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?
A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.
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.
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.
[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.
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.
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.
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.
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".
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.
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?
"(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."
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.
Are we great again yet?
https://www.transportation.gov/briefing-room/national-fact-s...
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.
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...
> 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...
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.
"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...
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.
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.
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).
> dDevelop guidance for Federal Aviation Administration managers and inspectors
> <strike>P</strike>rovide Federal Aviation Administration managers
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.
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?
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
Boeing is dead.
supportengineer•4h ago
heywoods•3h ago
kayfox•2h ago
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.
umeshunni•2h ago
https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-a...
The 737 assembly happens in Renton, WA
bboygravity•3h ago
tptacek•3h ago
user3939382•3h ago
HeyLaughingBoy•3h ago
If you have evidence to the contrary, by all means let us know.
tptacek•2h ago
(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).
rcxdude•3h ago
RandomBacon•3h ago
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.
BolexNOLA•3h ago
CGMthrowaway•3h ago
MrZongle2•3h ago
kevin_thibedeau•3h ago
user3939382•3h ago
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.
vel0city•3h ago
But hey I guess they did some kind of mind control on him.
duk3luk3•3h ago
That statement is so weak it's better at inflaming the conspiracy theory than quelling it.
vel0city•2h ago
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?
BolexNOLA•31m ago
That one word is doing a lot of heavy lifting. Y’all feel free to hit us up when “supposedly“ becomes “actually exists.“ There are a lot of things that “supposedly“ exist in the conspiracy world. I remember Tucker Carlson “supposedly” had all the damning info on Hunter Biden a half dozen times, including the infamous laptop contents, which a courier “lost” during the show and they also made no copies - quite the unlucky turn of events! “Supposedly” there’s a little damning blackmail list from Epstein, which Trump was supposedly going to finally reveal if the conspiracy theorists are to be believed.
It’s always striking to me how good the deep state is at suppressing these things that “definitely exist” making sure they never ever get leaked in any form, but they sure are terrible at stopping everybody from knowing they exist in the first place.
I’m happy to drop the sarcastic bit here, but I hope my point is clear. If you believe in a conspiracy theory, you can simplify things because something that isn’t true is infinitely reducible, to the point where it makes it palatable. After that all you have to do is make it so whoever “they” are (the deep state, the powers that be, the Jews, take your pick) are capable when something doesn’t add up but very incapable when you want to explain how it’s “so plainly obvious” they did something nefarious.
vel0city•25m ago
Y'all are really reading a lot into my usage of supposedly in that statement.
AnimalMuppet•13m ago
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.
almosthere•3h ago
BolexNOLA•3h ago
almosthere•3h ago
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
BolexNOLA•3h ago
lukan•3h ago
ryandrake•3h ago
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!
pishpash•3h ago
almosthere•3h ago
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.
metabagel•3h ago
HeyLaughingBoy•3h ago
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.
tiahura•3h ago
cosmicgadget•3h ago
metabagel•3h ago
renewiltord•3h ago
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.
mschuster91•3h ago
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.
visarga•3h ago
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.
metabagel•3h ago
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.
aboodman•2h ago
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.