Originally published at: NTSB Door-Plug Hearing Lambastes Boeing, FAA - AVweb
Inadequacies on three fronts blamed for Alaska Airlines door-plug blowout.
Trying to privatize a government function will eventually lead to this type of failure since promoting safety and making a profit are sometimes in conflict, usually the short term. Management bonuses are almost always based on short term metrics (at least where I have personal knowledge). Unfortunately the FAA is never funded for the long term or staffed fully with the highly paid staff needed for inspections. Well maybe before fired the old FAA staffersâŚ
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The answer(s) are actually quite simple but will cost everyone involved. When Boeing adopted LEAN Manufacturing they elected to completely ignore the realities of human nature and mechanical reliability. They adopted standardization for the sake of standardization and made assumptions about reliability that have no basis in reality. LEAN must go and endpoint quality inspections must be restored.
The FAA, at the direction of John Duncan adopted the âkinder gentlerâ compliance philosophy in the new SMS/SAS systems that also ignores basic human nature and changed the role of the ASI from Inspector to Auditor; effectively putting the fox in the henhouse.
Unless and until these two philosophies are cast aside and the industry returns to basics we should expect more âquality escapesâ and experienced ASIs can go back to not holding their collective breath waiting for the next smoking hole. It is coming, rest assured.
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Privatization of government oversight seldom works out well .
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Itâs remarkable that the union employees that removed and others that installed the plug could not be identified. Real standup folks.
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Concerning that people would do something involving undoing bolt and not record it.
Different from just unlatching a standard 737 overwing exit.
In this case the exit had been de-activated hence the bolts, no handle inside, I presume had to remove at least a bit of trim to get at the bolts.
Amazing.
Part of the chain to failure and perhaps evasion was two different organizations working on the airplane - Spirit work was âtravelledâ from Wichita to Renton, with people from Wichita and local contractors working on the airplane.
Concerning that people would do something involving undoing bolt and not record it.
My understanding is that the removal was recorded, but, due to software incompatibility, the replacement procedure was not triggered.
In this case the exit had been de-activated hence the bolts,
Nothing to deactivate; the exit hardware was never there - nothing to activate in the first place. Just a plug secured by spring-loaded fittings, with four bolts that locked the fittings closed.
I presume had to remove at least a bit of trim to get at the bolts.
Yes; the interior paneling was removed.
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