We’re looking into the Boeing 737 Max 9 airplane that has been in the news again on Jan 5, ’24, following a very frightening incident where part of the body blew out leading to a sudden depressurization and emergency landing. From a manufacturing perspective, why did this occur? Are there more quality and reliability issues to worry about? We give our take based on news reports here, although do note that the NTSB report has not yet been published.
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According to the National Transportation Safety Board, the door plug for the fuselage of a Boeing 737 Max 9 fell off a few minutes after Alaska Airlines Flight 1282 took off from Portland International Airport on Jan. 5, depressurizing the cabin and exposing passengers to open air thousands of feet above the ground. No one was seriously injured and the plane made an emergency landing safely. This isn’t the first time the 737 Max has suffered from problems, and, in the past, some planes even crashed with many lives lost. So we delve into the problems suffered by this airplane and discuss whether they are design, manufacturing, or quality related.
What happened on Alaska Airlines Flight 1282 on Jan 5th, 2024?
A door plug blew out during take-off of the flight headed from Portland to Ontario, Canada, at 16,000 feet leading to a sudden depressurisation, fortunately, no passenger was sitting next to that wall panel who may have been sucked out and no one was seriously injured, but it has led to the 737 Max 9 fleet being temporarily grounded for safety checks enforced by the NTSB (National Transportation Safety Board).
The NTSB usually investigate accidents, such as crashes, and has been responsible for creating the rules that have turned the air travel industry into one of the safest modes of transport where in any given year there are on average zero fatal accidents. The rules are ‘written in blood,’ as the learnings came from fatal accidents in the past. Therefore, this near miss is very worrying for the aviation industry and airplane maker Boeing. (01:18)
Has the FAA been going too easy on Boeing?
In light of this near disaster, questions can be asked about whether the FAA has been strict enough with Boeing about their 737 Max airframe (after all, there were two fatal 737 Max crashes in 2019 resulting in hundreds of deaths). In the case of one giant manufacturer like Boeing, regulators tend to go easy on them. Also, where you have one large national airline, the regulator can sometimes adopt their processes as the standard, but this leaves the situation open to mistakes and errors if the regulator is not scrutinizing them enough. (05:03)
Did Boeing’s rush to redevelop the 737 lead to catastrophic problems from the start?
There was strong economic pressure on Boeing because American Airlines was about to award a large contract to Airbus for the A320 neo series planes (launched in 2010) over Boeing’s old 737 airframes launched in 1968. To win the business, Boeing had no time to develop a new plane from scratch and instead rushed out upgrades to the old airframe and released the Max in 2011. To be fair, the Max represents a large improvement over the old 737, as they added new larger and more efficient engines, a longer range, and more passenger capacity. But a key issue with the new engines appeared. Due to their size, they had to position them further forward affecting the balance of the plane itself. To compensate, they implemented MCAS software to automatically correct the angle of the plane and push its nose down (that could be pointed in that way due to the engines) in certain circumstances, but this caused the crashes in 2019 for two reasons.
- The software relied on just one sensor and when it was not working on a couple of planes, it kicked in to push down the plane’s nose unnecessarily.
- The pilots hadn’t been trained about this software and didn’t realise that this was new over the old 737s, so their confusion in the cockpit meant they didn’t have enough time to react before the planes went down.
The danger of rushing a new plane to market is apparent, and it might be argued that the regulator should also have seen that an important safety system had a lack of redundancy (the plane relied on only one sensor instead of more) and that the pilots were not trained in new software functions, and clamped down on Boeing before the disasters occurred. It also didn’t help that Boeing was secretive about mistakes and even blamed the pilots, initially, when the disasters occurred, even though it was later found to be design flaws that led to the crashes. (06:33)
Why was Boeing under such economic pressure? A look back over a few decades.
In the ’70s, ’80s, and ’90s, Boeing was one the jewels of American industry. A highly-respected airplane manufacturer where engineering and innovation were put first. Eventually around the 2000s, the CEO of McDonnell Douglas who was previously at GE under Jack Welch became Boeing CEO and he started to run Boeing in the same way as Welch had run GE … focusing on increasing profits every quarter, cost-cutting, stretching performance goals, admonishing management for not reaching them, etc. Aside from this negative culture change, Boeing started to make other mistakes, such as moving away from an engineer focus where management would often be reigned in by engineers saying that something couldn’t be done in a certain way and moving the HQ from Seattle to Chicago to put distance between the decision-makers and the engineers and factory. There was also formidable competition from Airbus to contend with, too. (10:57)
Worrying stories from angry former Boeing employees and the supply chain.
Over recent years there has been no shortage of disgruntled former Boeing employees ready to tell the press about some of the negative things happening at the company which shows how toxic the culture had become. For example, complaints about a focus on finishing the job ahead of being concerned about quality, such as continuing production when a part is missing and deciding to ‘add it in later.’ This means that the product cannot be tested properly as it is still missing some components and that could lead to all kinds of quality and safety problems.
The fuselage supplier, Spirit Aerosystems, was also in the news recently as they incentivized their workers to have fewer defects, the problem is that these were self-reported defects. This means that workers were tempted to let defects go to obtain a bonus, and are said to have ignored warnings about their products.
There are also reported incidences of Boeing staff who complained about issues they saw during their day-to-day work being sidelined or forced into early retirement to silence their criticism. (13:43)
737 Max 9 grounding post-incident.
Out of 218 737 Max 9 aircraft in service around the world, 171 were grounded and remain so since Jan 5th. That’s the majority found to have quality and reliability issues, and it’s a classic case of pay me now or pay me later regarding reliability, where Boeing may have been too lax on reliability and quality design and testing, and may now be heavily penalised if that is found to be the case by the NTSB. The issue which caused the door plug blowout was one of loose hardware, this means that screws, for example, are not tightened to within spec, rather than that they are rattling around and completely disconnected.
Here is a diagram of the door plug (source) which essentially acts as a normal piece of the plane body instead of being a door (which perhaps some configurations of the 737 may have instead):
You can see that it is meant to have bolts that secure it, and once it is in place the bolts should stop it from moving or being sucked out as happened on this flight:
If the bolts are not in place properly, or not present at all, you can see that the door plug could be more easily removed by vibration, turbulence, etc.
Alaska Airlines does not have a spotless record when it comes to safety and had a plane crash in 2000 due to poor maintenance, however, flight 1282 was a brand new plane that had only been in service for fewer than 2 months, so it would seem that maintenance was not the issue here. So, this defect on a new plane is very worrying, and the NTSB is still investigating, hence the grounding. Boeing’s CEO has apologised, but apologising and applying corrective actions so issues like this don’t reoccur are two different things and it may not be enough. (18:39)
Time for new leadership at Boeing?
Some comments in the media suggest that for Boeing to reverse its toxic culture it needs to install a new leadership team and CEO who have engineering backgrounds and understand airplane design. For a start, the CEO, Dave Calhoun’s office is in Chicago very far from the factory, and that is detrimental to improving the role of engineering. Calhoun is a trained accountant and also ex-GM and schooled in the Welch way of doing business, and he has been in control since 2020 and the culture still hasn’t changed, so can he now reverse it? There needs to be a leader whose focus is not predominantly on the financial aspect of the company, but one who will walk the factory floor and discuss what the design and engineering teams are doing and really see and add to the culture of quality and reliability to bring it back to what it once was. (22:38)
FAA to audit Boeing.
In light of this near accident, the FAA will audit Boeing, which probably means that they will go to the factory and check the production line, management, processes, etc, to get down to the root causes and be able to identify the contributing factors. Other planes may be affected if the same problematic processes were used, and the NTSB investigators will remove the wall panels and check the torque on bolts and their positions, etc, rather than leaving it up to the airlines and Boeing to self-check. (26:52)
Had warnings been properly heeded?
There had been warnings about loss of pressure in Max 9s before the incident, so it is possible that a door plug was starting to move on some planes, but was it ignored? Alaska Airlines had rerouted the plane in question to fly overland routes so it could be landed more easily in an emergency, so this suggests that someone knew that something wasn’t right. But instead of taking the plane out of service to do a thorough investigation, they kept it flying but on a safer route. The airline management and Boeing will certainly be waiting nervously for the verdicts of the audit and investigation and may need to answer tough questions because they got lucky in this case that no one was killed. (29:32)
Next steps and takeaways.
The investigation hasn’t been concluded yet, but more facts will probably come out that make either Boeing, their fuselage manufacturer, or the airline look bad. The products should also be ‘contained’ until they’re found to be safe, so that means planes grounded. A root cause analysis will be done that could find some causes. Then the NTSB will make suggestions on how incidents like this should be prevented in future.
The door plug design appeared to be sound from what we understand from researching the case, where the door plug falls into place and is so solid that it probably wouldn’t move anyway except under extreme conditions and the bolts are merely a failsafe. Since the bolts were not found, could it be a manufacturing failure and/or did they fail to inspect the door plug before using it? The NTSB will try to determine this in their report. (34:12)
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- ‘Loose hardware’ found on more Alaska Airlines 737 MAX 9 planes
- What happened after the Alaska Airlines flight took off, in 5 charts
- NTSB not sure if the bolts on blown-out door plug on Boeing MAX 9 were even attached (Video)
- Alaska Airlines Blowout Reveals Cockpit Door Vulnerability on Boeing Jet
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