2. damaged rivets discovered and lots of back and forth to get them repaired. boeing does the doors and spirit does the rivets.
3. rework on rivets needed door plug to be removed, someone at boeing (who is not onsite) sees that the door plug needs to be removed, escalates this request but notes that work must wait for the next week because the only door person who is qualified to remove plugs is on leave.
4. door manager - on the day of the plug removal - de-escalates the door plug removal request. later that day the door manager, door master and three door crew enter area near the fuselage & door plug - correct documentation of removal not generated and none of them were trained to remove door plug. No one knows who removed the plug.
5. a boeing technician moves a stand that has what he believed to be a door plug bolt on top of it. he "strapped it and let it hang" to the fuselage.
6. Spirit indicates plug was removed and reworks rivets
7. No one checks the door plug was reinstalled correctly
Also, Boeing spun off Spirit in 2005 to juice its own profit margins, so the poor coordination between these two entities is ultimately Boeing's poor judgment. And more specifically that of Harry Stonecipher, perhaps the worst American CEO this side of Jack Welch.
A benefit of being a golden child business to the US government is you don’t have to worry about economic consequences like a normal business. They’ll still make money off gov contracts and the “local jobs” monopoly system that congress protects like the mob.
Having been on an air crash investigation kind of vibe since the Air India accident, I have conflicting opinions on boeing.
On one hand, their quality control, engineering etc has been declining, not to mention the suspicious deaths of whistleblowers..
But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire.
There are at least 3 accidents on airbus planes which can effectively be attributed to dual input. Loss of situational awareness, highly technical changes in the way the aircraft controls (why would this ever be a good idea), given certain circumstances.
Imagine dying because of the different between ‘pull down’ and ‘push down’. On a boeing, when the captain pushes the nose down, you see immediately what he means. On an airbus, you’re dead by the time the captains input override is acknowledged.
There are definitely pro’s to the airbus system but why cant we add input feedback?
FWIW Airbus has tested a force-feedback side stick. Why they don't already offer it as an option I do not know. Maybe they are calmer now but for decades they took the attitude that "We built an un-crashable airplane because we are smarter than you" and took any criticism as a personal attack.
If you're curious the 757, 767, 777, and 787 are all fly by wire but use both physical linkage under the deck and force-feedback servos to transmit control surface feel back to the pilots. But they also have torque tubes that can be overpowered and ... shocker... in a dual input situation they do the same as Airbus: average the inputs. But at least you have to really yank on the controls to make that happen.
Part of me wonders if the plug could be designed such that it's obvious when the bolts are missing. Would this have happened if it were impossible to assemble without them, or if it were easy to verify their presence?
Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.
"To the Federal Aviation Administration:" " Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)"
This article: https://aerospaceglobalnews.com/news/boeing-completes-design..., suggests that the design enhancement will add "secondary retention devices" that "prevent installation of the cabin sidewall panels unless they are properly engaged." The article indicates that the existing bolts will also get lanyards that will "'permanently secure the bolts to the plug' and provide a visual indication' of whether they have been installed correctly."
It sounds like Boeing is doing a design enhancement. I found this article [1] that describes features for the bolts as:
> The fix also includes adding lanyards atop the door-plug bolts to “permanently secure the bolts to the plug” and “provide a visual indication”, says Crookshanks. “They’ll hang there and be visible to a mechanic that had taken the bolts out.”
The general principle would be making other parts with interference fit such that it or they visibly do not align without properly tightening/attaching parts below/about them. For example, the door plug should not sit in the correct position unless door plug bolts are all tightened and untightened door plug bolts shouldn't allow installing other parts like trim pieces to be flush.
Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.
I don't know if you were joking about the hammer or referring to a Russian assembly worker who used a hammer to install accelerometers in a rocket into a wrong position which caused it to attempt to fly downwards (no people were injured) [1].
> Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)
It sounds like Boeing is currently working on designing and certifying a design enhancement to the MED plug to make it obvious if one is not closed properly. Not sure where to find the details on it though.
The plugs are designed to be semi-permanent because they are only for emergency exits on certain high-capacity seat layouts not used by most US airlines (or any airline that has first class seats I believe). When you have more seats you need more exits.
Given their nature the original intent was probably that they were secured at the factory and never touched. But because they are convenient for access during maintenance/inspection they get used more often.
This issue, the oxygen mask, and the child restraint issue are the NTSB doing the proper "what if things had been slightly different" calculation.
Airline maintenance removes and reinstalls these doors. They could accidentally commit the same error so Boeing should change the design such that the door will not stay in-place when the bolts are removed. Could be as simple as springs that force the plug open without the bolts. If the door won't stay closed without the bolts like a light switch it will be forced to clearly show when it is safe vs not.
Child restraints were mentioned partially because if a lap child had been in that row they'd have been sucked out by the decompression and free-fallen 14000 ft. It was entirely luck that it didn't happen.
Oxygen masks mentioned because the pilots had some trouble getting them on in a timely manner. If the incident had been sudden onset of thick toxic smoke one or both could have passed out before getting the mask on and oxygen flowing. That's like a fire extinguisher with a complicated pin mechanism. Adrenaline dump during emergencies ruins fine motor control, critical thinking, etc. The worst possible time to have something be fiddly and complicated. You want it to be muscle memory. So trivial a 5 year old child could do it without being taught.
And the CVR issue is just the NTSB mentioning that yet again for like the 100th time the CVR circuit breaker was not pulled so we lost the recording and any potential learnings to be had from examining them. This is a problem that just keeps happening over and over. Because it relies on pilots, after a huge emergency, to remember to pull a circuit breaker when they have a thousand far more important things to worry about (not to mention coming down from the adrenaline high) and the thing only keeps the last two hours... which was a standard set when they were continuous loops of wire before the switch to magnetic tape. All the new ones are little computers and flash chips.
> Given their nature the original intent was probably that they were secured at the factory and never touched
Specifically in this case, that factory being Spirit Aerosystems in Wichita where the 737 fuselage is manufactured. Part of the problem here is that Boeing in Renton didn't have processes for removing the MED when necessary on the final assembly line (in this case to rework rivets near the door). Without processes, there was one senior guy on the door team who taught himself how to do it, this was only needed a few times a year, but he was on vacation when this airframe needed the MED removed. Someone else did it (the NTSB couldn't determine who), the work wasn't tracked, and a separate team (the team literally sealing it up so it could be moved outside) put the MED back in but didn't install the bolts (which were gone).
>. If the incident had been sudden onset of thick toxic smoke
Pinpoint "seems reasonable" changes like that without regard for the whole system of interactions are what sank Thresher.
The "sudden onset of thick toxic smoke" is rare. It's either not that toxic or the onset isn't that sudden. You can't just design the system based on assumptions of needing to cover a rare corner case without taking a look at the whole general thing and the frequency of various anomalies and crunching the numbers to see if you're not actually making it worse. I agree that the masks should be simple and reflexive but you absolutely could compromise the whole system if you prioritize reflexive over other attributes without actually taking a full stack look at the tradeoffs in all areas. Aircraft manufactures employ people to think about this stuff and they're frequently why "seems reasonable" changes don't get made.
That's true and part of the reason designing for aerospace applications is tricky.
That sort of thing is also one of the legitimate reasons the FAA can have for not adopting an NTSB recommendation. Requiring a seat for small children is one of those calculations. The FAA ran the numbers and assumed some portion of those parents wouldn't fly and of that portion some would drive. Some portion of flights are for physical or emotional health that would not be handled (you can calculate the increase in suicides from things like missing a loved one's dying moments). And of course driving is way way more lethal. So you have to weigh the deaths from not flying plus deaths from driving against deaths avoided if lap children were prohibited.
The FAA allowed us in the place that Boeing could get itself into this situation. Allowing Boeing to self certify was just bizarre at best. The NTSB report is much too kindly worded for my liking, but that's why I'll never be a political creature
McDonald-Douglass management (of the Jack Welch school) took over at Boeing post-merger. Widgets are widgets and people are just another kind of widget. Job #1 was to screw labor and engineering out of money so that money could go into management's pocket (in the name of shareholders but screwing shareholders is also part of the deal).
They moved HQ away from Seattle specifically so engineers and production personnel couldn't stomp into management's offices and yell at them about safety or anything else.
Then they started outsourcing whatever they could to remove as many people as possible from Boeing's union contracts, corporate benefits, etc and replace those highly paid professionals with the cheapest bodies they could find. After all - the Jack Welch school of thought is the Important People (managers) just need to break down the process (any process) into enough small simple steps that a monkey could do it. Then you could hire the cheapest possible unskilled labor and pay them peanuts but it wouldn't matter because a widget is a widget. People are just widgets. Swap an expensive widget for a cheap one. Duh.
This first came home to roost on the 787 project. Boeing outsourced vast amounts of the project which came back to bite them in the form of delays. They were supposed to start flying in August 2007 and deliver to customers in 2008 but horrible subcontractor designs, rework, unfinished work, etc led to huge assemblies arriving in Everett in a shambles. Repeated delays meant the first aircraft wasn't delivered until September 2011 a full three years behind schedule. Boeing had to buy back in-house a number of their contractors to even make that happen.
That was promptly followed by battery fires that grounded the entire 787 fleet for part of 2013. The first grounding of a transport category airliner since 1979.
Did I mention the 787 had quality problems from 2019 until 2023 (some say ongoing problems even up to today), resulting in missing fasteners (!!!), improperly installed fuel lines, and other issues. For some time they not only had to halt deliveries they had to halt production.
Does any of this sound familiar? It should because the exact same issues plagued the 737 MAX from the start! Rushed engineering without internal peer review or proper consideration (single data source). Rosy assumptions about how pilots would handle various emergencies. Outsourcing to screw labor. Terrible mis-management. Incompetent contractors. Complete lack of process control inside Boeing and complete lack of shits given by Boeing management at any level. Callus lack of regard for any human anywhere (passengers, pilots, airline employees, their own employees)... Boeing knew there was a problem with MCAS and their published guidance wasn't the final word but lied to Ethiopian airlines about it (whos pilots asked some excellent pointed questions). Those lies likely directly leading to the second hull loss event.
Also the same expensive "solutions". Huge re-certification of their process and self-certification procedures. Buying back in-house contractors they originally spun out to cut benefits.
And the 737 MAX itself being a terrible idea, cancelling the clean-sheet A32x competitor in favor of more duct tape and bailing wire on a design with way too many manual reversion modes. On the 787 alternate gear extension is a button press. Dual generator failure auto-starts the APU and deploys the RAT. Electric re-routes automatically. On the 737? LOL nope. All manual. Manual gear means copilot has to stand up, get behind their chair, open a floor panel, then pull three separate cables to about chest-height. Bird ingestion dual engine failure at 1500ft? Not a chance that's happening. But hey according to Boeing's new CEO that is all fine, we aren't doing "the new airplane".
The amount of value destruction of Boeing as a company, Boeing's market share, Boeing's brand, and ultimately Boeing's share price as a result of management trying to screw over labor and taking a short-term view of everything is jaw-dropping.
Nothing has changed at Boeing. They got caught with their hand in the cookie jar. They are doing the absolute bare minimum to make everyone shut up about it and get back to the status quo. How many more times are they going to lose self-certification status? How many more times will they be told to overhaul internal procedures and come up with yet another System to make sure they follow their own rules. All the while management keeps rewarding themselves for outsourcing, cutting pay/benefits, and business as usual. How long will this supposed new quality attitude last? Anyone gonna get promoted to SVP because we didn't have anymore accidents? Gotta weigh that against the exec who outsourced production of control surfaces so we could lay off 500 machinists at $150/hr fully loaded so a contractor can hire $25/hr smucks to do the work thus saving us millions. Gee wonder who's gonna get that promotion after all?
> We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled.
A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.
Also, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".
Agreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training.
In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.
In the end - action matters. Somebody didn’t put the bolts back in.
Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.
Modern safety analysis acknowledges that humans are fallible, and they are generally acting in a good faith way to try and do their jobs correctly within a given system they are operating in.
That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.
Super underrated point - and one that I am not sure the general public always keeps top-of-mind, as human imperfection should be the default assumption. The whole system of air travel is designed so that wherever possible, multiple f*ck-ups can occur and not result in a catastrophe. The success of people involved with anything touching on aviation safety is best measured as in "how many f*ck-ups can occur in the same episode and have everyone still walk away alive?" If you can get that number up to 3, 4 complete idiotic screw-ups one after the other, and the people still live, you've really achieved something great.
This is absolutely incorrect. It runs counter to every high functioning safety culture I've ever encountered.
The system allowed the human to take the incorrect action. If your intern destroys your prod database, it's because you failed to restrict access to the prod database. The remediation to "my intern is capable of destroying my prod database" is not "fire the intern" it's "restrict access to the prod db".
Even the best trained humans will make errors. They will make errors stochastically. Your systemic safety checks will guard against those errors becoming problems. If your safety culture requires all humans to be flawless 100% of the time, your safety culture sucks.
So no, this isn't a fault with a human. Because this was a possible error, it was inevitable that at some point a human would make that error. Because humans never operate without errors for extended periods of time.
There's a reason why Murphy's Law is so commonly acknowledged, though. When you've got a process like this that gets repeated over and over by a bunch of different people, you simply must recognize that that, if it's possible for someone to fuck up, then somebody will fuck up.
And a relatively straightforward corollary of that reality is that, when somebody fucks up, putting too much personal blame on them is pointless. If it weren't them, it would have been somebody else.
In other words, this "blame is due where blame is due" framing is mostly useful as a cop-out excuse that helps incompetent managers who've been skimping on quality controls and failsafes to shift the blame away from where it really belongs.
> There's a reason why Murphy's Law is so commonly acknowledged, though.
In particular, the original formulation of Murphy's Law. The folk version has morphed into "anything that can go wrong, will go wrong". But the original was "If there are two or more ways to do something and one of those results in a catastrophe, then someone will do it that way".
In the end, identifying where you can usefully take action to reduce the chances of something similar happen in the future is far more useful than assigning blame.
Yes! It's basically better to take all screw-up(s) and make their recurrence the assumption. 'Given people will forget to replace bolts how can we best make it so the plane cannot exit the factory without the bolts in place?'
Assigning blame is often the antithesis of safety.
In aviation and other safety-critical fields, we use a just culture approach — not to avoid accountability, but to ensure that learning and prevention come first.
Others already said it but since I'm the person you responded to, I'll reiterate that my suggestion was only about reordering the sequence of that sentence for better clarity, not about placing blame on individuals over process. When a failure can cause serious consequences including killing people, proper system design should never even permit a single point of failure to exist, especially one relying on humans to always perform correctly and completely. Even well-trained, highly-conscientious humans can make a mistake. While these people should have received better training as well as comprehensive sequential checklists, a good system design will have critical failure points such as this each verified and signed off by a separate inspector.
The problem with a culture which prioritizes "blame is due where blame is due" is it can cause people to not report near-misses and other gaps as well as cover-up actual mistakes. The shift in the U.S. from blaming (and penalizing) occasional pilot lapses to a more 'blameless' default mode was controversial but has now clearly demonstrated that it nets better overall safety.
Right, Alaska didn't buy an aeroplane from "manufacturing personnel" they bought it from Boeing. If Boeing don't want to sell aeroplanes that's cool, bye-bye Boeing, but if they want to sell aeroplanes then it's their responsibility to ensure those planes are safe and it cannot somehow be a transferable responsibility.
They know their business. The goal is safety, not punishment. Blaming workers is great if you're after revenge or a scapegoat, but generally doesn't improve safety.
> They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".
If I remember right: during the checks before they were allowed to fly again after being grounded after this incident, multiple operators found issues with the bolts for these door plugs on their planes.
Reading aviation-related NTSB final reports is kind of a hobby of mine, and I must say, the NTSB is generally a treasure! Sure, you can find issues with some of their investigations, roads they might not have probed down as far as they could, but their culture of root causing and transparently reporting should be emulated across the government. I really hope they don't fall victim to the casual, random destruction our current administration is inflicting on broad swaths of the government.
Reading NTSB reports themselves isn't for me, but I really enjoy reading this blog that does excellent write-ups of past plane crashes. It's really well written, easy to follow, and fascinating: https://admiralcloudberg.medium.com
There is the culture war but don't ignore the dealmaking and profiteering. This can create the appearance of randomness because any entity can appeal to the executive for favor.
Sounds like in this case either Boeing didn't donate enough or, more likely, nobody wants to f with airliner safety.
Why frame it as ideological though? That doesn't explain which agencies get protected and which get cut. The NTSB stays funded because rich people fly on planes too. But Medicaid gets cut because wealthy people don't need it.
Look at weather service cuts. They're gutting the National Weather Service while Trump's appointees have ties to companies like AccuWeather and Satellogic that would profit from privatizing weather data.
It's about class interests. Agencies that serve everyone or that rich people depend on stay funded. Programs that only help poor people get cut, or get privatized to benefit specific wealthy interests. Make the wealthy better off through tax cuts and new business opportunities, make poor people worse off through service cuts.
You're right that a lot of the NOAA cuts target climate research specifically. But think about who benefits from attacking climate science. Oil companies and existing wealth structures that profit from fossil fuels. Climate research threatens those business models, so gutting it protects those interests.
The cuts go way beyond climate though. They're cutting 107,000 federal jobs across agencies while defense spending increases 13%. Framing this as ideological makes it sound like an abstract battle of ideas, but it's not abstract at all. Real people are losing health insurance, real hospitals are closing, real communities are losing weather warnings. Meanwhile wealthy people get tax cuts and connected companies get business opportunities. It's about material interests, not ideology.
Can you point out what aspects of the bill relating to Medicaid are most concerning? I don't just mean the DNC talking points, but rather specific provisions. When I read through the actual provisions[1] they are far less scary than what I hear being used as DNC fundraising fodder. For instance, I can't just show up in the UK without any legal status and automatically have all free healthcare from the NHS[2]. But the provisions removing federal tax money support to provide free healthcare to the undocumented is one of the things being pointed to by opponents of the bill as being especially evil. If you feel that way, why is the US the only country that ought to do that?
The work requirements force people to file paperwork proving 80 hours of work monthly, and Arkansas showed this paperwork maze caused 18,000+ people to lose coverage even though 95% already met the requirements or qualified for exemptions. Arkansas spent $26.1 million just on administration with no increase in employment, and Georgia has spent over $40 million with 80% going to bureaucracy, not healthcare.
For rural hospitals, the bill cuts $58 billion in Medicaid funding over 10 years but only provides a $25 billion rural fund that covers less than half the losses. This puts 300+ rural hospitals at immediate risk of closure since they're already operating on thin margins.
For elderly people, the bill blocks nursing home staffing rules until 2034 and freezes home equity limits at $1 million permanently, plus adds more verification requirements.
The evidence shows these aren't about efficiency. They're about creating barriers that cost more money to administer than they save, while cutting care for people who already qualify.
It's not about whether they can work 20 hours. Most already do. Arkansas found 95% of people either met the requirements or qualified for exemptions, but 18,000+ still lost coverage due to the paperwork maze.
The requirements are designed to create barriers through bureaucracy. You have to report every month through a specific online portal, track your hours precisely, navigate exemption processes. Miss one monthly filing deadline and you lose healthcare. It's the most socially acceptable way to kick people off coverage without saying "we don't want poor people to have healthcare."
And it's not just work requirements. The bill also adds income verification twice a year instead of once, more asset checks, and cuts the actual funding. Each new hoop is another chance for eligible people to fall through the cracks. The goal is reducing enrollment through administrative friction, not promoting work.
What's the point of making requirements even stricter if they cost more to administer than they save and don't increase employment? The Congressional Budget Office estimates 5.2 million people would lose coverage by 2034, with savings primarily coming from eligible people losing coverage due to paperwork barriers rather than increased employment.[1]
The new bill allows states to verify monthly instead of every three months, so people lose coverage faster. Even working people get tripped up because 43% of workers would fail to meet 80 hours in at least one month due to variable schedules common in low-wage jobs.[2] People with multiple jobs have to submit paystubs from each employer monthly. Seasonal workers and food service workers are especially vulnerable because their hours swing wildly due to factors beyond their control.
The cost of government subsidies isn’t in just the subsidies or the administrative overhead alone. It’s in training people to rely on the government, in effectively subsidizing employers that pay less than a living wage, etc.
You're right that Medicaid subsidizes employers who pay poverty wages rely on taxpayers to provide healthcare for their workers instead of paying living wages themselves. But the solution isn't to eliminate Medicaid and leave workers with nothing. The solution is to raise the minimum wage or have universal healthcare so employers actually have to provide real benefits.
Most Medicaid recipients already work. They're not choosing dependency, they're working jobs that don't pay enough to afford healthcare. Taking away their healthcare doesn't suddenly make employers pay more, it just leaves workers desperate, which is exactly what those employers want.
You're essentially arguing we should eliminate the safety net that keeps our low-wage economy functioning. That would either force employers to pay living wages (unlikely) or create mass suffering among workers (more likely). Which outcome are you hoping for? Because right now it sounds like you'd rather have sick, desperate workers than challenge the employers who created this system.
AKA Boeing did not train, guide or oversee its people well → Workers skipped the process meant to keep track of bolts and hardware → The bolts for the mid-exit door were never put back → At 14K feet, the door blew free.
Physics question: why do I know (maybe wrongly) that in flight the doors are sealed shut by the difference in pressure ? And if so, why did it not work in this case ?
I don't know the answer for this specific case, but the pressure is high on the inside and low on the outside. If you have a hinted door that opens inward, then pressure will keep it shut. If you install the door wrong and forget to attach the hinge properly, it could be blown outward.
My favorite NTSB-ism is "controlled flight into terrain", which means "crashed". This is as opposed to "uncontrolled flight into terrain", which means "fell from the sky".
It's a legitimate distinction, "they were in control" and "they weren't in control". If the pilots are on a collision course with a mountain, but are happily sitting there thinking they're going the other way, there's nothing wrong with the plane, and the pilots are in control of the plane. In contrast to a horizontal stabilizer failure, where the pilots aren't in control, and instead say their goodbyes for the cockpit voice recording.
It’s a bit more nuanced than that. CFIT is intended to classify accidents where the aircraft itself was not causal. In any other case, it is assumed that there were mechanical or other aircraft-related factors that were contributory or causal.
CFIT is not necessarily pilot error. For example, if ATC vectored a plane without ground proximity warnings into the side of a mountain, that would also be CFIT.
At school (Polish class in Poland) we were always taught to prefer complex and compound sentences over simple ones, because it's more elegant and speaks well the speaker/writer.
Only if you're using technical writing in a situation where you shouldn't be.
Problem is the state of most English education doesn't even teach enough for people to recognize proper unambiguous technical writing, let alone appreciate it or attempt to compose it.
i imagine the language may change that though. With Polish having nominally 300k-400k words compared to English's >1m, i'd guess that it's a lot easier to misdirect and fluff up your writing in English.
This sentence isn't written for elegance but for meaning. The formal cause of the accident was the mechanical separation, but that happened for a reason, either mechanical failure (which means a failure in the engineering of the aircraft, which would have to be remedied by new engineering processes) or an assembly failure (which would have to be remedied by new assembly processes). In one sentence, the author drills down to exactly what went wrong that enabled the accident to happen. Identifying that is the first step to remedying it.
Could've been worse. In Korean schools they somehow find the worst, most meandering and pointless examples of English prose and shove them at poor students at exam time to test their "English comprehension" skills, when any reasonable native speaker would've said "Who the fuck writes like this?"
> We determined that the probable cause of this accident was the in-flight separation of the left MED plug
I find this very strangely worded. It was an "incident", not an "accident"; and "the in-flight separation of the left MED plug" was the incident, not the cause of a non-existent accident.
The actual cause of the incident (as determined by the NTSB) is what follows all that unnecessary verbage.
The accident happened because a piece on the airplane wasn’t put back on the right way. The company that made the plane didn’t teach the workers well enough or check their work carefully. Also, the people in charge of making sure planes are safe didn’t do a good job checking on things.
At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't, and people who are supposed to inspect their work who aren't inspecting, and people who are supposed to check the inspection process who aren't checking, and a legislative body who's supposed to regulate all the checking and double checking who aren't doing anything at all!
It's like vast swaths of people are just fooling around, collecting a paycheck, but aren't doing what they're supposed to be doing, and we're all just miraculously surviving our day-to-day because a bunch of denominators are very large numbers!
I have worked in the medical devices industry as a software engineer for about 20 years at this point. As you would expect, it's a very process-heavy field. I've generally worked with careful, competent people who want to do a good job and process goes a long way towards facilitating that.
Every time I think about process though, I remember an editorial I read a long time ago about an engineer's experience in the aviation industry. He wasn't too thrilled about process. Instead, in his own words, "we were motivated by a very sincere desire to not kill anyone.
> At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't
Meta observation - human society works by abstraction - leaky, and functional - not genuine understanding. Searle was wrong. There is no genuine understanding, only a web of abstractions that sometimes break.
In general, people do what the organization providing their paycheck asks them to do. If their manager tells them to cut corners, they'll likely cut corners.
Some people are opposed to bureaucracy and will tend to try to undermine processes which are designed to prevent errors in production and execution. Organizational culture needs to be established and maintained, which aligns everyone toward the processes needed to maintain required standards.
At the end of the day people have to care about their job, for a reason bigger than getting a paycheck. Society can coast for awhile when people don't care but things eventually break down.
You can add process but the people running the process have to care. You can add regulation, but then the regulators have to care.
At the end of the day people have to care. And it really has to be everyone, because if one group cares and another doesn't, the one that cares will soon get disillusioned.
Caring alone is not sufficient. You do need process to catch mistakes. But process alone is also not sufficient.
No, because some people still care and clean up enough after the slackers. The slackers also realize this and slack just enough for nothing major to happen often.
This is not true, when that many people stop doing their job it spreads like a virus and the ones that still stand for good either a) leave companies or b) become infected also.
They don't go against the grain. The people that do would have to have a constitution like no one you've met. Those people quit the moment covid-19 hit and they have since died or are just permanently retired.
As with all but the first few 737s, it was assembled at Renton. The door plug was installed in Wichita by Spirit Aerosystems and there were issues with rivets in the surrounding structure that Spirit removed the plug to correct in Renton.
As a result of this Boeing is now refusing to sign off on fuselages with defects found at Spirit to be transported to Renton. And also Boeing will be buying back Spirit, which had been spun out of Boeing by the McDonall-Douglass management that took over Boeing when McDonall-Douglass bought Boeing with Boeings own money.
Of note: the whistleblower we're talking about had already given testimony, which is to say the conspiracy theory requires you to believe Boeing was willing to kill a whistleblower, but only after they testified.
(Not that it could possibly have mattered, but he also never worked on the 737; several still-living current and former Boeing employees have filed complaints about 737 production processes).
If I was determined to commit suicide, I'd probably try to accomplish other goals with it if I could. For that person, FUD might have been his secondary goal.
I imagine if someone is contemplating suicide, they are not in a good place. Trying to sow FUD would be in line with that.
Are we still talking about John Barnett? This guy’s been talked about for years. You’re asking — we have Texas, we have this, we have all of the things. And are people still talking about this guy? That is unbelievable
There's supposedly video evidence of him parking his truck and nobody approaching it at all until people were there discovering the body. He had his personal firearm in his hand, ballistics suggest the bullet came from his gun, and it followed a path that made sense with him holding it and using it on himself.
But hey I guess they did some kind of mind control on him.
I hadn't watched the footage personally. Many other have and that was their conclusion.
The coroner's report also sure sounds like a suicide. Gunshot to the right temple, very close range, from the victim's gun. No evidence of any struggle or forced entry. No evidence of anyone being with him. A note with only his fingerprints in what seems to be his handwriting.
Obviously there's no possibile way a mentally unstable person under a lot of continued stress would ever take their own life, just never happens. The only way people die are because corporations have them executed.
Is there even a single shred of evidence suggesting someone else pulled the trigger?
I mean lots of local news agencies played clips of it. Numerous agencies got a copy of it. Few seem to deny its existence from what I can tell. It's not like certain lists that are one person's desk one day and never existed the next. The video is out there, I just hadn't personally watched it before so I personally couldn't vouch for it absolute existence. I guess a ton of people's beliefs entirely hinge on if I, vel0city, have personally examined the materials.
Y'all are really reading a lot into my usage of supposedly in that statement.
Hmm. When you put it that way, it rings a bell. One of the things in the fascist playbook is that the enemy is both very strong and very weak.
Looking through Eco's 14 points of fascism, I could see conspiracy theories fitting numbers 2, 4, 7, and 8, and having a tendency toward 5, 6, 9, 10, 11, 13, and 14.
I hadn't considered conspiracy theory believers to be in any way related to fascists. But maybe I could see it. Both are a simplistic overarching narrative with clear-cut good guys and bad guys (and therefore at least an implied morality). But still, I'm kind of surprised here. I'm not sure I know what to make of this.
We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process."
My experience is somewhat limited professionally in software (just under a decade), but with very few exceptions I've seen little in terms of genuine professionalism as it pertains to anything that could be called "engineering."
Most design/implementation decisions were basically (or literally) equivalent to "we use Kubernetes cause we've already got a lot of existing Terrraform for it", or "we have React developers." I know real professionalism and maybe even "engineering" practice exists somewhere (I mean it has to, for something rigorously proven, right?), but I've not personally experienced it; I've seen this everywhere, as a consultant and employee, both in the public and private sector.
The number of times I've been on meetings or similar where there's tradeoffs backed by quantifiable data was a handful, at best, so the AI trend makes perfect sense to me.
I really don't imagine with something like Boeing where there's a far higher burden of proof there's discussions around, like, some equivalent subjective thingy like "code smells" or "anti-patterns."
> I mean it has to, for something rigorously proven, right?
I have been thinking about this recently. What are the most rigorous "software actual engineering" fields, or projects?
Autopilot systems in airliners came to mind. Not just autopilot, but FADEC, and other flight control systems. Medical devices? ... Or, are all those teams just winging it as well?
There's always consequences for people in charge! It's just that all of the consequences are related to not-enough-profit, which explains everything you need to know.
Obviously, such mistakes have no bearing on the content of the report. However, there are usually certain expectations of a formal report from an official government bureau, including a standard of presentation.
1. boeing and spirit both work on planes
2. damaged rivets discovered and lots of back and forth to get them repaired. boeing does the doors and spirit does the rivets.
3. rework on rivets needed door plug to be removed, someone at boeing (who is not onsite) sees that the door plug needs to be removed, escalates this request but notes that work must wait for the next week because the only door person who is qualified to remove plugs is on leave.
4. door manager - on the day of the plug removal - de-escalates the door plug removal request. later that day the door manager, door master and three door crew enter area near the fuselage & door plug - correct documentation of removal not generated and none of them were trained to remove door plug. No one knows who removed the plug.
5. a boeing technician moves a stand that has what he believed to be a door plug bolt on top of it. he "strapped it and let it hang" to the fuselage.
6. Spirit indicates plug was removed and reworks rivets
7. No one checks the door plug was reinstalled correctly
https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123
Extremely sad to learn this. It could have been prevented.
On one hand, their quality control, engineering etc has been declining, not to mention the suspicious deaths of whistleblowers..
But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire.
There are at least 3 accidents on airbus planes which can effectively be attributed to dual input. Loss of situational awareness, highly technical changes in the way the aircraft controls (why would this ever be a good idea), given certain circumstances.
Imagine dying because of the different between ‘pull down’ and ‘push down’. On a boeing, when the captain pushes the nose down, you see immediately what he means. On an airbus, you’re dead by the time the captains input override is acknowledged.
There are definitely pro’s to the airbus system but why cant we add input feedback?
If you're curious the 757, 767, 777, and 787 are all fly by wire but use both physical linkage under the deck and force-feedback servos to transmit control surface feel back to the pilots. But they also have torque tubes that can be overpowered and ... shocker... in a dual input situation they do the same as Airbus: average the inputs. But at least you have to really yank on the controls to make that happen.
Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.
"To the Federal Aviation Administration:" " Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)"
This article: https://aerospaceglobalnews.com/news/boeing-completes-design..., suggests that the design enhancement will add "secondary retention devices" that "prevent installation of the cabin sidewall panels unless they are properly engaged." The article indicates that the existing bolts will also get lanyards that will "'permanently secure the bolts to the plug' and provide a visual indication' of whether they have been installed correctly."
Apparently, if only one of the four bolts was installed, it may have been sufficient to prevent the accident, according to: https://www.nytimes.com/2025/06/24/us/politics/boeing-alaska...
> The fix also includes adding lanyards atop the door-plug bolts to “permanently secure the bolts to the plug” and “provide a visual indication”, says Crookshanks. “They’ll hang there and be visible to a mechanic that had taken the bolts out.”
[1] https://www.flightglobal.com/safety/details-emerge-about-boe...
Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.
[1] https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failur...
It sounds like Boeing is currently working on designing and certifying a design enhancement to the MED plug to make it obvious if one is not closed properly. Not sure where to find the details on it though.
Given their nature the original intent was probably that they were secured at the factory and never touched. But because they are convenient for access during maintenance/inspection they get used more often.
This issue, the oxygen mask, and the child restraint issue are the NTSB doing the proper "what if things had been slightly different" calculation.
Airline maintenance removes and reinstalls these doors. They could accidentally commit the same error so Boeing should change the design such that the door will not stay in-place when the bolts are removed. Could be as simple as springs that force the plug open without the bolts. If the door won't stay closed without the bolts like a light switch it will be forced to clearly show when it is safe vs not.
Child restraints were mentioned partially because if a lap child had been in that row they'd have been sucked out by the decompression and free-fallen 14000 ft. It was entirely luck that it didn't happen.
Oxygen masks mentioned because the pilots had some trouble getting them on in a timely manner. If the incident had been sudden onset of thick toxic smoke one or both could have passed out before getting the mask on and oxygen flowing. That's like a fire extinguisher with a complicated pin mechanism. Adrenaline dump during emergencies ruins fine motor control, critical thinking, etc. The worst possible time to have something be fiddly and complicated. You want it to be muscle memory. So trivial a 5 year old child could do it without being taught.
And the CVR issue is just the NTSB mentioning that yet again for like the 100th time the CVR circuit breaker was not pulled so we lost the recording and any potential learnings to be had from examining them. This is a problem that just keeps happening over and over. Because it relies on pilots, after a huge emergency, to remember to pull a circuit breaker when they have a thousand far more important things to worry about (not to mention coming down from the adrenaline high) and the thing only keeps the last two hours... which was a standard set when they were continuous loops of wire before the switch to magnetic tape. All the new ones are little computers and flash chips.
Specifically in this case, that factory being Spirit Aerosystems in Wichita where the 737 fuselage is manufactured. Part of the problem here is that Boeing in Renton didn't have processes for removing the MED when necessary on the final assembly line (in this case to rework rivets near the door). Without processes, there was one senior guy on the door team who taught himself how to do it, this was only needed a few times a year, but he was on vacation when this airframe needed the MED removed. Someone else did it (the NTSB couldn't determine who), the work wasn't tracked, and a separate team (the team literally sealing it up so it could be moved outside) put the MED back in but didn't install the bolts (which were gone).
Pinpoint "seems reasonable" changes like that without regard for the whole system of interactions are what sank Thresher.
The "sudden onset of thick toxic smoke" is rare. It's either not that toxic or the onset isn't that sudden. You can't just design the system based on assumptions of needing to cover a rare corner case without taking a look at the whole general thing and the frequency of various anomalies and crunching the numbers to see if you're not actually making it worse. I agree that the masks should be simple and reflexive but you absolutely could compromise the whole system if you prioritize reflexive over other attributes without actually taking a full stack look at the tradeoffs in all areas. Aircraft manufactures employ people to think about this stuff and they're frequently why "seems reasonable" changes don't get made.
That sort of thing is also one of the legitimate reasons the FAA can have for not adopting an NTSB recommendation. Requiring a seat for small children is one of those calculations. The FAA ran the numbers and assumed some portion of those parents wouldn't fly and of that portion some would drive. Some portion of flights are for physical or emotional health that would not be handled (you can calculate the increase in suicides from things like missing a loved one's dying moments). And of course driving is way way more lethal. So you have to weigh the deaths from not flying plus deaths from driving against deaths avoided if lap children were prohibited.
Are we great again yet?
https://www.transportation.gov/briefing-room/national-fact-s...
It is tough to understand your snark.
McDonald-Douglass management (of the Jack Welch school) took over at Boeing post-merger. Widgets are widgets and people are just another kind of widget. Job #1 was to screw labor and engineering out of money so that money could go into management's pocket (in the name of shareholders but screwing shareholders is also part of the deal).
They moved HQ away from Seattle specifically so engineers and production personnel couldn't stomp into management's offices and yell at them about safety or anything else.
Then they started outsourcing whatever they could to remove as many people as possible from Boeing's union contracts, corporate benefits, etc and replace those highly paid professionals with the cheapest bodies they could find. After all - the Jack Welch school of thought is the Important People (managers) just need to break down the process (any process) into enough small simple steps that a monkey could do it. Then you could hire the cheapest possible unskilled labor and pay them peanuts but it wouldn't matter because a widget is a widget. People are just widgets. Swap an expensive widget for a cheap one. Duh.
This first came home to roost on the 787 project. Boeing outsourced vast amounts of the project which came back to bite them in the form of delays. They were supposed to start flying in August 2007 and deliver to customers in 2008 but horrible subcontractor designs, rework, unfinished work, etc led to huge assemblies arriving in Everett in a shambles. Repeated delays meant the first aircraft wasn't delivered until September 2011 a full three years behind schedule. Boeing had to buy back in-house a number of their contractors to even make that happen.
That was promptly followed by battery fires that grounded the entire 787 fleet for part of 2013. The first grounding of a transport category airliner since 1979.
Did I mention the 787 had quality problems from 2019 until 2023 (some say ongoing problems even up to today), resulting in missing fasteners (!!!), improperly installed fuel lines, and other issues. For some time they not only had to halt deliveries they had to halt production.
Does any of this sound familiar? It should because the exact same issues plagued the 737 MAX from the start! Rushed engineering without internal peer review or proper consideration (single data source). Rosy assumptions about how pilots would handle various emergencies. Outsourcing to screw labor. Terrible mis-management. Incompetent contractors. Complete lack of process control inside Boeing and complete lack of shits given by Boeing management at any level. Callus lack of regard for any human anywhere (passengers, pilots, airline employees, their own employees)... Boeing knew there was a problem with MCAS and their published guidance wasn't the final word but lied to Ethiopian airlines about it (whos pilots asked some excellent pointed questions). Those lies likely directly leading to the second hull loss event.
Also the same expensive "solutions". Huge re-certification of their process and self-certification procedures. Buying back in-house contractors they originally spun out to cut benefits.
And the 737 MAX itself being a terrible idea, cancelling the clean-sheet A32x competitor in favor of more duct tape and bailing wire on a design with way too many manual reversion modes. On the 787 alternate gear extension is a button press. Dual generator failure auto-starts the APU and deploys the RAT. Electric re-routes automatically. On the 737? LOL nope. All manual. Manual gear means copilot has to stand up, get behind their chair, open a floor panel, then pull three separate cables to about chest-height. Bird ingestion dual engine failure at 1500ft? Not a chance that's happening. But hey according to Boeing's new CEO that is all fine, we aren't doing "the new airplane".
The amount of value destruction of Boeing as a company, Boeing's market share, Boeing's brand, and ultimately Boeing's share price as a result of management trying to screw over labor and taking a short-term view of everything is jaw-dropping.
Nothing has changed at Boeing. They got caught with their hand in the cookie jar. They are doing the absolute bare minimum to make everyone shut up about it and get back to the status quo. How many more times are they going to lose self-certification status? How many more times will they be told to overhaul internal procedures and come up with yet another System to make sure they follow their own rules. All the while management keeps rewarding themselves for outsourcing, cutting pay/benefits, and business as usual. How long will this supposed new quality attitude last? Anyone gonna get promoted to SVP because we didn't have anymore accidents? Gotta weigh that against the exec who outsourced production of control surfaces so we could lay off 500 machinists at $150/hr fully loaded so a contractor can hire $25/hr smucks to do the work thus saving us millions. Gee wonder who's gonna get that promotion after all?
Good to know it was written by a human and not an LLM.
A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.
In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.
Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.
That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.
The system allowed the human to take the incorrect action. If your intern destroys your prod database, it's because you failed to restrict access to the prod database. The remediation to "my intern is capable of destroying my prod database" is not "fire the intern" it's "restrict access to the prod db".
Even the best trained humans will make errors. They will make errors stochastically. Your systemic safety checks will guard against those errors becoming problems. If your safety culture requires all humans to be flawless 100% of the time, your safety culture sucks.
So no, this isn't a fault with a human. Because this was a possible error, it was inevitable that at some point a human would make that error. Because humans never operate without errors for extended periods of time.
And a relatively straightforward corollary of that reality is that, when somebody fucks up, putting too much personal blame on them is pointless. If it weren't them, it would have been somebody else.
In other words, this "blame is due where blame is due" framing is mostly useful as a cop-out excuse that helps incompetent managers who've been skimping on quality controls and failsafes to shift the blame away from where it really belongs.
In particular, the original formulation of Murphy's Law. The folk version has morphed into "anything that can go wrong, will go wrong". But the original was "If there are two or more ways to do something and one of those results in a catastrophe, then someone will do it that way".
In aviation and other safety-critical fields, we use a just culture approach — not to avoid accountability, but to ensure that learning and prevention come first.
https://en.wikipedia.org/wiki/Just_culture
The problem with a culture which prioritizes "blame is due where blame is due" is it can cause people to not report near-misses and other gaps as well as cover-up actual mistakes. The shift in the U.S. from blaming (and penalizing) occasional pilot lapses to a more 'blameless' default mode was controversial but has now clearly demonstrated that it nets better overall safety.
Doesn't this mean it should happen a lot more?
The goals are both obvious and specific; it’s a culture war being fought at the funding level.
Sounds like in this case either Boeing didn't donate enough or, more likely, nobody wants to f with airliner safety.
If that would be more likely, Boeing wouldn't be, where it is.
To me it seems more likely Boeing has now too much attention on them, making fraud here even more dangerous/expensive.
Look at weather service cuts. They're gutting the National Weather Service while Trump's appointees have ties to companies like AccuWeather and Satellogic that would profit from privatizing weather data.
It's about class interests. Agencies that serve everyone or that rich people depend on stay funded. Programs that only help poor people get cut, or get privatized to benefit specific wealthy interests. Make the wealthy better off through tax cuts and new business opportunities, make poor people worse off through service cuts.
The cuts go way beyond climate though. They're cutting 107,000 federal jobs across agencies while defense spending increases 13%. Framing this as ideological makes it sound like an abstract battle of ideas, but it's not abstract at all. Real people are losing health insurance, real hospitals are closing, real communities are losing weather warnings. Meanwhile wealthy people get tax cuts and connected companies get business opportunities. It's about material interests, not ideology.
[1] https://www.kff.org/tracking-the-medicaid-provisions-in-the-...
[2] https://www.nhs.uk/nhs-services/visiting-or-moving-to-englan...
For rural hospitals, the bill cuts $58 billion in Medicaid funding over 10 years but only provides a $25 billion rural fund that covers less than half the losses. This puts 300+ rural hospitals at immediate risk of closure since they're already operating on thin margins.
For elderly people, the bill blocks nursing home staffing rules until 2034 and freezes home equity limits at $1 million permanently, plus adds more verification requirements.
The evidence shows these aren't about efficiency. They're about creating barriers that cost more money to administer than they save, while cutting care for people who already qualify.
The requirements are designed to create barriers through bureaucracy. You have to report every month through a specific online portal, track your hours precisely, navigate exemption processes. Miss one monthly filing deadline and you lose healthcare. It's the most socially acceptable way to kick people off coverage without saying "we don't want poor people to have healthcare."
And it's not just work requirements. The bill also adds income verification twice a year instead of once, more asset checks, and cuts the actual funding. Each new hoop is another chance for eligible people to fall through the cracks. The goal is reducing enrollment through administrative friction, not promoting work.
It’s on those individuals to not “fall through the cracks” if they truly need our money to fund their healthcare — I don’t see the problem.
The new bill allows states to verify monthly instead of every three months, so people lose coverage faster. Even working people get tripped up because 43% of workers would fail to meet 80 hours in at least one month due to variable schedules common in low-wage jobs.[2] People with multiple jobs have to submit paystubs from each employer monthly. Seasonal workers and food service workers are especially vulnerable because their hours swing wildly due to factors beyond their control.
[1] https://ccf.georgetown.edu/2025/05/27/medicaid-and-chip-cuts...
[2] https://www.cbpp.org/research/health/medicaid-work-requireme...
Most Medicaid recipients already work. They're not choosing dependency, they're working jobs that don't pay enough to afford healthcare. Taking away their healthcare doesn't suddenly make employers pay more, it just leaves workers desperate, which is exactly what those employers want.
You're essentially arguing we should eliminate the safety net that keeps our low-wage economy functioning. That would either force employers to pay living wages (unlikely) or create mass suffering among workers (more likely). Which outcome are you hoping for? Because right now it sounds like you'd rather have sick, desperate workers than challenge the employers who created this system.
"(pilot control state) flight into (outcome of flight)"
One of those pieces of jargon that feels silly until you go, "Oh, actually, this makes a lot of sense when you deconstruct it."
Problem is the state of most English education doesn't even teach enough for people to recognize proper unambiguous technical writing, let alone appreciate it or attempt to compose it.
I find this very strangely worded. It was an "incident", not an "accident"; and "the in-flight separation of the left MED plug" was the incident, not the cause of a non-existent accident.
The actual cause of the incident (as determined by the NTSB) is what follows all that unnecessary verbage.
It's like vast swaths of people are just fooling around, collecting a paycheck, but aren't doing what they're supposed to be doing, and we're all just miraculously surviving our day-to-day because a bunch of denominators are very large numbers!
Every time I think about process though, I remember an editorial I read a long time ago about an engineer's experience in the aviation industry. He wasn't too thrilled about process. Instead, in his own words, "we were motivated by a very sincere desire to not kill anyone.
Meta observation - human society works by abstraction - leaky, and functional - not genuine understanding. Searle was wrong. There is no genuine understanding, only a web of abstractions that sometimes break.
Some people are opposed to bureaucracy and will tend to try to undermine processes which are designed to prevent errors in production and execution. Organizational culture needs to be established and maintained, which aligns everyone toward the processes needed to maintain required standards.
You can add process but the people running the process have to care. You can add regulation, but then the regulators have to care.
At the end of the day people have to care. And it really has to be everyone, because if one group cares and another doesn't, the one that cares will soon get disillusioned.
Caring alone is not sufficient. You do need process to catch mistakes. But process alone is also not sufficient.
They don't go against the grain. The people that do would have to have a constitution like no one you've met. Those people quit the moment covid-19 hit and they have since died or are just permanently retired.
when you pay utter shit but the c-level earns many 100x the salary of the workers, of course they don't give a fuck.
If they can avoid weed long enough to pass the drug tests, they’ll be playing Candy Crush on their phone when inspecting.
They just don’t have the mental horsepower. Like being upset a jellyfish didn’t discover calculus.
Patio11 calls this The Sort. I thought it was good name.
As a result of this Boeing is now refusing to sign off on fuselages with defects found at Spirit to be transported to Renton. And also Boeing will be buying back Spirit, which had been spun out of Boeing by the McDonall-Douglass management that took over Boeing when McDonall-Douglass bought Boeing with Boeings own money.
https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-a...
The 737 assembly happens in Renton, WA
If you have evidence to the contrary, by all means let us know.
(Not that it could possibly have mattered, but he also never worked on the 737; several still-living current and former Boeing employees have filed complaints about 737 production processes).
I imagine if someone is contemplating suicide, they are not in a good place. Trying to sow FUD would be in line with that.
A tragedy begetting more tragedy.
Aliens are visiting and/or we have electro-gravitics (which would likely imply visitors too)
9/11 - the story we were told isn't true - building 7? passports found?
there are 2 dead Boeing whistleblowers
the openai whistleblower
This is one of two. As theories go conspiracy is pretty plausible in this case. Unless you’re just naive about how the world works.
But hey I guess they did some kind of mind control on him.
That statement is so weak it's better at inflaming the conspiracy theory than quelling it.
The coroner's report also sure sounds like a suicide. Gunshot to the right temple, very close range, from the victim's gun. No evidence of any struggle or forced entry. No evidence of anyone being with him. A note with only his fingerprints in what seems to be his handwriting.
Obviously there's no possibile way a mentally unstable person under a lot of continued stress would ever take their own life, just never happens. The only way people die are because corporations have them executed.
Is there even a single shred of evidence suggesting someone else pulled the trigger?
Y'all are really reading a lot into my usage of supposedly in that statement.
Looking through Eco's 14 points of fascism, I could see conspiracy theories fitting numbers 2, 4, 7, and 8, and having a tendency toward 5, 6, 9, 10, 11, 13, and 14.
I hadn't considered conspiracy theory believers to be in any way related to fascists. But maybe I could see it. Both are a simplistic overarching narrative with clear-cut good guys and bad guys (and therefore at least an implied morality). But still, I'm kind of surprised here. I'm not sure I know what to make of this.
We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process."
Most design/implementation decisions were basically (or literally) equivalent to "we use Kubernetes cause we've already got a lot of existing Terrraform for it", or "we have React developers." I know real professionalism and maybe even "engineering" practice exists somewhere (I mean it has to, for something rigorously proven, right?), but I've not personally experienced it; I've seen this everywhere, as a consultant and employee, both in the public and private sector.
The number of times I've been on meetings or similar where there's tradeoffs backed by quantifiable data was a handful, at best, so the AI trend makes perfect sense to me.
I really don't imagine with something like Boeing where there's a far higher burden of proof there's discussions around, like, some equivalent subjective thingy like "code smells" or "anti-patterns."
I have been thinking about this recently. What are the most rigorous "software actual engineering" fields, or projects?
Autopilot systems in airliners came to mind. Not just autopilot, but FADEC, and other flight control systems. Medical devices? ... Or, are all those teams just winging it as well?
> dDevelop guidance for Federal Aviation Administration managers and inspectors
> <strike>P</strike>rovide Federal Aviation Administration managers
Boeing is dead.