To understand Boeing’s situation you have to understand McDonnell Douglas. And we go back to the DC-10 cargo door issue.
That’s a long read, so here’s the short version. The DC-10 cargo door was held on from the outside by rotating latches; when fully engaged the pressure inside the aircraft would push the latches closed so the door was VERY secure, but if the latches weren’t fully engaged the pressure would push the latches open. The telltale showing the cargo operator that the latch was fully engaged wasn’t connected to the latch, but rather the handle, which was itself connected to the latch via a spring. If the operator pushed the latch closed too hard or too fast, the spring would bend, and the telltale would show the door as latched, even though it wasn’t.
If the door flies open in flight that means explosive decompression of the cargo area. That means the pressure of the air in the passenger cabin pushing down on the floor is huge, measured in tons per square meter. It’s worth noting that the control cables that carry movement from the yoke to the rudder/elevator control surfaces in the tail go through the floor.
One of these failed on a mostly empty flight. The floor buckled and a few seats were sucked down through the floor and out of the airplane. The pilots lost all rudder control but miraculously were able to land the jet without further injury. FAA investigated and found the problem, Douglas made a ‘gentleman’s agreement’ with FAA that they would fix this quietly without an embarrassing Airworthiness Directive (forcing all operators to comply and damaging Douglas’s reputation). At all points, the priority for Douglas management was avoiding bad reputation and excess expense, not making sure the aircraft were safe.
A European operator then wasn’t subscribed to Douglas’s maintenance service so the update never happened. And another one failed- this one on a VERY full flight with ~350 people on it. The added weight on the floor caused a much larger section of the floor to fail, the control lines were all severed, and the plane crashed with no survivors.
In the 1990s, McDonnell Douglas and Boeing merged. The Boeing management team (mostly engineers) was replaced with the Douglas management team (bean counters). Their headquarters then moved from Seattle (where they build planes) to Washington, DC (where they lobby for federal contracts).
Granted it’s 30 years after that merge, but it’s pretty obvious the same management strategy is still in charge.
Take the 787 Dreamliner. Their strategy there was reduce all the expensive engineers, instead just write the specs and outsource design and build of entire subsystems. It had lots of teething problems, I’ve heard reports that some parts with tolerances measured in tenths of a millimeter were off by half an inch or more (and that was the reject pile, ones off by less were ground down and hammered into place). Other than some battery problems the aircraft has been pretty safe though.
And now take the MAX product line. A few years back you had issues with MCAS- a computer that makes the new jet fly like the old jet so pilots won’t need retraining, even though the new jet ISN’T like the old jet and flies quite differently and if MCAS fails you’ll have a very different beast on your hands (none of this was mentioned in the operation manual). That caused some crashes.
Now you have this door plug issue. It’s worth noting that Boeing has outsourced assembly of the entire fuselage to another company, who (from what I’ve read) is constantly pressured to increase production and decrease costs. NOT a safety culture.
From some reports I’ve read, procedure at the other company was to make the bolts on the door plug ‘finger tight’ for transport, because not all customers would want the door plug, some would want the actual emergency exit door. So that means with a little bit of vibration on those bolts, the door plug is only held in place by gravity and prayers.
FAA is now supposedly doing some kind of major audit of Boeing manufacturing, and is considering no longer allowing Boeing to self-certify their quality control processes. I’m quite sure it’ll turn up a lot of dirt.
What I HOPE happens is that the market, both the stock market and the aircraft market, heavily punish Boeing and/or demand that their management be replaced. I’m not holding my breath though.
Man this is a very informative, scary and infuriating write-up. Thank you for sharing.
I understand the need for corporations but I also get so fucking angry knowing that no-one ever gets criminally charged for negligence in cases like this.
Charging anyone with a ‘crime’ for something like this is really hard. You have to prove that a. someone in authority, b. knew that a deficiency existed, and c. explicitly directed the deficiency to exist or that it not be fixed, d. knowing that doing so was against regulations or policy or could cause a crash.
‘We did the best we could but it wasn’t good enough’ is a defense against criminal charges, especially when you can produce reams of paper showing how hard you tried.
There’s a saying- airplane safety is like swiss cheese. Every layer has holes, the more layers you stack on top of each other, the less likely there will be holes that line up from top to bottom. Doubtless even with Boeing crappy leadership there are still plenty of layers, there was just some change that was communicated but didn’t get routed to the right department or something.
It’s not illegal to drive your suppliers hard. It’s not illegal to push for higher production and lower costs.
So chances are this door plug thing will be a series of such mistakes, where everybody was ‘doing it right’ but not coordinated enough so the net result was it got done wrong.
The best solution would be to fire most/all of Boeing management, ideally without golden parachutes. That will only happen if their stock takes a BIG dive, AND if investors recognize that the current fuckup is only because of that management. I don’t know what their current investor makeup is. But I think THAT will only happen if a number of big customers start cancelling orders, or if there is major FAA enforcement action.
Cancelling an order is a major undertaking for an air carrier. Most aircraft aren’t directly owned by their carriers, there is a complicated financial structure where the aircraft itself and each of the engines are leased/financed and are technically the property of some finance group. These deals take months to set up and millions to unwind. Plus the air carrier will have further millions invested in other parts of the deal- their mechanics are trained on that manufacturer aircraft, they have parts supply deals, pilots are trained to fly that model aircraft, etc.
So for any airline to just ‘dump Boeing’ is a monumental and very expensive effort. That’s why all the carriers are taking measured ‘wait and see’ stances with statements like ‘we are working closely with FAA and Boeing to ensure the safe return of these aircraft to flight’ rather than ‘we’re unloading this junk and buying better airplanes’ or even ‘we’ve halted our purchase of further MAX airframes’.
There’s also the question of supply- even if a carrier WAS to dump Boeing, it’s unlikely that Airbus could increase production by any meaningful rate. And it’s not exactly like Airbus has a ‘stock’ of dozens of aircraft sitting around waiting for customers. The aircraft are built to order.
What may hopefully happen, is Boeing itself is found liable for some huge negligence, and given an astronomical fine as well as forcing Boeing to pay for major refits of all customer airplanes. That might be enough to get investors to act on removing Boeing’s leadership.
If they required professional engineers to be in charge,and to sign off, you don’t need any crime. Screw up, lose your license, be provided from working. But “industry” bought an exemption in congress from licensing law.
Well right now I’m sure they have plenty of professional engineers in charge of the design, who have signed off on everything and done a good job at that. Those engineers aren’t in charge of the company though. And the people in charge of the company are literally on the other side of the country.
Look at any of the insider leaks from Boeing, they are all saying upper management never visits the aircraft plant.
So you have a great design, that on paper is a safe airplane, and then you have it assembled by a bunch of people who are overworked and underpaid and don’t have enough quality inspections.
And the result is situations like the door plug. You have a design that is strong as hell, but just requires a few basic bolts to keep the strong latches engaged and whoops we just forgot to put those bolts in so the airplane hits a bump in turbulence and the door flies off in mid-flight.
Sometimes there are design deficiencies, that are caught after the fact. That’s true with any airplane all the way from an ultralight kit plane you build yourself that runs on a lawn mower engine all the way up to a jumbo jet. The question is how quickly those get fixed. And that’s an upper management decision, not an engineer decision.
For example, the latest 737 has a design deficiency in the de-icing system for the jet intake. When flying through clouds in cold weather, ice can build up on leading edges and cause air flow problems. So you need heated surfaces on the leading edges of the wings and tail and around the edges of the engine intake. They found that the current design has a flaw, if it is activated for more than 5 or 10 minutes when there is NOT icing conditions, the heat strip can peel off and get sucked into the engine. Since the heat strips on both engines would overheat pretty much simultaneously, this could, in theory, lead to a situation where surprise! both engines suck in bits of heat strip at the same time meaning engine failure and potentially bits of debris shooting out of the engine casing and into the cabin.
Boeing is working on a redesign, but they’ve gotten a bunch of approvals to keep selling airplanes with the old design. Solution, for the moment, is tell pilots not to leave the system on if there’s no ice. Hope nobody forgets to turn it off. But point is, they are continuing to sell airplanes with this known design flaw rather than giving a fix top priority. That’s not the engineers, that’s upper management deciding where to allocate resources. And then tried to do this with a newer model and FAA finally told them no, fix it before you sell the airplane not at some point in the future.
To understand Boeing’s situation you have to understand McDonnell Douglas. And we go back to the DC-10 cargo door issue.
That’s a long read, so here’s the short version. The DC-10 cargo door was held on from the outside by rotating latches; when fully engaged the pressure inside the aircraft would push the latches closed so the door was VERY secure, but if the latches weren’t fully engaged the pressure would push the latches open. The telltale showing the cargo operator that the latch was fully engaged wasn’t connected to the latch, but rather the handle, which was itself connected to the latch via a spring. If the operator pushed the latch closed too hard or too fast, the spring would bend, and the telltale would show the door as latched, even though it wasn’t.
If the door flies open in flight that means explosive decompression of the cargo area. That means the pressure of the air in the passenger cabin pushing down on the floor is huge, measured in tons per square meter. It’s worth noting that the control cables that carry movement from the yoke to the rudder/elevator control surfaces in the tail go through the floor.
One of these failed on a mostly empty flight. The floor buckled and a few seats were sucked down through the floor and out of the airplane. The pilots lost all rudder control but miraculously were able to land the jet without further injury. FAA investigated and found the problem, Douglas made a ‘gentleman’s agreement’ with FAA that they would fix this quietly without an embarrassing Airworthiness Directive (forcing all operators to comply and damaging Douglas’s reputation). At all points, the priority for Douglas management was avoiding bad reputation and excess expense, not making sure the aircraft were safe.
A European operator then wasn’t subscribed to Douglas’s maintenance service so the update never happened. And another one failed- this one on a VERY full flight with ~350 people on it. The added weight on the floor caused a much larger section of the floor to fail, the control lines were all severed, and the plane crashed with no survivors.
In the 1990s, McDonnell Douglas and Boeing merged. The Boeing management team (mostly engineers) was replaced with the Douglas management team (bean counters). Their headquarters then moved from Seattle (where they build planes) to Washington, DC (where they lobby for federal contracts).
Granted it’s 30 years after that merge, but it’s pretty obvious the same management strategy is still in charge.
Take the 787 Dreamliner. Their strategy there was reduce all the expensive engineers, instead just write the specs and outsource design and build of entire subsystems. It had lots of teething problems, I’ve heard reports that some parts with tolerances measured in tenths of a millimeter were off by half an inch or more (and that was the reject pile, ones off by less were ground down and hammered into place). Other than some battery problems the aircraft has been pretty safe though.
And now take the MAX product line. A few years back you had issues with MCAS- a computer that makes the new jet fly like the old jet so pilots won’t need retraining, even though the new jet ISN’T like the old jet and flies quite differently and if MCAS fails you’ll have a very different beast on your hands (none of this was mentioned in the operation manual). That caused some crashes.
Now you have this door plug issue. It’s worth noting that Boeing has outsourced assembly of the entire fuselage to another company, who (from what I’ve read) is constantly pressured to increase production and decrease costs. NOT a safety culture.
From some reports I’ve read, procedure at the other company was to make the bolts on the door plug ‘finger tight’ for transport, because not all customers would want the door plug, some would want the actual emergency exit door. So that means with a little bit of vibration on those bolts, the door plug is only held in place by gravity and prayers.
FAA is now supposedly doing some kind of major audit of Boeing manufacturing, and is considering no longer allowing Boeing to self-certify their quality control processes. I’m quite sure it’ll turn up a lot of dirt.
What I HOPE happens is that the market, both the stock market and the aircraft market, heavily punish Boeing and/or demand that their management be replaced. I’m not holding my breath though.
Man this is a very informative, scary and infuriating write-up. Thank you for sharing.
I understand the need for corporations but I also get so fucking angry knowing that no-one ever gets criminally charged for negligence in cases like this.
Charging anyone with a ‘crime’ for something like this is really hard. You have to prove that a. someone in authority, b. knew that a deficiency existed, and c. explicitly directed the deficiency to exist or that it not be fixed, d. knowing that doing so was against regulations or policy or could cause a crash.
‘We did the best we could but it wasn’t good enough’ is a defense against criminal charges, especially when you can produce reams of paper showing how hard you tried.
There’s a saying- airplane safety is like swiss cheese. Every layer has holes, the more layers you stack on top of each other, the less likely there will be holes that line up from top to bottom. Doubtless even with Boeing crappy leadership there are still plenty of layers, there was just some change that was communicated but didn’t get routed to the right department or something.
It’s not illegal to drive your suppliers hard. It’s not illegal to push for higher production and lower costs.
So chances are this door plug thing will be a series of such mistakes, where everybody was ‘doing it right’ but not coordinated enough so the net result was it got done wrong.
The best solution would be to fire most/all of Boeing management, ideally without golden parachutes. That will only happen if their stock takes a BIG dive, AND if investors recognize that the current fuckup is only because of that management. I don’t know what their current investor makeup is. But I think THAT will only happen if a number of big customers start cancelling orders, or if there is major FAA enforcement action.
Cancelling an order is a major undertaking for an air carrier. Most aircraft aren’t directly owned by their carriers, there is a complicated financial structure where the aircraft itself and each of the engines are leased/financed and are technically the property of some finance group. These deals take months to set up and millions to unwind. Plus the air carrier will have further millions invested in other parts of the deal- their mechanics are trained on that manufacturer aircraft, they have parts supply deals, pilots are trained to fly that model aircraft, etc.
So for any airline to just ‘dump Boeing’ is a monumental and very expensive effort. That’s why all the carriers are taking measured ‘wait and see’ stances with statements like ‘we are working closely with FAA and Boeing to ensure the safe return of these aircraft to flight’ rather than ‘we’re unloading this junk and buying better airplanes’ or even ‘we’ve halted our purchase of further MAX airframes’.
There’s also the question of supply- even if a carrier WAS to dump Boeing, it’s unlikely that Airbus could increase production by any meaningful rate. And it’s not exactly like Airbus has a ‘stock’ of dozens of aircraft sitting around waiting for customers. The aircraft are built to order.
What may hopefully happen, is Boeing itself is found liable for some huge negligence, and given an astronomical fine as well as forcing Boeing to pay for major refits of all customer airplanes. That might be enough to get investors to act on removing Boeing’s leadership.
If they required professional engineers to be in charge,and to sign off, you don’t need any crime. Screw up, lose your license, be provided from working. But “industry” bought an exemption in congress from licensing law.
Well right now I’m sure they have plenty of professional engineers in charge of the design, who have signed off on everything and done a good job at that. Those engineers aren’t in charge of the company though. And the people in charge of the company are literally on the other side of the country. Look at any of the insider leaks from Boeing, they are all saying upper management never visits the aircraft plant.
So you have a great design, that on paper is a safe airplane, and then you have it assembled by a bunch of people who are overworked and underpaid and don’t have enough quality inspections. And the result is situations like the door plug. You have a design that is strong as hell, but just requires a few basic bolts to keep the strong latches engaged and whoops we just forgot to put those bolts in so the airplane hits a bump in turbulence and the door flies off in mid-flight.
Sometimes there are design deficiencies, that are caught after the fact. That’s true with any airplane all the way from an ultralight kit plane you build yourself that runs on a lawn mower engine all the way up to a jumbo jet. The question is how quickly those get fixed. And that’s an upper management decision, not an engineer decision. For example, the latest 737 has a design deficiency in the de-icing system for the jet intake. When flying through clouds in cold weather, ice can build up on leading edges and cause air flow problems. So you need heated surfaces on the leading edges of the wings and tail and around the edges of the engine intake. They found that the current design has a flaw, if it is activated for more than 5 or 10 minutes when there is NOT icing conditions, the heat strip can peel off and get sucked into the engine. Since the heat strips on both engines would overheat pretty much simultaneously, this could, in theory, lead to a situation where surprise! both engines suck in bits of heat strip at the same time meaning engine failure and potentially bits of debris shooting out of the engine casing and into the cabin.
Boeing is working on a redesign, but they’ve gotten a bunch of approvals to keep selling airplanes with the old design. Solution, for the moment, is tell pilots not to leave the system on if there’s no ice. Hope nobody forgets to turn it off. But point is, they are continuing to sell airplanes with this known design flaw rather than giving a fix top priority. That’s not the engineers, that’s upper management deciding where to allocate resources. And then tried to do this with a newer model and FAA finally told them no, fix it before you sell the airplane not at some point in the future.