Raf
Urgency vs. Bureaucracy.
Urgency vs. Bureaucracy.
Didn’t Collins only inform Boeing about the quantity, date and failure analysis in late August? If the NTSB had the information and had done the analysis 7 months ago, what recommendation(s) did they issue at the time? The NTSB seems to be doing a lot of arm waving for political effect since of late—for the past 6 years at least—kowtowing to Congress’ desperate recourse to sensationalism to appear competent at something and of some use.
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I’m not certain I understand your point. This incident happened back last February, the NTSB then began an investigation and investigations take time. Once they determined a preliminary cause, the actuator built by Collins they informed Boeing and Boeing’s response was a lackluster message saying at some point the actuator needs to change and then recommended a dangerous workaround.
The NTSB, already stating that the workaround had risks and seeing that Boeing wasn’t moving fast enough or the FAA wasn’t responding with any seriousness put out a safety notice. So where’s the criticism towards the NTSB? How are you seeing this from a political point of view.
If you’re finding fault, look no further than Boeing because when told of the issue not only failed to respond in an immediate fashion but it would seem fail to inform international carriers. I could see fault with the FAA for not pushing harder on Boeing. I’m not saying the NTSB is perfect, but their job is to investigate and inform, not enforce. If you have a problem with the lack of enforcement feel free to make complaints to the FAA and to Congress.
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The takeaway from this situation is that safety can’t afford to wait for bureaucratic red tape. The bottleneck problemreveals a deeper systemic issue in how urgent safety concerns are prioritized. If anything, the NTSB’s urgent recommendation highlights the need for faster responses and better communication across all parties involved.
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It’s apparent that the FAA is incapable of timely action in anything. STCs, unleaded fuel, safety concerns, and space have all been recent failures.
What should happen to an agency whose charter is “safety” yet consistently makes things less safe?
On February 28 Collins and the NTSB were actively testing for freezing of moisture ingression as the cause, having done some work earlier in the month. (Source is NTSB’s press release, not its report.)
Collins did give Boeing a list of affected actuators in August.
Between those dates we don’t know all that was done, but AWST says the NTSB issued a preliminary report six months ago which is roughly March or April. I CORRECTED WHAT I SAID, I’ve confused the preliminary report with the recent safety recommendations.
I haven’t seen Boeing’s rumoured MOM from March. An MOM alerting all operators to the moisture problem would motivate good operators to check their aircraft. (I don’t now how visible the bearing is insitu - appears to be on the bottom of the unit.)
NTSB now says FAA did little, but that claim seems to only relate to NTSB’s recent preliminary report. https://aviationweek.com/air-transport/safety-ops-regulation/ntsb-chair-disappointed-faas-response-737-rudder-issue
FAA and NTSB have been slow and sparse lately, web sites don’t work correctly to get reports and history.
Boeing should have sent an MOM to all operators the moment that cold soak testing showed the problem, that was known at the end of February if not earlier.
Aviation Week magazine says NTSB issued a preliminary report six months ago, which is roughly March-April.
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According to the NTSB’s recent press release, the problem was identified by the end of February by cold-soak testing at Collins in Iowa, with NTSB participation.
Boeing should have issued an MOM at that time.
NTSB was slow to issue a preliminary report.
CORRECTION:
There was a preliminary report from NTSB, not dated in website version but apparently issued in March-April time.
Boeing didn’t issue a workaround. The NTSB is referring to the long-standing general procedure for jammed controls—which calls for the application of brute force to attempt to free the control—for lack of any other germane procedure, and is calling it “Boeing’s workaround.” It has asked Boeing to come up with a different workaround due to the high probability of an abrupt maneuver when the control becomes unjammed, which could lead to loss of control. Whether this new procedure is to be for general use or only for this particular actuator is not clear. The NTSB’s stance is strange. I’d rather stomp on a jammed control to free it while anticipating the need for immediate correction of the excessive control input that may ensue rather than just sit there doing nothing out of fear of causing an upset and let the airplane head into peril.
The NTSB’s investigation report dated Sept 24 says:
On the basis of the results of postincident testing conducted in July 2024…
If the testing that revealed the cause of the incident was only done in July, what sort of “action” is the NTSB expecting the FAA or Boeing to have taken prior to that?
When exactly did the NTSB make safety recommendations based on the findings of the investigation?
As I noted in the other thread, the NTSB’s interim report stated that Collins and NTSB met in Iowa on February 28 to discuss and test, and found that cold soaking triggered actuator being hard to turn.
The July date is in the safety recommendations document of September.
I go with the interim report because it has detail of troubleshooting by UA and discusses the problem.
NTSB confuses people.
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Confuses people indeed! I scrutinized the Sept document to see what type of document it is and could only find “Accident Investigation Report” with document number AIR2406. No indication of Preliminary, Interim or Final. No indication of Press Release or any other type of publication. The content does read like an investigation report and even has the signature page and usual disclaimer of not intended to assign blame etc. but is missing other metadata parts such as participants, TOC, appendices, etc.
It does say in the introduction, “As a result, the NTSB is issuing two urgent safety recommendations to The Boeing Company and two urgent safety recommendations to the FAA.” The use of the present tense is congruous with the absence of anything indicating or implying that testing had been done earlier than July 2024 or that a safety hazard had been recognized earlier or that these (or any) recommendations had been issued previously. Furthermore, the progression from the July testing to the August 12 date that Collins notified Boeing of the failure analysis of the defect, the quantity of defective actuators and the time period over which they were delivered is reasonable, such being possible only when the cause of the problem was nailed down and the extent of the problem could be derived. Boeing’s issue of the MOM on August 23 seems to be a prompt response to that assessment. The NTSB’s assertion that there needs to be a procedural response other than stomping on the control implies a cause-based response but determining the cause would be a fool’s errand and impractical and Boeing would have replied so. It seems that over the course of the Sept report the NTSB changed its mind from requiring different pilot procedure to removal of the affected actuators. If the NTSB thinks that various parties didn’t respond quickly enough to its concerns it should review the adequacy and appropriateness of its communications (if any) that conveyed those concerns. I haven’t seen the preliminary or interim report but the September document doesn’t conform to the typical format of anything! Maybe, with so few accidents to investigate as agency-in-charge, the NTSB has lost its competence over the years.
Boeing would have been gun shy to react to anything from the NTSB that didn’t appear to be a formal public communiqué, having been very recently and very publicly (and very unnecessarily) censured for mentioning certain details of an investigation supposedly known only to investigation participants. With the NTSB providing regular and very public updates to Congress, Boeing can hardly be criticized for not keeping track of which details had been made public and which had not. Furthermore the NTSB criticized Boeing for publicly speculating on the cause of the plug blowout before the investigation had determined such, which is laughable. A detailed enough narration of the sequence of events had been published anonymously online by end January, which credibly and adequately established that there was no paperwork. So in July, instead of having investigated why there was no paperwork, the NTSB was still accusing Boeing of not furnishing paperwork that clearly didn’t exist. Sadly, even the later (unnecessary) public hearing only yielded more granular details of events leading to the opening of the plug by “someone” without paperwork but didn’t reveal why the procedural steps that would have resulted in “manufacturing planning” personnel generating the paperwork were not initiated—because no one asked the right questions. That would have led to something actionable to prevent its recurrence.
Besides, someone needs to remind the NTSB that in gross violation of the gag clause of Annex 13 of the ICAO convention, they not only provided public testimony to Congress less than three weeks after the Ethiopian Airlines crash in 2019 before even a preliminary report was issued, but the testimony given about the function and purpose of the column cutout switches was patently false. Then followed a bizarre (and false) explanation of why the runaway trim procedure manages to stop a runaway without mentioning the column cutout switches at all. And for the most egregious cherry on top of the pudding, the change in operation of the aft column cutout switch for the MAX was declared as having prevented the pilots from recovering from a runaway stab trim and therefore caused the crash, which was also patently false. All of the nonsense was claimed to be recalled personal knowledge acquired from training/flying the 737 a decade prior and spawned yet one more media-propagated fallacy about the design of the MAX. Later, in October 2019, the NTSB doubled down on that fallacious testimony in another Congressional hearing. I don’t recall if the investigation report issued years later included the NTSB’s false assessment, but the Ethiopian investigative agency certainly indicated their contempt for the NTSB by roundly ignoring their recommendations for revisions to the draft report, as well as the NTSB’s protest after the final report was published without the revisions.
You didn’t look far.
My summary to Dominic Gates of the Seattle Times:
" The safety recommendations press release NTSB Issues Urgent Safety Recommendations on Boeing 737 Rudder System links to an ‘interim report’, Mitigate Safety Concerns Involving Boeing 737 Airplanes with Collins Aerospace SVO-730 Rudder Rollout Guidance Actuators (ntsb.gov).
Searching NTSB.gov for ‘737 rudder system’ gives a link to “Boeing 737-8 Rudder System Anomaly’, DCA24LA094.aspx (ntsb.gov), which covers the February 28 meeting at Collins in Iowa and reports that cold greatly increased torque required to move the actuator.
(Collins design being in Cedar Rapids IA, actuator made elsewhere I gather.)
The Boeing ‘737-8 Rudder System Anomaly’ document has a link to a Preliminary Report which appears to be circular, Boeing 737-8 Rudder System Anomaly’ is the preliminary report. (As different from ‘Interim Report’.)
The document linked to by label ‘interim report’ but titled ‘Aviation Accident Report AIR-24-06 includes “Afterward, three additional SVO-730 rudder rollout guidance actuators were examined and tested in the same manner (cold soaking) as the incident actuator. One actuator was an in-service unit that United Airlines removed from another Boeing 737 airplane in its fleet as part of a removal service bulletin that the airline requested from Aviation Investigation Report AIR-24-06 5 Boeing regarding the actuator as a result of this incident.’, referencing 7 “A service bulletin, dated May 6, 2024, provided instructions that allowed United to permanently remove the SVO‑730 rudder rollout guidance actuators from its 737 airplanes.” (UAL did not want the system, it was on a few airplanes that were originally built for someone else.)
(And now there is a blast from Chair of NTSB against FAA for not reacting immediately to the safety recommendations of September.)
Aan AWST article also has information.
It took me a while to fully grasp the difference between the September safety recommendations document – the ‘interim report’ - and the earlier preliminary report.
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The Chair of NTSB blathers but does not run a good shop.
Hopefully the US congress will stop playing games with budgets, that motivates capable experienced people to retire early in disgust with ability to get work elsewhere. (Some become DERs, I knew one whose work included the Japanese airliner that was flight testing in Moses Lake.)