“A Rambling Shambling Disaster” Anonymous Insider Reveals How 737 Max Flew with Door Plug Unbolted

January 24, 2024 / 8 Comments

An Anonymous commenter on the aviation industry news site leehamnews.com has provided a lengthy and what he or she claims is a first-hand account of how the door plug blew out on Alaska Airlines flight 1282 on January 5th, turning the short journey into a nightmare for all onboard.

Editor-in-Chief Scott Hamilton published the astonishingly frank account of what led to the near disaster with the disclaimer that while the details are uncorroborated the production quality control systems described are accurate.

On Thursday, Boeing’s Renton factory workers will participate in a “safety stand down.” At the same time, dozens of inspectors from the Federal Aviation Administration are arriving and FAA administrator, Michael Whitaker, promises they will remain “until they’re comfortable the quality assurance system is working properly.”

All involved should keep in mind the professed insider’s characterization of production quality control as “a rambling, shambling, disaster waiting to happen.”

Here’s the story in a nutshell. According to this person, the door plugs made by Spirit AeroSystems are supposed to arrive at Renton ready to be installed. Then, the door folks at Boeing verify they are in satisfactory condition. But according to the insider, over the past year, the teams reported “392 nonconforming findings on 737 mid-fuselage door installations.”  That is described as “a hideously high and very alarming number.” One does not need to be an expert to find that credible.

The insider’s account is highly detailed and I am opting not to share it in its entirety since this person is not claiming that A led to B which then led to C. Instead, an out-of-order alphabet soup of discrepancies was being lobbed back and forth as Boeing and Spirit folks argued about who was responsible for what. Adding to the mayhem was a two-level discrepancy reporting structure at the factory. One kind of record keeping is used for gathering data about problems and another is intended to make sure said problems actually get fixed.

What you need to know is that during all this,  it is discovered that the door pressure seal on the airplane intended for Alaska is damaged. This means the door plug must be opened or taken off completely. Either way, the four bolts holding the door in place (and about which we have heard so much over the past few weeks) had to have been removed to do the work, but though the pressure seal fix is documented, the removal of the door is not. Because there’s no record of that, no quality assurance inspection of whether the bolts were in place was required.

On September 19, 2023, the paperwork was done.  N704AL soon leaves the factory for Alaska Airlines where just months later it will scare the beejeebies out of Alaska’s passengers and crew.

Now Boeing executives want to take some time to evaluate what’s going on. Its customers, meanwhile are growing more vocal with their dissatisfaction and frustration.  Alaska and United, with a combined 171 airplanes they cannot fly thanks to Boeing, are angry. This is far from the first time the company claimed it would reckon with its shortcomings, without actually or perhaps I should say effectively doing so.

Maybe more insiders like the one posting on Hamilton’s site will share what they know. Stories like this one are a metaphor and a reminder that problems need to be exposed if they are to be solved.


Categories: Flying Lessons

8 responses to ““A Rambling Shambling Disaster” Anonymous Insider Reveals How 737 Max Flew with Door Plug Unbolted”

  1. Ron Whipple says:

    Boeing has been for years a leader in the System Safety field in aviation. I am surprised that appropriate system safety procedures of assigning a system safety engineer to a panel of system engineers regarding these reported door problems was not completed with appropriate mitigations applied. That would be a good question to ask.

  2. J Thomas says:

    Boeing’s downfall began more than 30 years ago with the rudder reversals. Corrective action was inadequate. They became worse with the MCAS accidents. Again corrective action was inadequate. Now Boeing is paying the price.

  3. Rod says:

    Further to J Thomas’s post, I wonder whether a Downfall of Boeing is even possible given its key position in the US economic & military structure.
    It certainly deserves to fall; just doubt that that is possible — Too Big to Fail.

  4. One problem is that Boeing seems to have out-sourced too many items. Of course, even if made in-house they would still have to be rigorously checked; that’s not the issue, which is that each out-sourcing comes with its own manufacturer, and each has its own propblems, shortcomings and failures. Each outsourcing, then, represents not one possible failure and but a huge number of possible failures.

  5. Kurt W says:

    The track was laid when Boeing shifted from being an Engineering driven company to a Finance driven company. What they don’t recognize is that it’s their engineering that drove their finances, meanwhile FInance believes it’s their cost cutting efforts that drives their financial success.

  6. Paul Salerno says:

    System Safety principles teach us the need to maintain balance between production and protection. Without adequate production the company would not be profitable. Without adequate protection (i.e., properly functioning safety and quality management systems, quality escapes will occur and accidents can happen. Production is relatively easy to measure and manage, but It’s extremely difficult to know if the organization’s QMS and SMS systems are working properly and effective. Boeing stakeholders at all levels are now learning painful lessons as to what can happen when their systems of production and protection fall out of balance, and when quality assurance breaks down. I believe most of Boeing’s woes can be traced back to deficiencies in organizational culture at various levels of management.

  7. John Darbo says:

    Another excellent factual article from Ms. Negroni.

    An insider manager told me 5 years ago that Boeing’s QA was taking attacks from production.

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