The National Transportation Safety Board (NTSB) cited Boeing for inadequate “training, guidance, and oversight” that ultimately led to the now-infamous in-flight blowout of a mid-exit door (MED) plug on a near-new B737-9 a year and a half ago. That’s the conclusion the NTSB reached in a public hearing into the incident today (June 24).
The NTSB further concluded that Boeing’s two-year-old (at the time) voluntary safety management system (SMS) “was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks.” The board further cited the FAA as being ineffective in ensuring that Boeing addressed “repetitive and systemic” non-conformance issues that were part of the manufacturer’s parts-removal process.
NTSB Chairwoman Jennifer Homendy said at the hearing, “The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA—[they] should have been preventable. This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”
A further result of today’s hearing is new safety recommendations from the NTSB to the FAA and Boeing. The board also reiterated previous recommendations made to the FAA, Airlines for America, the National Air Carrier Association and the Regional Airline Association.
An online summary of today’s hearing is available here.
Trying to privatize a government function will eventually lead to this type of failure since promoting safety and making a profit are sometimes in conflict, usually the short term. Management bonuses are almost always based on short term metrics (at least where I have personal knowledge). Unfortunately the FAA is never funded for the long term or staffed fully with the highly paid staff needed for inspections. Well maybe before fired the old FAA staffers…
The answer(s) are actually quite simple but will cost everyone involved. When Boeing adopted LEAN Manufacturing they elected to completely ignore the realities of human nature and mechanical reliability. They adopted standardization for the sake of standardization and made assumptions about reliability that have no basis in reality. LEAN must go and endpoint quality inspections must be restored.
The FAA, at the direction of John Duncan adopted the “kinder gentler” compliance philosophy in the new SMS/SAS systems that also ignores basic human nature and changed the role of the ASI from Inspector to Auditor; effectively putting the fox in the henhouse.
Unless and until these two philosophies are cast aside and the industry returns to basics we should expect more “quality escapes” and experienced ASIs can go back to not holding their collective breath waiting for the next smoking hole. It is coming, rest assured.
Privatization of government oversight seldom works out well .
It’s remarkable that the union employees that removed and others that installed the plug could not be identified. Real standup folks.
Concerning that people would do something involving undoing bolt and not record it.
Different from just unlatching a standard 737 overwing exit.
In this case the exit had been de-activated hence the bolts, no handle inside, I presume had to remove at least a bit of trim to get at the bolts.
Amazing.
Part of the chain to failure and perhaps evasion was two different organizations working on the airplane - Spirit work was ‘travelled’ from Wichita to Renton, with people from Wichita and local contractors working on the airplane.
My understanding is that the removal was recorded, but, due to software incompatibility, the replacement procedure was not triggered.
Nothing to deactivate; the exit hardware was never there - nothing to activate in the first place. Just a plug secured by spring-loaded fittings, with four bolts that locked the fittings closed.
Yes; the interior paneling was removed.