Alaska Airlines B737 Max | Looks like bolts are missing | Did Boeing forgot to install them?
Link to Blancolirio KZhead channel latest video: • "Yes, We Have No Bolts...
An Alaska Airlines Boeing 737-9 MAX, registration N704AL performing flight AS-1282 from Portland,OR to Ontario,CA (USA) with 171 passengers and 6 crew, was climbing out of Portland's runway 28L when one of the cabin windows/emergency exits and its holding panel as well as parts of one un-occupied seat (seat row 26) separated from the aircraft, the passenger oxygen masks were released. The crew donned their oxygen masks, stopped the climb at about 16,000 feet, declared emergency reporting depressurization of the aircraft in a very noisy transmission, initiated an emergency descent to 10,000 feet and returned to Portland for a safe landing on runway 28L about 20 minutes after departure. No injuries are being reported. An emergency exit and whole panel at the left hand side of the aircraft was missing.
Boeing is going down hill fast. The 737max has been a disaster for them. As a frequent flyer it does not give you confidence. This accident is a great, advocate for wearing your seat belt during the flight. If the plane had been at cruising altitude, it would have been a different story. Thanks for sharing, Denys.
Bring a helmet and a parachute too.
this plug design is not new and not specific to the MAX family. it just happened to blow on a MAX a/c. Assembly problem, perhaps, but does not reflect on the MAX a/c itself.
No more worker's pride and ability to think critically.
Understatement of the century. I should be surprised but I’m not. The airline industry is money first, safety last.
@@dawhikethe culture starts at the top. Plenty of companies still make great products, it's just not the ones run by consultants worried about the next earnings call
This is why every time when I'm getting on a plane I count the engines and wings to make sure no one forgot to install one. Trust, but verify.
Stick to Airbus or any non Max Boeing.
@@blackterminal, I blame Southwest and Ryanair. Both of them buy these planes by the hundreds and insist Boeing not make any changes that alters the type certificate. The previous Boeing CEO actually expressed a desire to be done with 737 and start with a whole new clean sheet. Most people aren’t aware that he said it many times and interviews prior to the max disaster but he’s beholden to those two companies.
Hahahaaa
@@DaveP-uv1ml This falls on the FAA who is corrupt and prevented any other agency from canceling the type cert. Canada tried to stand up to them and seemingly was strong armed into not doing it. The FAA was directly involved in the coverups at boeing because they allowed boeing employees to represent the FAA with "self certification".
Also, never touch the "wings on/off" switch!
All aircraft construction has a paper (electronic) trail. Someone signed their name to the steps that installed that door plug. An inspector followed and inspected the installation and applied their stamp (nod of approval) to that document. People can be found liable for how this happened.
Really, this happened with the DC-10 cargo door issues back in the 70's.....modifications were supposed to have been made to the door mechanism but in reality they never were. The paper trail bore all the necessary signiatures and the inspector stamp was also on the documents. This all came out in the lawsuit against McDonald Douglas......this discrepacy was never explained and remains a mystery to this very day.
for so many to be lose its very strange@@jb-xc4oh
@@jb-xc4oh The Boeing 747 had a similar issue, with at least one fatal accident, and likewise murky design and maintenance issues.
And those union stooges will swear on a stack of Bibles they followed the written procedure to the letter. The union will back them up. Nothing will happen to them. At worst, all involved will get “additional training”.
Here's the thing, if the actual door was in place like it was designed to have, this wouldn't have happened. The door is designed to open inward and is larger than the opening, so this never would have happened. The plug to leave the door out, not as big. The cargo door issues for the DC-10's was on doors that opened outward, not inward like the escape doors do.
They knew that there were panels in the door that could blow out but they did NOT know that the whole door would blow open. From what I have seen, no 737 pilots knew/know that the cockpit door is actually designed to blow completely open. It sounds like this is new for the 737 Max 9 and is another example of an undocumented “feature” of the 737 Max 9. Love your work Denys!!
Yes, with the cockpit door blowing open you would be shocked also trying to get your mask on. And the loose check sheets blowing out of the plane through the hole in side of the plane.
This is incorrect. The flight deck door is designed to open during an explosive decompression event to equalize the pressure between compartments to protect the flight deck bulkhead. This is a common design on many commercial airplanes including other manufacturers. Much worse things happen when you trap air in a compartment like the flight deck during an event like this. The goal is to protect the airplane, to land safely. This is known physics on commercial aircraft and it is actually baffling how many comments and videos I've seen that have no understanding of this concept/design that is used on almost all commercial airplanes.
@@joshkeller4343 Pilots have said already that they thought the pressure panels on the door would blow out to equalize pressure, but the door would remain secure which is how it is alegedly written in the manual for the aircraft.
Also you can see the panels on the door@@MrGeneralScar
Pilots should know this, OK maybe 3rd world ones do not ! Our Pilots do !!
It's not about what broke. It's about what is missing. This is when the dancing starts.
What is missing is part of "what is broke". In this case, the aircraft was not broken, inspection process during manufacturing is BROKEN. The missing stop bolts should have been caught. Boeing is needs to double up, triple up on the sign off process. Sidetrack comparison, I once owned a 2015 Subaru Outback. Japanese designed car, manufactured in Indiana. The very first time I opened up the hood and looked at the engine compartment, I noticed three sign offs on every attachment point. Every screw and bolt head had three different sign-off stamps, all distinct colors. Whatever number of sign offs Boeing has, they need to add another
@@phxpaul what are their criteria for employees? I think they are not properly trained.
You are right some DEI hire never installed the required bolts, Another DEI hire inspector certified they were there when they weren't. The total root cause is that Boeing is hiring unqualified workers and engineers to build their planes in order to comply with DEI rules
The cockpit blow-out panels didn't blow (as everyone expected) the whole door blew open, the paperwork and everything movable was sucked out of the cockpit, so of course, the first order of business is to don oxygen masks and switch over to them on the comms panel. You can hear on the communications to ATC that they are in masks. Other operators are doing inspections even before the NTSB understood enough about the door plug system to start writing an emergency notification, and loose bolts on another part of the assembly have also been found. Juan also explains how the repeated faults in the pressurisation automation could have a link to the door blowing off.
@@Plutogalaxy My understanding is that it's the other way around. The panels were installed in the doors post 9-11 since the doors were supposed to remain closed and locked, but there would need to be a way to quickly equalize pressure in the event of a decompression such as this. Therefore the pilots and crew were expecting the panels to blow, not the entire door. From what I have heard, this specific door design is new to the Max-9 and is not mentioned clearly in the handbooks
Yes you are right, Only Wide body A/C we have have the panels !@@FoxDragon
The door opening under high pressure has been a feature since the beginning.Panels blow inwards, the door blows outward. have a 747 lock in front of me. Design is essential, and aircraft could be lost just by depressurization if they didn't open under pressure. main electrical distr. is on the bulkheads behind the pilots.@@FoxDragon
The paper and such that blew around would also blow around if a panel blew, just as if a door blew open. Consider maybe the door was not properly latched by the crew.
The paper and such that blew around would also blow around if a panel blew, just as if a door blew open. Consider maybe the door was not properly latched by the crew.
In an emergency I was taught “First fly the airplane.” In this instance I would so preoccupied with managing the situation that making an announcement would be absolute last priority. Lower the nose, declare an emergency, figure out how to manage altitude and airspeed between here and the airport, and WHICH airport, what heading. The workload would be huge and need to done quickly.
Right, I was taught: Aviate - fly the damn plane Navigate - get somewhere safe without running into the ground or another aircraft Communicate - let others know what you're doing There are proceedures we learn to deal with planes that can't be talked to or heard from - but as of yet there is nobody else responsible for the operation of a specific aircraft other than the flight crew.
And all with no emergency checklist.
@@Real_Tim_S I'm not a pilot but have heard the aviation,navigate, communicate expressed elsewhere.
The first theee emergency checklist items are: Fly the plane Fly the damn Plane God damn it fly the damn plane Rule four: Do it forget. Your plane flys due to a principle discovered by Bernoulli not Marconi. Then you navigate Finally you communicate. Pilot, USAF Aero Club trained.
Right, I'm no pilot, but would much rather pilots focus on the plane than taking time to inform people that cannot influence the outcome at all what's going on.
The other KZheadr is Juan Browne. He is a commercial pilot and does an excellent job of explaining the circumstances of aircraft incidents and accidents.
Misleading title. "Bolts not found yet", not bolts are "missing". Broken or loose bolts would have departed the aircraft and probably never found. When they examine the bolt holes they will be able to determine if there where bolts installed. Having no bolts installed might explain this but that would be an extreme assembly failure and mean that any part on the plane could be missing.
I think the consensus is Boeing never told anyone that the door is designed to open in a rapid decompression. I am a flight attendant and have been 737 qualified for 39 years. From the originally designed door to the hardened door, we have always been told the door has blow-out panels to equalize pressure. Nothing further. Side note, I'm not an engineer, but the 757 door has the same appearance, just taller. So my question to Boeing would be, does the 757 door do the same thing?
It wasn't a door ,it was a door plug. A cheaper and lighter replacement for a door that wasn't used in that configuration.
Denys, you continually amaze me. I wonder when you ever take time to sleep or go out and have any fun between this and your other channel. I am very impressed with you, keep up the good work, but take a break once in a while for your own health.
Something seriously amiss with Boeings quality control and inspection procedures here.
Yeah, cause they got rid of them or slowly getting rid of them
Check this KZhead video. 'Not a good thing': Boeing whistleblower reacts to Alaska Airlines mid-flight incident At 8.53 into the video, he is saying that the company has been removing quality control inspections. More than likely this is contributing to the 'sloppy' workmanship going out the door. Some airlines are going down this road by removing Independent Quality Control Inspectors , (those individuals independent from production). So QC is being 'watered down'.
@@John-nc4blyes, my experience back when I was working in a cement manufacturing company, was like this. Production was not responsible for quality, that was the work of the pesky, and completely unreasonable, quality control guys!
yeah, considering lose bolts on other aircraft and not just the pins but apparently the ones that attach the guide fitting to the door, and in december boing asked 737 max operators to inspect specific tie rods that control rudder movement bc a bolt with a missing nut was found on a mechanism in the rudder control linkage during a routine inspection of an airline. they also found a loose bolt on an undelivered aircraft. this is mentioned among other things in " "Yes, We Have No Bolts" 9 Jan 737 Max-9 Update " by blancolirio on youtube posted 5sec before denys showed the channel 😅
@@ismailnyeyusof3520 Fuselages are produced by Spirit for Boeing. Still acceptance QC
Denys, from my understanding, most crews are aware there are panels on the door that will blow out during explosive decompression. The problem here is the entire door blew open and nobody has been told that from Boeing. Another omission from Boeing that we are only finding out about from Boeing post incident! What else don't we know? Unfortunately this rings similarly to the whole MCAS problem. Juan brown on blancolirio (777 pilot) has expressed exactly this opinion too, panels should blow out, but the entire door?! Sounds like a security risk too, terrorists could utilize this gap in the system to enter the cockpit in some kind of scenario.
The same comment that I was going to make. So the question would be: was the door really supposed to be blown open or not? If so why is this not listed in the Boeing manuals? All 737 pilots are aware of the panels, so there is a mistake somewhere.
I don’t understand your panel vs door question. The pilots are trained for what to do in an emergency decompression, clearly. But they aren’t expecting either a panel or a door to blow. They aren’t expecting any uncommanded decompression. Most pilots will never experience this in their careers.
What kind of scenario can the terrorist enter? Would love to know
@@mattym8 Actually, in a case like this, they would except the panels in the door to open, not for the entire door to open. It's a big difference.
As a former 737 NG pilot I would expect the pressure equalization panels on the door to vent but not for the entire door to blow open. Sounds like the latch or door was defective if that's what happened.
Thanks for giving a shoutout to Blancolirio -- everytime there is something like this I watch the news, but I am really only waiting for Blancolirio's videos before I make any kind of opinion about it. Anyone who is truly an aviation aficianado should subscribe. He is indispensable for his amazing knowledge and reasoned calm analysis.
I second that
Juan Browne (blancolirio) and Ward Carroll (the latter for military and geopolitical aspects) are my go-to sources for aviation news. While others such as Dan Gryder, Mike Patey, Mentour Pilot and many others offer unique and fascinating perspectives, sometimes needing a dose of salt, Juan and Ward are the most trustworthy, knowledgeable, balanced and humane reporters, commentators and/or interviewers today.
One has to think about the pilots right at the time the depressurisation happened. The Cockpit door blew open and hit lav door, all the checklists and paper in the cockpit blew out, at the same instant additioanl warnings/alarms would have been going off. Memory items would have the pilots donning thier oxygen masks and restoring cockpit communications, and then stop the climb and start decending before radioing ATC to declare an emergency. So with all that in mind, the pilots did a crazy good job at staying focused, and stopping the ascent at 16000 before starting to decend. Kudos to the pilots for such an amazing job, the whole door blowing open when said design action was not even in the aircraft manual would have caught them by surprise initially. ATC I feel gets s small pass because of the pilots having to talk through masks also with the background noise it could be hard to hear, but I think ATC could have done better to convey information between the controllers. Boeing gets yet another gigantic F - FAIL for just being Boeing it seems these days.
Avherald reported that the headset of the FO had been blown off, too. So a lot going on
Boeing does get a gigantic fail, but the problem is actually more complicated than Boeing. It comes back to Southwest and Ryanair. They buy these planes by the hundreds more than anyone else. And they resist any design changes or proposals that would alter the types certificate as it is costly to their airline business as they are business is built around buying as many of these as cheaply as they can in one type. This is why they will not buy Airbus aircraft because Airbus cannot sell them a plane at the cost of 737, it doesn’t matter how efficient it is. Efficiency and flyby wire do not bring sufficient benefits to offset the higher acquisition price of the more capable aircraft. Most people don’t realize that the previous Boeing CEO who presided over the max disaster, who was an engineer, not an accountant, like is often erroneously reported, had given several interviews prior to the max disaster, expressing his desire to be done building 737 and move onto a clean sheet redesign.
@StevenStrain-uv1ml Yeah, i can understand that. But Boeing shouldn't compromise safety for profits. There are not many manufacturers out there building jets the size of 737. I dont know all of them, i think maybe only Bombardier other than Airbus and Boeing, I know there is probably more, but i am not familiar. If Airbus is too expensive for aircraft plus retraining, and Boeing had stuck to needing a new type and doing it properly, making it more expensive, what choice do the airlines have? Instead, Boeing chose to cut corners (with the 737 max initially with MCAS) just to be able to type rate it the same as a normal 737. Doing so meant they could market it as not needing significant training, which translates to less cost. To do this, Boeing conveniently started leaving things out of the manual. And that's just reckless in my mind. You have to wonder after MCAS and now this cockpit door design. What else are they not printing in their manuals?
@@DaveP-uv1ml It all comes down to manufacturing defects on a 3 month old aircraft. Aircrafts being built by DEI hires
Ehh, the copilot sounded freaked out and unstable. Not a confidence-builder
From my understanding the cockpit door completely opened and not just the blow out panels I think that's what the pilots were confused of at least that's what I took from blancolirios video (777 pilot)
Thank you for the update, Captain Denys. I appreciate your insight.
When the pressurization warning blasts out, don't bother trying to correct the problem, just change the route! They were GD lucky it didn't happen at 35k altitude aye? 😮
They stopped their ascent and descended. Were your ears plugged with wax when that was clearly stated? They were still ascending through 14,800 ft when the event occured, stopped their ascent quickly at 16K, then descended quickly back to 10K. Also, as an aside, you don't stop breathing oxygen after 10K feet. Pilots have survived well above 20K feet without pressurization, but the precaution at 10K feet is where degradation of oxygen intake is sufficient to the point that prolonged exposure becomes an issue. The higher you go above 10K, the quicker the degradation. It is NOT instantaneous. I swear, the ignorance of the average YT viewer is staggering.
@@kurtfrancis4621I don't quite see what ignorance you are commenting on. The poster has simply expressed his feelings about how lucky they were that it did not happen at their cruising altitude, where everything might have been a little more complicated
If nothing else they would have freezed
The discussion about the plug assembly and how it works (around 15:20), and that it had been in use for decades, reminds me of a documentary I saw years ago about railway accidents. If something can only occur once in a million times, do it a million times and it will. Thanks for this post and keep them coming.
Any safety engineer will tell you that a one in a million failure that causes a fatality is a totally unnacceptable outcome.
This is true. I meant the comment as support for the engineers, pilots and crew who go above and beyond to make sure these things don't happen. One of the best TV series I watched was about air crashes (called Blackbox, air crash investigation, or May Day - anyone else remember ????) which had as its first episode an explanation about the De Havilland Comet failing because of metal fatigue around the 'square' framed windows. Another good watch is the James Stewart movie, 'No Highway in the Sky' about little understood metal fatigue in aircraft. In context. I think the 'one in a million' includes things we have yet to fully understand and engineers should be supported in their efforts in dealing with often what is unknown. Regards and thanks for your comment, Jeff @@jb-xc4oh
I’m pretty skeptical about the statistics of one in 1 million or one and 100 catastrophe occurrences. They are dependent on so many factors including the big one which is saving money by skipping installation procedures that throw it throw the numbers off to a meaningless value
You misunderstand, its not the statistics that matter, from a safety engineering point of view any failure that causes a fatality is unnacceptable. That is the design philosophy. In Sept 2021 there was a cable car runaway in Italy that killed 14 people. The car needed maintenance because the brakes were dragging on the main cable. Due to high demand and time constraints and management pressure the cable car mechanic disabled the entire braking system on the cable car to keep it in operation. The emergency braking system is two separate reduntant fail safe braking systems to hold the car in place if the pull cable were ever to break.Two days later the pull cable snapped and the car accelerated down the main cable, hit a pylon and plunged to the ground killing 14 of the 15 people on board. When confronted the cable car mechanic stated that he didn't intend any harm and in twenty years on the job he had never seen a pull cable break and that it was a one in a million failure he could never anticipate. One of the safety inspectors got so infuriated by that statement that he called the cable car mechanic a fucking lunatic. The mechanic and some management personnel were charged with criminal negligence. @@RiDankulous
"Do it a million times and it will": actually, it can happen at any time. It's just that on average it may happen once in a million times, but that once is equally probable every time (unless it's a steady wear and tear issue, and then components have specified lifetimes before replacement).
This will have serious consequences, when anyone chooses their seat preference it’s definitely not going to be next to a door plug. ( I didn’t know existed). This was a knife edge situation where someone could have been sucked out, very lucky result for Boeing.
First of all, most aircrafts dont have door plugs, they have actual doors with slide rafts so its very dependant on aircraft type. Second, pax are too stupid to know which row is where and i highly doubt people will be avoiding more leg space areas in the future. Thats not how aviation works, you dont just expect from now till end of times that doors will be exploding left and right. This could be the only incident in the next 50 years. Last time I checked Malaysian Airlines are very succesfull even after 2 deadly crashes in one year. People didnt just stop travelling with that airline because an accident is just that, an accident. It cant be a recurring problem.
@@WickedlNl It's got much in common with the MD DC-10 cargo hold issue 20 years ago. The failure mode was different (that one was a bent locking bar), but closure from outboard was the same.
@@JelMain Not even close!
I think the airlines should provide a parachute for a person that sits in that seat.
@@RiDankulous At 30 000', that's cruelty. They'd asphyxiate.
No communication because they couldn't hear over wind noise, as reported by woman 3 rows ahead of hole. She found out from the young man moved after incident. They had to communicate by phone text. Pilots couldn't hear.
After over 50 years of professional flying I remember what I was told by another senior pilot. He said there is no aircraft built today or in the future, no matter how safe or automated, that cannot kill you and if given the opportunity, won't try. The idea is, let's do everything possible to eliminate the opportunity for the aircraft to try. Good will come from this.
Mr. Pilot Blog, wonderful delivery of the facts of the rather mysterious case and event of the dangers of flying, generally, being shown by yourself. Thank you for your good teaching to Day!
I had a panel on the belly between the main gear not be completely attached after MX, the type of fittings used were impossible to see on the walk around. When we started our decent into Bali the angle of attack allowed the front (unattached) portion of the panel to wobble or vibrate. We could feel it and the flight attendants heard and felt it too. If that panel had departed we might have had impact with that panel on our stab. Same with the door, if it had impacted the stab or tail section it could have been curtains.
The confusion of the flight crew wasn't the blowout panels in the cockpit door, it was the whole door flying open, which is not in the manual according to blancolirio (a pilot KZheadr). The manual says the panels handle the pressure, but the NTSB just said the whole door is designed to fly open, which is not in the manual.
Is it possible that the plug on the left side of the aircraft is normally left in the open position during the aircraft build? One may do this to give easy access to the interior of the aircraft in this section for cables giving power to the power tools and even more so providing quick & easy access to the workforce working on the interior build. Perhaps the finished interior panels were fitted covering what would be the bolt locations. This would bring about the situation that this left side door plug never ever had its 4 locking bolts fitted & if they were fitted they were removed to gain access as I have described.
@18:00 - This is all about Risk Management. For example, if an interior item in the plane is secured by six bolts and one bolt missing, this will probably not result in a catastrophic failure. The airframe fuselage and the door plug are life and death components and failure to properly install can result in a catastrophic failure of the aircraft.. I will guarantee you in the written and established assembly process, there is a separation-of-duty function where a person separate of the initial installer is tasked to verify the proper securing of the door plug and the torquing of the bolts BEFORE interior panels are put in-place (with signed off checklist). Boeing knows what happen for the plane assembly and has the documents (as these things are audited) internally and externally. The reason the planes are still grounded is likely because a pattern of not following the assembly process has been identified. I think it will all be revealed shortly as the Boeing CEO is hinting the workers must do better and the whistleblowers are saying we tried to warn you but Boeing retaliated against us.
Keep up great work Denys!
The 12 stop fittings/pads take all the pressure of the plug trying to push outward against the frame during pressurization differentials (flight). The 4 locking bolts ONLY serve to prevent vertical movement of the plug roller track off of the upper guide roller (at the top of the plug) and the plug hinge guide fitting off of the lower hinge bracket (at the bottom of the plug). The plug must be able to travel vertically at these points so the the stop fittings on the plug can move vertically enough to clear the stop pads on the frame and release the door. My uneducated opinion is that it is EXTREMLY likely there were NO locking bolts in place at all. Why? Because there is very little to no shearing pressure on the bolts by design - 4 independent bolts would all have to sheared off and under low shearing pressure. If they were installed "improperly", for instance castle nuts only hand tight with no locking pin then the likelihood that they all could have spun loose several rotations each and then all 4 bolts slide out out position is just not realistic. Simply 1 bolt in place would prevent vertical movement of the plug. I'm going to venture that somebody at the Boeing factory or somewhere else didn't install the bolts to secure the plug from moving vertically. More than likely everything was basically mechanically held in place by friction and the weight of the plug and with primary force being outward and not upward during pressurization all was good for some number of flights until just the right combination of pressure differential and jarring of the aircraft knocked the plug vertically enough that the top protruded up and out and was caught by passing air flowing along the exterior hull which violently ripped the plug out causing fracturing of the guide rollers tracks on the plug. In summary NO BOLTS at all installed.
Excellent explanation! I just hope Boeing remember to install the bolts that hold the wings on.
Even if just one bolt were installed the door plug should not have been able to move upward. More than likely none of the four bolts had even been installed.
It’s the bracket bolts that are found loose. There’s 1 1/2 inches of upward clearance that allows the door to go out normally. There is a way Boeing (has a option)to have a regular emergency exit door that stays covered and uncommissioned
For that door open, those bolts have to be missing entirely.
How many hands did the jet go before getting to the pilots/owners...? FAA drawing...seem off like for an active escape hatch versus a plug...
The FAA time line report shows, that the aircraft was on auto-pilot for takeoff and climb (Normal procedure), and that is why it was still climbing. Then they set the 'target' altitude in the AP, and the aircraft began it's descent.
Great analysis Denys. Thank you for the clear explanations
I’m glad the crew didn’t panic. Everyone was safe.
A couple decades ago, a group of psychologists got permission from the FAA to review the cockpit voice recorders of aircraft that crashed. They were trying to find out of the flight crews panicked during the crash. What they found was that the amount of profanity increased, but no crews panicked. They were still going through their checklists and still trying to fly the aircraft on impact.
If you're driving down the road in your car, and a tire blows, you don't panic, let go of the wheel and start crying and screaming...you try to avoid objects and get to a stop.
Nice explanation keep up the good work
Great to see you doing videos on this channels
so cool you mentioned Blancolirio channel!
.. and 'john' lol
Denis thanks for the fairly full NTSB press conference sped up and your personal comments. Just amazing it takes someone in Ukraine to give the best coverage of an incident happening in the USA.
He ran away to Switzerland I believe and will likely never go back to Ukraine.
A good reason not one more penny of American taxpayers money should be given to corrupt ukraine, a nation of draft dodgers that cannot win. Lost cause.
Interesting how the iPhone survived the fall but when you knock one off the kitchen table and it lands on a tile floor it shatters.
I agree with your video recommendation at the end. Very detailed and good information in that guy's videos.
Denys thanks for your pilots perspective. It was very helpful. Eventually the cause will be narrowed to a manufacturing or an operational issue or some combination of both. If people could keep their emotions in check until we have some conclusions that would be be more supportive. Thanks again.
To me, having a cockpit door designed to blow open during decompression, is a safety Hazzard that could allow the wrong element into the cockpit.
You have to remember that the pressurization light was an intermittent problem. They may have got no indications of a pressure issue on the ground. It may have not even leaked until the airframe was under the strain and stress of flight. They probably either thought they had fixed it or ran tests and didn’t find any sign of the problem so may have done something like replace the controller even though it passed tests just because they couldn’t find a problem on the ground. Alaska took it off ETOPS not because it had a current problem, but because it had recurrent issues in a short time period. They would not have put it back on ETOPS even if they found the problem with the door and fixed that. It was just protocol in case an plane presented another problem in a short timeframe as it already had multiple problems in a short timeframe. Again, they may have even thought the issues were fixed before this flight but it was still off ETOPS because of the rate at witch minor issues were occurring. How do you fix a plane if you already think you fixed it and can’t find anymore problems? The plane didn’t have any hard landings reported and you’re not looking for loose bolts because something like that causing pressure issues has never happened before. Those types of things are supposed to be triple checked and a nonfactor when a mechanic is checking a plane where no one has loosened any airframe bolts during maintenance. I don’t think that Alaska flying passengers on the plane even though it was off of ETOPS was a problem in any way. If they thought there was a chance of severe life threatening problems they wouldn’t fly it at all. They just didn’t want to have a small bug in the middle of nowhere with none of their own engineers around to look at it to confirm it’s a small problem, like a pressure sensor on the fritz, that they can OK on the ground for the pilots to take it somewhere with one of the redundant systems inoperable. It would cost a lot and take time if that sort of minor thing happened where they had no employees or facilities.
Finger trouble there
I suspect that since the 737 Max still retains a lot of the design features as the original 737. IOW: compared to other current aircraft, it doesn't rely as much upon "fly by wire." If there were air leaks various systems that maintain cabin pressure in a more intense "fly by wire" system, there would be records of attempts to cope and estimates of the leaks would be available. Would that have given the maintenance folks sufficient information to suspect the plug door? Who knows?
From the NTSB press conference, they believe that the controller itself thought it was faulty, not that it was detecting pressurization issues. They don't see it as at all related to the accident, but they did ask Boeing to send an expert over to analyze the controller. The system has two automated controllers, and the pilots can manually command the outflow position if both fail. This similar to the strategy used by the failed sensor in the MAX crashes, at least to the point that the primary controller alternates on every flight, but perhaps doesn't require changing these pilot flying to use the secondary air pressure controller during flight.
@@johnhaller5851 -- OK. It's just a "coincidence" that there are problems with the cabin air pressure system(s) followed by a failure of the door maintaining the pressure. Perhaps. It would be interesting to see what Boeing says after they completely check out the pressure maintenance systems.
It was the exact problem the whistleblower had described in exquisite detail, just in a specific example
Thank you Captain, very educational and behind the scene!👍
Thanks Denys, that explained a lot.
There was no cockpit voice recorder as it was overwritten. They forgot to pull the circuit breakers after they had landed which would have stopped the recording to the Black Box. As to the cockpit door it is now designed to blow out. Whereas before it had blow out panels for pressure equalisation . Nobody had informed the pilots of the change in procedure.
Flight recorders go for 2 hours or so, from what i read it was a compamise with the unions because pilots didnt want every second to be recorded during flights... they only wanted the last hours as it would be used for accident investigation.
@@williamhaynes7089 As I understand it the circuit breakers are meant to be pulled stopping power to the Black Box. Thus the last 2 hours are kept. In a catastrophic accident all power would be lost and thus doesn’t matter. In this case the circuit breaker should have been pulled thus cutting power and keeping a record of the accident. As they didn’t, probably making sure the passenger’s were safe, the internal power of the aircraft kept the recorder going and the two hour period was written over!
@@marcuswardle3180 - RIGHT! but with current tech.. why limit it to 2 hours?
Regarding the human factor: I understood the journalist's question to be about something far more concrete. In recent years there have been reports of Boeing sacking conscientious workers who are trying to prevent incidents such as this one. This new company ethos also affects other components, and therefore similar incidents are likely to happen with other, potentially even more critical components, as well. I won't be too surprised if next time an engine falls off.
Pilots said, like you indicated, that they knew that panels were supposed to blow out but it sounds like the actual entire door blew open. That's what every pilot said was not in Boeings manual.
Great for pointing out Juan Browne‘s work! He is a great guy! 👍
Seems highly unlikely that the bolts were completely missing. More likely, the bolts were installed by finger, and then they forgot to torque them with a wrench. That is an extremely common error. Considering Boeing just cut a huge amount of inspectors, I guess this isn't surprising. So the loose bolts, took some time to completely rattle out. The plane was only a couple months old, so that sounds about right. The pressure warnings probably started when it was down to 1 bolt remaining, and the door was shifting around in the opening.
When an aircraft leaves the Boeing main production line, the interior of the cabin area is just a hollow shell. Contractors for the airline than add all the furnishings to match the airlines specifications. Seats, lockers, carpet and galley equipment are bulky and heavy. This leaves me wondering whether in order to make access easier and avoid damage, the door had been removed and refitted without the alignment jigs and correct tools to torque the nuts. If the nuts were stretched to specification originally, they would not be reusable. Binning fixings and replacing with new, is standard procedure in most airframe maintenance. To fully understand the reasons, you need to understand the first and second modulus of elasticity laws. Engineers use them all the time, but shopfitters are mostly clueless.
@@wilsjane I'm an engineer and do understand these things. I doubt those are highly stressed bolts, so they are probably reusable. A lock washer or drop of Loctite would solve the problem. I have no idea if a contractor removes that door. If they do, I'd be certain there is a very specific procedure they need to follow. I rather doubt they do remove it, since there are several other doors available, and the few steps of moving the equipment isn't worth the extra effort and red tape. Even though that work is done by a contractor, they also need to follow procedures. And they may actually be even more tightly controlled by Boeing is. The fact that this is the first time this has happened in billions of flights, tells me something very stupid happened. (i.e. Somebody forgot to tighten the bolts)
These retainer bolts are under low tension, since high tension would damage the upper brackets and lower fittings. This means that they cannot be torqued to a point that would prevent them from becoming loose under vibration, and rely sole on the cotter pin retainers on the nuts. The door could have sat in place without any bolts for a while due to its design, and slowly worked itself loose to the point it blew out.
@@GoCoyote I did not know that. So seems like maybe they forgot the cotter pins.
@@paulgallagher2937 They could have even forgot the bolts altogether, as the door plug would still have stayed in place until the exact combination of vibration and pressure differential allowed it to ride up past the bracket and retaining pads into the open position.
Wow this is shocking and still proves Boeing has not changed their shocking ways.
Well, when they moved the main factory down south thats when the problems started. The corporate rot set in after the MD merger. The Seattle 737s NG were near impeccably assembled.
I bet they saved a whole dollar perr aircraft on the bolts. totally worth it.
@@EdgyNumber1 you know what you’re right when they had everything in House in Everett Seattle there was barely any problems except for when they had the dream liner built because they branched out and want everyone to be a part of that so you’re completely right
@@SuperAirplanemaster 737s are built in Renton. The South Carolina plant only does final assembly on 787s. Quality dropped when management moved to Chicago and profit, not quality became the top-down enforced "culture."
@@EdgyNumber1you dumb? The max is assembled in Washington… The fuselage arrives there without plugs for interior installation. We assemble 787 at Boeing South Carolina and havent had any blowouts.Boeing Wichita assembles the fuselage but is shipped without doors and plugs. But, GG precious union labor in Washington.
It's interesting on what they have been reporting of the operation of the Flight Deck Door. I'm not sure what the system description states in the AFM (Aircraft Flight Manual), however as per the Boeing Aircraft Maintenance Manual Part I - SDS (System Description) for the 737-7/8/8200/9/10, ATA Chapter 52-51-00-005 states: "Control Cabin Door Decompression Panels The door has blowout panels that will open if there is a rapid decompression in the flight compartment. A rapid decompression will cause a sudden change in pressure between the flight compartment and the passenger cabin compartment. For each decompression panel, one edge is attached to the flight compartment door assembly with retractable bolts, while the other edge is secured to the door assembly with a mechanical pressure release latch. The mechanical latches are set to release under a pre-determined pressure, which will cause the decompression panels to open into the flight compartment. In the case of a rapid decompression in the cabin compartment, the door is able to withstand the pressure difference due to the small area of the flight compartment." The decompression panels (there are 2 of them) are hinged to allow the panels to fold inwards to the Flight Deck if the Flight Deck looses pressurization. The panels remain closed against the frame of the reinforced Flight Deck Door in the event of a Cabin depressurization. The Flight Deck Door latch should be strong enough to hold the door closed when the electronic Flight Deck Door lock is engaged in either the Auto mode or Deny mode on the FLT DK Door control panel.
Thanks Denys ❤✈!!!!! Great work, much appreciated!!!!! Wish you a peaceful day 🇳🇱🇺🇦!!!!!! Xx.................
All I know is the bolts were secured with castle nuts and then a cotter pin....if installed correctly it would e unlikely to self disassemble
The "lock-bolt" uses a castellated nut and pin but the bracket (it locks into) is mounted to the airframe with hex-head caps (unwired).
@@CraftAeroOne would hope that those hex heads would’ve been screwing into self-locking nuts. I also don’t see how those loose hex heads would’ve allowed the door to translate vertically since there are a total of 4 bolts that prevent that motion. My bet is that those bolts (with the castle nuts) were never installed.
@@nhatmanduI seen on another thread that the 4 bolts were missing, if that’s the case then if jolting from turbulence could indeed unseat the door plug.
@@rbwoodwork1890The NTSB mentioned that they haven’t found those bolts but haven’t confirmed whether they were there or not yet. I suspect that they weren’t. Like all four of them, not just 1, 2, or even 3.
@@nhatmanduOr nuts or cotter pins
Denys, the cockpit door, as a whole, opened. THAT's what they didn't know. They thought the same as you, that the blowout panels would equalize the pressure. The loss of the QRH sheets would seem to be the real problem there. What use is an emergency checklist if it is sitting in seat 8D? Cockpit noise second. Cockpit security last.
Blowout panel will also send paperwork flying. Same result. Suggest they secure the paperwork before take off.
@@davidgenie-ci5zl It would be even better if you could just say, “Siri, pull up the Explosive Decompression QRH”. The iPads are already there.
I'm sure everyone is aware of the panels which blow out, the whole door opened which others pilots have also said they were not aware of. Hardly anyone is aware of that
Great job reporting thanks!
The air pressure drop was very significant ; around 3 PSI. This means the difference in pressure between the cockpit and cabin was around 2000 square inches X 3 PSI ( the approximate area of the cockpit door ), or about 3 tonnes of force on the cockpit door.
Correct, the door is designed to open into the PAX cabin at these pressures to stop structural damage. Aircraft structure is not in the QRH. too much irrelivant data.
@@rafbarkway5280 many people don't realise that most structures collapse entirely at around 5 to 7 PSI over pressure, even the most hardened facilities cannot withstand more than 30 PSI, and tbh, no people can either.
The complete door opened not just the blow out panels.
Agreed, this guy kinda put it in the arrogant way implying pilots should've known when other pilots have already said very few know that the whole door can blow out which isn't even in the manual. The panels everyone knows about
This is what "Cost, Schedule, & Shareholder Value above Quality and Safety" produces!
Thank you for speeding up the dialog.
This sort of thing happens where a part is removed for maintenance and then not replaced. They haven’t been able to stop this human error no matter what they do over the decades. We really need a better system. Maybe you 3d scan the area and a computer compares that to the ideal model and verifies if everything was put back together correctly. I can think of a few accidents that were this issue.
Merely painting the internals of the bolt holes with a bright orange colour; maybe with a black light optimization for additional integrity verification would give an immediate visual clue that a necessary bolt is not fitted. Incorporation of additional spring-loaded espagnolette locks that need the extra step manual over ride would be potentially fool-proof insurance. The plug is, after all, not designed to detach. Bad design yet again; employ better intellects not Titan-minded ones.
I worked as a kid in BAe aerospace. The most feared department was the QA department - a QA engineer had more authority than the site's manufacturing director - managers lived in constant fear of these people. To sign-off on a door assembly like this with no bolts means a total failure of all QA controls at the plant. NTSB/FAA are asleep.
SOP during a decompression incident is to first set auto to 10000 and then to land. This is their training. What communication needed to take place between the cabin crew and the cockpit, which had a priority on their hands
The whole cockpit door evidentially blew open per design that was not mentioned in the manual, not just the panels
With all the tech nowdays. How hard it would be to photograph of these critical parts at the factory after installation. And in maintenance too.
It wouldn’t be but I bet some bean counter said it was too costly and would impact schedule.
@@nhatmanduyou hit the nail on the head!
That's a good idea, but it wouldn't reveal if the bolts were torqued correctly or not.
@@chrisantoniou4366 in some car companies they have torque wrench that records all the data to cloud. Then they put paint marks to every bolt that is torqued.
We cant take pictures of anything.
"Bolts missing " It is more like someone went to take his lunch and when he came back, he forgot where he left off.
Generally, there are written, or electronic, work instructions with a buyoff for each step. The work instruction should tell them where they left off.
Last year, I watched a story about a similar incident. A flight from Hawaii, had a section break off, at over 30,000, and a passenger was sitting next to it. His parents had to go to the U.S. mainland, and investigated themselves. After traveling around the country, going to various technical businesses, they discovered that the bolts, were not large enough, from what I recall. I don't know if it was the same aircraft. But the message they gave, was that it is "collateral damage". It was not possible to inspect all aircraft, and make them in perfect flying condition.
Having done QC from time to time, I can honestly say I've never signed of my own work. Also I do love to drive a convertible, but not at 20,000 ft.
Boeing is a perfect example of too big to fail and profit first safely last. When corporations like these preaches EBITA, productivity levels, shareholders first to guys on the shop floor. This is the terrifying result we get.
I’m just a passenger but I follow Aviation a little bit. The way I see it as a passenger, it is possible to avoid these planes I looking at the equipment when you select your flight. It is absolutely something I will do. I totally trust the older 737s too.
It's worse. Safery was no longer a Bonus criteria. DEI advancement was.
I know where the bolts are! The bolts are in the parts bin, marked, “Bolt’s for Plug Door,” on a shelf where the plane was manufactured.
Thank you for your video. Safe sky's.
Missing your Pilot Blogs! Hopefully you will make a few more when you have time between war updates.
Boeing needs to hire some airbus mechanics to add just some "little bolts''
Boeing detractors need to take some time to learn about Airbus emergencies.
@@GH-oi2jfWhy don't you detail them here?
Thank you, Denys, for the update. Slava Ukraini! 🇨🇿 🇺🇦 🇦🇺
You are awesome Denise this is bizarre i miss the old 707 Notice the pilots cant talk or not aloud too.
Thanks Denys. I have been following your Ukrainian updates everyday. Im glad to see you covering this incident.
If you look closely under the left rear it probably says "Made in China".
Just like your iPhone?
Denis, the whole cockpit door blew open, not just the panel. The checklists were torn out of t heir hands and their headsets were torn off.
Thanks Denys.
I will NEVER EVER fly on Alaska again. That plane was supposed to be grounded....they filled it full of people and flew it anyways...ALL fingers should be pointing to Alaska FIRST...
Actually the manufacturer issues something called an MEL (minimum equipment checklist) this comes directly from Boeing and gives the carrier guidance on what they can and can't take off with. Alaska were perfectly within Boeings guidelines which is more of the problem here. All evidence points to Boeing at this stage, but we will see in the final report.
Humm, seems to be a diversity news conference, the NTSB has one of every race, age, and gender but no Asians?
Poor girl on the right. She was not allowed to speak. Made me wonder why she was even there.
The United States is a diverse nation. All of the people appearing on behalf of the NTSB work for the NTSB. The gentleman on the left is the Chief Investigator. He has worked for the NTSB for a quarter century.
Why didn't he speak if he leader of the team?
@@denault3985 he did at one point during the question portion. Unlike the other girl who was never asked anything nor spoke a single word.
"Boeing has an accountant as their CEO while Airbus has a test flight engineer as their CEO. I think that speaks volumes about each company."
Love your PA imitation!
Hall monitors every third seat connected to an enhance sensor system with dual redundant common systems. This might cut passenger payload in half but everyone needs to feel safe.
Thank you very much for the Debrief and also the Recommendation of Juan Browne = Blancolirio!🙂👍
This post is speculation, but several airlines have now reported loose bolts on similar door plugs on these aircraft. There may be an issue with those bolts having sufficient locking mechanisms (thread locker, lock washers, locking or pinned nuts) to prevent loosening and fall out of these bolts. If the bolts fell out, the roller pins would not be held down, and the door plug could slip up on a bump or something then the stage would be set for the plug to blow out. Finding any of the bolt hardware, washers, nuts, bolts, etc. would be a potential indicator of this, though they may very well have been swept out of the aircraft in the blowout.
The door panels that you reference are designed to blow _in_ when the cockpit depressurizes but the cabin is at normal pressure. What happened here is that the door blew _out_ when the cabin depressurized with the cockpit at normal pressure. That was and is unexpected. I would go a bit further and argue that it's a security vulnerability, because in the wake of this incident every hijacker will know exactly how to force the cockpit door open. BTW and in re: 11:17, I always thought that ETOPS stood for Engine Turns Or Passengers Swim...
For the past five years or so I make a sigh of relief when I am flying Airbus. Boeing gotta put their act together
That’s a very diverse briefing.
Denys *the cockpit door opened as a whole, the panels did not detach on decompression* I believe I saw that on the Blancolirio (Juan Brown) channel.
Hi Dennis. This is a reaction-video. Where is the link to the original one?
Hi Denys, I look forward to your content everyday. I’m not a pilot but I love flying and aviation in general. I also watch Juan’s content as well, I don’t understand a lot of the technical aspects of aviation but Juan makes the information he speaks about very ‘listenable’ for people of all levels of aviation awareness. 🇺🇦🇦🇺
It’s a testament to the idea of redundancy, ingenuity and the level of engineering and design that the door plug remained in place, WITHOUT any bolts, as long as it did, even more so considering how many pressure/de pressure cycles it went through in its short life.
The key mantra pilots are trained to do in an emergency is this: 1. Aviate (Fly the plane) 2. Navigate (Don't run into a mountain, etc.) 3. THEN Communicate.
At the time, the pilots had no guarantee that more pieces were going to fall off the airplane. Therefore, they were absolutely correct in prioritizing getting the plane onto the ground as soon as possible, and not worrying too much about communicating while they did that.
Regarding missing bolts, anticipate an AI driven robotic imagining system that will be able to not only compare individual components against blueprint, but also verify if components are in correct position or missing. Tork specification should also be verifiable.
That seems way overboard! All that is needed is a quality assurance check, which was probably eliminated to cut costs and reduce production times. Re: torque marking, in automotive assembly a simple paint mark is used to show if a bolt has been torqued.
The Journalist was just looking for something to sensationalise for his headline ,ad the NTSB lady did a great job of shutting that question down - Great job👍
Bolts were used as part of a locking device assembly. Not as hold downs. They were not required to be treated as level 1 material control
7:05, it seems that they are talking about the entire door opening up, not door panels on the door. If so, then it would seem like you are also not aware of this feature. The referenced Blancolirio channel mentions this too.
It might have been a very different story if the door had blown out at 28, 000 ft and the seats nearest the door had been occupied.