane was approaching stalling, would run again, with no limits placed on the number of times it could intervene.

This is what caused the roller coaster on the fateful crashes, as MCAS would force the nose down, pilots would trim it back up, and the cycle repeated.

Then there was the issue with the manual system. By the time the pilots disabled the trim system, the aerodynamic forces were that great, that the worlds strongest man would struggle to wind the trim handles.

I seem to remember one of the crews did disable the system, but then couldn’t get the plane back into trim.

Certain factions wanted to blame it all on the pilots, but they were put in a situation by a system they didn’t know existed, let alone how it operated. Which was compounded by a ‘back-up’ system they couldn’t physically operate. Those same factions were also willing to say how US pilots would never let it happen, but I don’t remember any US operated planes being found to have suffered from a similar sensor failure.

Ultimately hiding MCAS was a profit driven decision to bury the handling issues and avoid re-training, which had been stipulated by one of Boeing’s biggest customers.

Not clear to me how the cultural issues described at Boeing are only impacting these later 737 derivatives, or were they not designing and building other stuff in the last 5 years?

Fear of change, I suspect, because change incurs costs.

You can sort of see it in the 787 as well, which is very impressive under the skin from a technical perspective and handles like a gem in turbulence, but has been hamstrung by management refusing to accept changes to the way things operate. So you end up with a lot of unnecessary button pushing and knob twiddling in the flight deck because “the 777 does it this way”, or “that’s how we did it on the 707”, while the flight management computer frequently thinks it’s a 767.

There are little things, like the park brake being electronic yet designed to mimic the mechanism they nicked off a ride-on lawnmower in the 60s, and then bigger issues like the utter refusal of the computers to tell you what they’re actually thinking.

Not clear to me how the cultural issues described at Boeing are only impacting these later 737 derivatives, or were they not designing and building other stuff in the last 5 years?

A lot of it is the length of the design cycles.

I did some design and layout work in aerospace in the mid 90’s (Bit of Rolls Royce, bit of Airbus, bit of Boeing).

By the time those layouts (Engineering Concept stuff) hit their first prototype flights, i’d moved into Automotive, designed a complete platform, launched it, done two facelifts (inc. a new powertrain), started designing the replacement platform and started planning for End Of Life of the original one. Also then emigrated and started on a new platform launch.

So the MD take over took a couple of decades to bite properly. There were lots of odd decisions being made, but the engineering organisation and processes are massive and have a lot of inertia.

I would guess it really bit hard once you had finally got rid of the majority of those time served guys who had been in senior tech roles through the 80’s and 90’s. So those who were in their mid 30s and over when the merger happened. Who will mostly be retired by now. And most of *their* managers and directors would have been gone 10-15 years ago.

it might surprise you to learn that the engines are held on with less bolts

3 in most/many cases.

Well, with wing mounted engines anyway.

You wouldn’t use a halfords torque wrench to do them up…

So, who wants to fly on the 777-X with folding wingtips, designed and built by the same people………..

So, who wants to fly on the 777-X with folding wingtips, designed and built by the same people………..

What’s the non-normal checklist if they suffer unscheduled disassembly?

“I’m sure there’s a reset for that……..”

Tui Norwegian and Icelandair fly the MAX too

Tui are mostly Max 8, but they’ve cleverly left off the Max on the side of the plane and the in flight safety sheet.

Just says 737 8.

Flown on 4 of them now with Tui. No choice really other than not doing a Tui holiday (which would be my choice, not a fan of package holidays, but it’s a group decision).

While the nose diving is considered “fixed” I’m still wary. I believe the fix is training and also concerned it’s aerodynamically unbalanced and requires computers to correct it in flight. If something goes down and had to glide or without the computer, it’s going down hard. Though it’s all fly by wire these days in most modern jets anyway.

The issue is the thrust vector of the engines, so it will glide just as well as any other aircraft.

This pitch/power couple is not uncommon. The venerable 747 had a similar issue.

https://www.bbc.co.uk/news/business-68534703

Not at all suspicious 🤨

I can hear to post that.  As if Boeing weren’t already under scrutiny….

Got hit by a falling door plug??

A self inflicted gunshot wound to the back of the head?

A self inflicted gunshot wound to the back of the head?

Twice, just in case the first one didn’t do the job.

I believe the fix is training and also concerned it’s aerodynamically unbalanced and requires computers to correct it in flight. If something goes down and had to glide or without the computer, it’s going down hard. Though it’s all fly by wire these days in most modern jets anyway.

Literally everything now requires the computer to fly it / correct it / etc. The aerodynamic balance under high thrust conditions wasn’t the particular issue, it was the system designed to correct that is/was at fault.

Incidentally, the fix is not just training, the MCAS system has been redesigned: https://www.boeing.com/commercial/737max/737-max-update/737-max-software-updates#overview

Literally everything now requires the computer to fly it / correct it / etc.

All modern passenger transport planes are naturally stable apart from at the very extremes of their aerodynamic envelope. That’s why MCAS was introduced in the first place.

A self inflicted gunshot wound to the back of the head?

Same team who helped Dr David Kelly to “commit suicide”.