Another Close One: How Long Can Luck Last?

71

The number of cable TV experts on speed dial to add virtually nothing to our furtherance of understanding about what happened in Oregon on Friday afternoon is almost as staggering as the event itself. The need to get someone to talk about this inanely when only a few people have anything that could possibly contribute to the knowledge of what happened is, I guess, a testament to the endless news cycle. Honestly, if I hear the breathless CNN lady talk about passengers’ “hair blowing around” I might have to turn the channel. Yeah, right.

If I could have my wish of who to interview about this, it would be the suddenly shirtless little boy and his panicked mother who abruptly got a sweeping view of the post-dusk Oregon countryside. Those two individuals have a lifetime of stories to tell, if that’s how they choose to move on with a life journey they came ever so close to having ripped from them in the freezing slipstream. I would ask them how they could ever trust anything again when something as seemingly straightforward as a piece of the fuselage could fail so spectacularly and endanger them so viscerally. What were they thinking when that cacophony of violence enveloped them?

I write this after spending the day in the care of Boeing and its customers, although not on a MAX 9. I never gave a second thought to stepping aboard, but I did check the seat card that identified the aircraft. Both were 737 800s, the NG series that preceded the MAX and have a pretty good safety record. There are plenty of people who know more about such things than I who thought that should have been the final iteration of the world’s most numerous airliner. Boeing figured it could get one more squeeze out of the lemon and I have to say, notwithstanding my nonexistent understanding of the nuts and bolts of aerospace engineering, I now question that wisdom.

So, where do we go from here? That question might be easier to answer if the 737 mishap didn’t happen barely a week after the runway collision in Japan that tragically killed five people but miraculously didn’t kill the other 400 or so involved. Sheesh. And I suppose we can take some comfort from the fact that the outcome at Haneda is at least partly attributable to engineering and materials advances, not to mention the training and commitment of the frontline airline workers—advances made through the grim experience of the thousands of less fortunate aircraft crash victims who preceded the “lucky” survivors in Japan.

And let’s not forget the 19 really close shaves, and hundreds of merely sphincter-tightening moments at U.S. airports in the past year, any one of which could have had a huge body count. Part of me thinks that it all points to a system that is over capacity, a workforce that is stretched to the limit and a bureaucracy that seems powerless to do anything but study it. The other part of me is just thankful aviation’s number isn’t up yet.

It makes me want to do something and it frustrates me that I can’t. I’m hundreds of miles from those pretty Oregon woods where a Boeing 737 MAX 9 door plug lies waiting to give up its secrets. NTSB Chair Jennifer Homendy has asked residents of the area south of Portland to get out in the damp and mild Oregon winter air, to poke around their backyards and look in the ditches for the hunk of aluminum and plastic that dropped into their lives after so profoundly affecting those of so many others. I’d like to give them a hand because at least that piece of aerospace flotsam holds some answers to how we might prevent whatever design, material or workmanship deficiency that led to the Friday miracle from striking again.

Icing on the cake would be having that boy and his still-shaking mom along when we spot the glint of shine in the mossy dankness. Because not only would it begin the dry and monotonous technical study of just how something so freaking simple could fail, it might also give that mother and son tactile context for an event that will likely shape their lives from here on.

Russ Niles
Russ Niles is Editor-in-Chief of AVweb. He has been a pilot for 30 years and joined AVweb 22 years ago. He and his wife Marni live in southern British Columbia where they also operate a small winery.

71 COMMENTS

  1. I agree with you, Bruce. The overwhelming presence of cable TV experts discussing the Oregon incident appears incredibly uninformed, like a ‘big gaping hole.’ It’s good that you want to hear from the passengers involved—the victims. Your skepticism about Boeing’s decision to continue with the MAX series, despite the NG series having a solid safety record, raises valid concerns regarding prioritizing safety over corporate decisions. Then there’s the young man who lost his shirt and his parents who were fortunate that they were not physically harmed. But emotionally?

    Regarding the B737 Max aircraft, a friend pointed out that, comparing aircraft complexity from his days in the USAF on a scale from 1 to 100, where the B29 is a solid 20, the B737 Max is significantly higher, perhaps 80 or more. He emphasized that while no aircraft is completely safe to operate, some can be made to be less safe than others. We agreed that problems are inevitable, but it is crucial that these issues don’t stem from bad or sloppy practices. I hope the “door plug” is found to help with bring about a solution.

    In conclusion, my wife and I are both passionate about aviation, having backgrounds in flight instruction and air traffic control (Ret). We liked Boeing. The old saying, ‘If it ain’t a Boeing, I ain’t goin’,’ doesn’t hold true for us anymore. Right after I heard about the ‘door plug’ problem, I called my wife to ensure her next flight wasn’t on a B737 Max.

    • Raf, I don’t know when your wife’s next flight is, but all of the affected airplanes have been grounded for inspections. And it’s not every MAX. It’s not even every MAX9.

      The flying public, and you, and your family, are being shown the reasonable care and diligence that we all deserve.

      • David Bunin, I am aware of the “door plug” and that they do not apply to all Max 9. Only to those that have the “door plugs”. At this point, our perspective on the Boeing 737 Max is unfavorable but had gained trust. The two crashes involving the B737 Max in 2018 and 2019, as well as subsequent investigations, raised serious concerns about the aircraft’s safety features and the approval process. The issues related to the MCAS and its role in the accidents and the handling of the situation by Boeing, including communication and transparency, left a bad impression, and are fresh in our minds. Despite some restoration of trust, the latest incident has once again impacted on our tolerance for risk. These safety concerns make for uncomfortable rides.

        • I appreciate and respect your concern for your family. I work in the maintenance community, and I share the concern. I hope (and fully expect) that she has a safe flight, regardless of the aircraft type. Commercial air transport is as close to perfect safety as mankind has ever created. The alternative modes of transportation (even our beloved GA) are a significantly higher risk.

          Ironically, one of the things that makes GA flying safer is that private operators (we) recognize that it is a hazardous activity and are motivated to mitigate the inherent risks by training, currency, good maintenance, and all of the other costly and time-consuming things that we recognize as necessary.

          • Pilot: Something loose in cockpit.
            Maintenance: Something tightened in cockpit.

            2024.01.08
            According to The Washington Post, Alaska Airlines reported that the plane’s auto-pressurization fail light indicating cabin pressure control issues, had activated on three flights in the weeks leading up to the incident (Dec. 7, Jan. 3, and Jan. 4). Maintenance conducted tests and resets, and as a precaution, the aircraft was prohibited from flying to Hawaii, anticipating potential pressure-related problems.

            However, despite this precaution, a subsequent request by Alaska Airlines for a more thorough inspection remained unfulfilled before the incident on Friday. This failure to address the reported auto-pressurization problems raises concerns about the effectiveness of maintenance actions and overall safety procedures.

          • I agree, although the stats aren’t so good if you look at deaths per journey (which is what we are really interested in), rather than deaths per mile flown as airlines like to quote.

      • Unless it cost too much! Pressure from “upper managements” in both design and Mfg areas, in reality, spoken or unspoken, compromise safety everyday. Do you want to fix it, really fix it? Let’s put the top CEO / CFO of both Boeing and Airbus, and their immediate family members, in the first 100 hours of commercial flight, for all new aircraft designs, upgrades, stretch versions etc… All of a sudden we would see safety number one again, and profit well down the list of priorities. Every airline and plane mfg will always claim “safety is number one”, but anyone who seriously analyzes the industry will see the compromises…. Make all the excuses you want, but if safety was #1, we would see much less “fly-by-wire”, then, trying to correct the issue with more “fly-by-wire” software. Yes, there are two parallel computer systems for back-up, but ask the 2 plane load of people aboard the 737 max aircraft that were dumped into the ocean at 540 knots what they think… (oh, we can’t can we). Let’s just blame the pilots like Air France flight 447 did when the “trust your instruments” rule that every IFR rated pilot has drilled into their training, fails because Air France and Airbus didn’t bother to change out the known pitot tubes freezing issues. We could go on for hours and hours… don’t even get me started on the DC-10. These issues have nothing to do with “armchair quarterbacking”, but everything to do with what is so obvious to anyone carefully watching the commercial aviation industry. A simple example would be Southwest. Anyone observing commercial traffic could see the stress they were putting on their 737 airframes, why couldn’t Southwest. That said, most Southwest pilots are absolutely fantastic airmen and airwomen. In general, the vast majority of commercial pilots are exceptional. More pilots “save the day” that cause the problems regardless of what “the blame the pilots” crowd of airline bean counters and Mfg’s and Insurance companies say. One other important issue for the flying public, statistics without a deeper dive into an airline or manufactures operation is always a flawed analysis. A little educated intuition is also very necessary because the numbers alone only give part of the real picture. I guess that is obvious, but I still see many airline “safety ratings” type websites using only statistics. As many others have pointed out here on this excellent site, “Safety Is A Culture” within a company. Focus first on building a great product and profit will always follow. But starting with only profit as a motive will always eventually fail…. and the “bean counters” will already be down the road ruining the next company…. And, they will always grab the golden parachute and run.

        • If you select employees by any criteria other than competence, you will get less competence. Boeing and Spirit have both been boasting about hiring people by skin shade. Almost 50% of Boeing’s new hires in 2022 were “people of color.”
          Perhaps if David Calhoun had not “doubled down” on diversity, he wouldn’t have to plead with his employees to “double down” on doing their jobs right.

          • What evidence to you have to show that “competence” and “skin shade” are mutually exclusive? That sort of ignorant comment would have you scorned out of a seventh-grade debate class.

            The most charitable explanation for your post is that it is a troll; go back under your bridge and eat grubs.

  2. Ok, so what’s the answer? What’s the solution? Another study? Another committee? Years of analysis by a group of human beings whose first priority is their heterogeneous make up? By a culture, our culture which abdicates responsibility on a regular basis? Don’t be surprised with the answers you get. We are already reaping what has been sown.

  3. let’s restrict our comments to the actual issue, not airline economics, overcrowding, Boeings corporate culture, or anything else. a structural part failed, for reasons yet unknown. this failure may have only been restricted to this one aircraft. however, the prudent thing is to ground all aircraft that have that part in the fuselage to determine whether that part on those aircraft are in some ways flawed. once that flaw is found, the next step is to correct it.
    On the emotional side of this event, yeah! it’s pretty scary. And it’s easy to begin to thinking that somehow this is connected to other scary things–how the planes are built, how they are operated, how the whole commercial flight sector operates, and whatever else might scare people.
    however, until proven all those other scares are just our brains taking notice of things that might go wrong. and which will be forgotten when the next OMG event occurs. and that OMG event doesn’t have to be related to aviation.

  4. Kid invested the price of a ticket, and lost his shirt…

    “…the suddenly shirtless little boy and his panicked mother who abruptly got a sweeping view of the post-dusk Oregon countryside.” That’s good. After the partial “unscheduled deconstruction”.

    I’ll wager they both got a rush of bad chemicals that the mom at least, won’t soon forget, but depending on his age and outlook on how close he came to dying (how seriously he took/takes it), the kid might be like – Yeah, it was wild!, when he tells and retells that story to his friends, etc. in future.

  5. “The number of cable TV experts on speed dial to add virtually nothing to our furtherance of understanding about what happened in Oregon on Friday afternoon is almost as staggering as the event itself. ”

    Yet here is a respected aviation site engaging in the same speculation that it condemns on the non-aviation site–calling for “SOMETHING TO BE DONE!” before the real cause is known.

    As journalists, have you ever heard the saying “Hoist with thine own Petard?”

  6. “Part of me thinks that it all points to a system that is over capacity, a workforce that is stretched to the limit and a bureaucracy that seem powerless to do anything but study it.”… well said Russ.

    “it’s the steady, drip, drip, drip, of quality escapes at Boeing that concerns me.”…equally well said David.

    I think the reality of…a system that is over capacity, a system I will, with a broad-brush, call technology. The massive amount of technology layers is oozing out of a lot of our daily products, especially in transportation, more specifically, airplanes and cars/trucks, for example. Because we can add so much layers of features/options by another series of software codes, with AI enhanced computer modeling, to “test” efficacy of functionality over average expected use, are we creating so much complexity that we cannot safely manage or maintain? In other words, just because we can…should we?

    Most customers purchasing a new car or truck, expects an incredible amount of safety features. There are two parts to this safety net. One safety net is to protect the car/truck mechanically from abuse, neglect, or ignorance from the owner/driver. The other is the multiple layers of technology to protect the driver from other drivers and their respective steeds anticipating every possible scenario of driving conditions, positions relative to each other, pedestrians, objects, barriers, construction,etc…to technically insulate, isolate, and thereby do everything to keep a vehicle between the white lines while not running into each other. Simply put, cars and trucks are engineered to protect us from ourselves. That amount of technology is almost standard on all vehicles produced today whose sheer amount of layers of protection is making it impossible to adequately understand plus explain to the average consumer, let alone have the consumer having the time, desire, demonstration and comprehension of all of these “features and benefits”.

    People are being overwhelmed by this amount of technology at the manufacturing level, consumer level, and maintenance level. When these new products such as smartphones, computers, watches to airplanes, cars/trucks, motorcycles, ATV’s, etc become used, the resale of them does not require any further education of all this technology. That puts a lot of products into the hands of the users with virtually no training of use other than trial and error. The economy of scale of mass production has facilitated technology overload. Technology overload, has been determined to be managed by…MORE technology.

    Airplanes are now falling into this technology overload at a pace that aviation in general has never been used to nor designed for simply because lack of economy of scale. However, that has radically changed allowing mass production of airliners in this case, at a scale impossible 10 years ago. Profitability is determined by economy of scale or lack of it. With so many rules and regulations to comply with because of the multitude of layered technology incorporated, it takes more technology to manage the quality AND the bureaucracy that created and demands it. The end result is what David accurately described as a steady “drip, drip drip” of the inevitable erosion of quality. Our system of manufacturing, product training, product sales, consumer knowledge including our body/brains to use all of these technology layers, are over saturated, over stimulated, and by design…can only tolerate so much. That means a relatively simple airliner door plug gets pushed out of its pressurized aluminum/carbon fiber/composite/plastic/metal tube.

    When will aviation’s number be up under these extraordinary complex and technology saturated times?

  7. Reflections on the “door plug” incident before going to bed.

    I am disappointed in the reporting quality of cable news networks. The so-called experts often lack depth and display ignorance, and the dramatic tones contribute to harmful hype.

    On the other hand, some aviation bloggers downplay the incident, acting like the incident isn’t a big deal. This negligence is perplexing, especially given the history of safety issues with the B737 Max series. While expert analysis is crucial, understanding the public’s worries is equally important. Dismissing these concerns worsens the trust issue in the aviation industry.

    Turning to the young man facing ejection due to depressurization, it’s crucial to acknowledge lasting trauma. As a parent, I would demand immediate and thorough care to address short-term and potential long-term effects. “This too shall pass”, ain’t going to cut it.

    Then there’s technological overload, where systems can worsen the “one hand not knowing what the other is doing” syndrome. (Thanks Jim Holdeman)

    Feeling for Alaska Airlines, I think they’re reliable and efficient. My positive view comes from their consistent and dependable service I’ve enjoyed, making them look good in my eyes.

    • How you can say Alaska is reliable and efficient, well I don’t quite get that. Instead of pulling an airplane with repeat write ups off line to troubleshoot, they ‘slapped it on it’s ass’, put a deferral on it and let it keep flying. Look at their history too. Wasn’t that long ago that Alaska lost that MD80 because of a trim jackscrew failure. And why was that? Because the Alaska management at that time thought they knew better than the manufacturer on what maintenance the airframe needed and extended the lubrication schedule on the MD80 fleet to save bucks and get increased utilization out of the fleet. Unfortunately, they got the FAA to buy off on the increased maintenance interval and the rest is history.

      Lot of people want to blame Boeing. Time will tell if this was a manufacturing defect or mistake. I’ll go on the record now, I’m guessing that area of the plane was serviced between the delivery and incident by Alaska. And even if it wasn’t, they had 3 warnings before it happened. Heck, I’ll even blame the Lion Air Max crash on maintenance. Again, on that flight the airflow angle sensor was written up multiple times. The real issue is that we have to stop pressuring to get the planes back on line. When an issue comes up, we have to find root causes, not reset the system and wait and see. And it’s not just Boeing. I flew the E190 when it first came out. For the first two years the airplane would ‘cry wolf’ with nuisance system trips and EICAS warnings. Which in turn bred a complacency in not taking warnings seriously.

      We owe our passengers better. At my first major, we had a 3 strikes rule. If we got the same issue written up, maintenance couldn’t defer or clear without a definitive fix. If that rule had been applied at Alaska, this airplane would’ve been grounded (before the incident) until something was found.

      • Mr. BusDriver-
        While I like your “3 strikes” rule and laud you for mentioning it here, I cannot ever remember inspecting the fuselage for evidence of structural failure in response to a cabin pressurization squawk. But then I only worked on FAR25 aircraft for 20 years. There is no way I would go back to wrenching, if I could, today. In my day, if the FAA said it was “good”, that was good enough for us – even on an older airframe. Today, it seems the FAA has no idea – not a clue.

        Lots of finger-pointing here. That’s not new. But maybe “we” have ourselves to blame. All of us. The demand for air travel has grown beyond most expectations 20 years ago, but “we” have accepted status quo – except in our cockpits. Twenty years ago, we had pilots who could fly an airplane and today, we have built “monsters” that depend upon computers with a myriad of warnings on top of warnings for each problem. But “we” save fuel.

        The same people who brought us automatic flight systems, telling everyone that they are safer, have developed some automatic systems of their own – to save money on the production line. You can save a lot of money by replacing a pair of informed human eyes with a robotic machine that both assembles and inspects in just one step. In my day, it stopped with “the right tool for the job” technology. And “we” laughed at the cartoon that placed a dog in the cockpit to bite the pilot if he tried to take the controls. “We” probably should blame ourselves for letting this happen. “We” used to have the public trust.

      • How can you say Alaska is reliable and efficient? I have always been satisfied with their service and professionalism. I have old friends who are Captains and FOs, flight attendants, and former students flying there. I trust them and feel safe. However, I’ve had reservations about their recent acquisitions of Boeing MAXs. I admit that this incident, as it is developing, is affecting my confidence in the MAX even more, and how the aircraft continues to influence operational standards.

    • “Turning to the young man facing ejection due to depressurization, it’s crucial to acknowledge lasting trauma.”

      “Lasting trauma?” Maybe, maybe not. In our current culture, it is far more likely that the assumption of lasting trauma will cause it rather than help that young man move on from it. I’m certain he was frightened but he wasn’t actually injured.

      I’ve been scared sh!@less doing aerobatics and riding a motorcycle and been buried under snow but nothing bad actually happened so I learned lessons from those experiences rather than dwelled on any “lasting trauma” from them. I raised my now thoughtful but fearless child the same way.

      That young man’s parents should undoubtedly be alert to signs of lingering emotional distress but they shouldn’t acknowledge either its existence or its inevitability in advance. They might do him more good by simply being grateful he’s still around and unharmed and joke with him about not being too eager to go shirtless in the future.

  8. There has been a lot of research into the relationship between precursor events and fatal accidents. One commonly sited ratio is 1000, 600, 30,10, 1

    1000 unsafe acts leads to
    600 near misses which leads to
    30 minor incidents/accidents which leads to
    10 major incidents/accidents which leads to
    1 fatal accident

    It would seem to me that sadly, the aviation system is overdue for a fatal accident….

    • Well, the plug door has been found and there is a maintenance issue unravelling where, according to the Washington Post, Alaska Airlines reported that the auto-pressurization fail light, indicating cabin pressure control issues, activated on three flights in the weeks before the incident. Maintenance conducted tests and barred the plane from flying to Hawaii as a precaution. However, a later request for a more thorough inspection went unfulfilled. Interesting!

      • Gee, I wonder what was leaking so much air that the pressurization light was coming on. Years ago I was preflighting a turbo prop airliner which was restricted to below 10000 feet due to a pressurization malfunction. While reading the maintenance log I discovered that the guys who “fixed the airplane” had wired the press/dump valves closed instead of open. Until explained to them they did not understand why that was a bad thing.

  9. Well, good news, Russ! “Bob” from Portland found the door plug in his yard. I suspect it’s going to show that somebody forgot to reinstall the four bolts that are supposed to secure those plugs after the plug was removed during final assembly. But we’ll see.

  10. Can I assume that the only reason mother and son were *not* ‘ejected’ was because they had the seatbelts fastened? If so, perhaps this is the one message that we can all take away from this and the aviation industry – as well as on-line ‘experts’ – should be shouting it from the rooftops.

  11. I was flabbergasted by the expeditious decision of the FAA that the MAX 9 could resume flights after a verification of the emergency exit doors. Only to revert that decision 3 minutes or so later.
    Maybe the Boeing/FAA combination needs some scrutinizing.

  12. I have 5 Boeing type ratings – 737, 757,767, 777 & 787. The 737 is not only my least favorite Boeing jet it is my least favorite of any jet ! The EMB145 felt more spacious than the cramped 737 cockpit and it had a better cup holder as well. (Actually the max’s do have one extra cup holder on the exterior side wall so that’s a step up.) I honestly feel sorry for guys at Alaskan and Southwest because that’s the only airplane they’ll ever get to fly.

    • Hugh,
      I didn’t fly all the Boeing jets but its a pity you didn’t fly the tri-motor 727-100. Best of the ones I flew. It’s primitive by today’s standards but having an extra set of eyes on a dark and stormy night was appreciated too.
      Then there is the -217 with the big motors….sparkling performance!

      • Sparky,
        I’m retired and consider myself lucky to have avoided the 737. That bidsheet never appealed to me. I’m typed and flew the 727, 757,767, 777, and 747. The 747 is a GREAT plane and while I enjoyed the 727, my favorite was the 757. A rocket that handled like a sports car compared to the other Boeings I flew. It saddens me to see what’s happened to a once great company.

  13. This was a close call and Boeing seems to have a QC problem that needs addressed but the 19 near misses are what really concerns me.

    The ATC system is maxed out and overwhelmed and the FAAs mismanagement of the training pipeline during Covid made things much worse. If not for TCAS, on the ball flight crews and sheer dumb luck there would have been hundreds killed. The FAA needs to get a handle on this now and a competent and experienced secretary of transportation would have already initiated code red, unfortunately we have a small town ex-mayor with no aviation experience appointed by a senile idiot in the White House overseeing the most complex transportation system in the world.

    Let’s cross our collective fingers luck holds out until something changes in Washington.

    • What did Biden and Butigegh have to do with the decision of Boeing to leave Seattle in search of cheap labor, no unions, and less oversight? Nothing. That decision started the decline of Boeing. Ya wann’a fly th’ low cost, high profit manufacturer? Hire the “merged” Boeing management model!

  14. Russ Niles the statement – “Honestly, if I hear the breathless CNN lady talk about passengers’ “hair blowing around” I might have to turn the channel.”

    I cannot agree more indeed!!! Great work discussing the way how armchair experts about anything report now a days….

    I still say instead of the MAX, the B-757 should have been reintroduced….. what a great aircraft in all regards!!

    • Couldn’t agree more on the 757. I think the whole concept of the 737Max series rests on Southwest’s shoulders. I’m certain they wanted something larger forcing Boeing to push the limits (beyond?) what the airframe can handle.

  15. Boeing is not concerned about quality, only quantity out of the door.
    Boeing has had design problems before; horizontal stabilizers failing on 707’s, 747 engine mount bolts, 737 rudder actuators; the list goes on.
    Boeing hit its’ peak with the 757/767/777; the 787 started a slide that is still happening.
    The 787 is a pretty good airplane, sometimes poorly built.
    The 737 Max is not good, “lipstick on a pig”; as people in the know put it.
    Decades in the industry; Airbus, (which is not perfect) Boeing, DeHavilland, Douglas, Dassault, and many more from single seat and up.

  16. Professional job on the part of the Alaska Airlines Flt 1282 crewmembers (Pilots and FA’s). It just goes to show, when the unexpected arises, the most important safety component on any commercial airliner, is a minimum of 2 well trained, well rested pilots on the flight deck. If you have ever seen the inside of a cockpit during an emergency, you know it can get busy fast. Fact: Some in the airline industry are putting profits ahead of safety by pushing to reduce the number of pilots on the flight deck? Don’t let it happen. Just say no to reduced pilot ops.

  17. Just to add to hubbub.
    1. Why were there no Max accidents with 1000’s of operations in the US yet two “developing world” accidents ?
    2. Did someone forget to retrieve the CVR before it was erased.

    Before someone calls me an American racist please know that I am a New Zealander living in Switzerland who owns a Lake Buccaneer based in Oregon.

    • #1 . . . Hand flying and basic airmanship skills do not have a high priority place in foreign training programs. Autoflight usage does and is encouraged by Boeing. Recognition of non-normal events and instinctive corrective action are mostly missing.
      #2 . . . Airline CVRs have a 30 minute loop (overwritten every 30 minutes). Jennifer Homendy, NTSB Chairperson, is criticizing the crew for not pulling the C/B to preserve cockpit conversation. Maybe she will read these AVweb posts someday. She will learn that disabling a voice recorder is not on any airline’s emergency procedure checklist. Rule #1 is to FLY THE AIRPLANE. The pilots in this cockpit were busy doing just that, executing the rapid depressurization checklist, possibly donning their oxygen masks, communicating with ATC, communicating with Southwest dispatch, communicating frequently with the cabin crew. Furthermore, I challenge any airline crewmember to look overhead in an emergency and immediately find the CVR circuit breaker in a mess of scores of other C/Bs, Jennifer . . . HELLO!

      • Pulling the CVR breaker isn’t done during the emergency- it’s after parking. Airlines need to have a checklist for ramp personnel in the event if an emergency return which includes deactivating the CVR.

  18. Honestly – are we not talking about the overall detoriating quality of US produced goods? The US has to improve in order to compete with the rest of the world in almost every field – and that is a long time journey. It all starts from the beginning in primary schools and has to follow all the way up to the production lines. It is really sad to note what has happened during the last 50 years when then US made goods was the sign and guarantee of quality goods!

  19. “19 really close shaves” – where does this number come from? I’m sure the real number is quite a bit larger.

  20. This incident reminds me of one that happened about 7-8 years ago. I worked in a comms center for an Aeromedical company and had an incident happen to a very good friend of mine that tells me of the effect it can have. This lady is an CFRN (Certified Flight Registered Nurse). The company I worked with had a fleet of about 6 EC-130 aircraft. They were on a return flight from someplace deep over the Appalachian Mountain ranges of southern West Virginia. The left rear door departed the aircraft, the one she was sitting by. Granted they were only up about 3-4 thousand feet, this traumatized her so bad, that after they landed, she stopped flying all together. She quit that job right then and there. She is a great nurse and paramedic that now works in hospitals and on ground units on occasion. You never know how traumatic events effect anyone. But even though she was strapped in, it still traumatized her enough to make a job changing decision. I haven’t talked to her much since then, but the idea of having an event such as this and the end result what it is, makes you wonder what kind of nightmares she may be having of this incident.

    • Interesting differences in psyche. I am a member of the British “Goldfish Club” for pilots who have survived ditching. Last Goldfish Club AGM I attended included 2 US GA pilots and a hundred British pilots. “Bloody inconvenient to have the Sea King gear box disintegrate over the North Sea in the winter. After rescue we went to the pub for gin and tonic” was the typical British attitude. The two US pilots of less spectacular ditchings in seaplanes were still overcomng their trauma years since their incidents. I had an engine failure 200 miles SE of Greenland, December 1979, am 83 and without psychological counseling am perfectly happy flying my Lake amphibian in the US every summer. People need to factor in that in the long run they are all dead.

  21. What is wrong with the format of these comments? The comments columns decrease in with until they are less than a WORD wide????

  22. From low-bidder subcontractors to offshore heavy maintenance to a dwindling supply of qualified aircraft maintenance techs, to an FAA that delegates its prime responsibility and then takes a nap, safety is not a “given” on the major airlines. They seem all too willing to accept whatever normalization of deviance their lower budget competitors set as SOP because the traveling public will only click on the cheapest ticket.

    Everyone knows that you get what you pay for, but the traveling public is discovering that “what” doesn’t automatically include safety.

  23. Bottom line…. it could happen to any one of us. Both flight deck crew and inflight are the last line of defense sometimes. The real issue, crews have to have the backbone to say no and do something.

  24. The Internet has made everyone a frisking expert overnight. So in the past you’d know the experts cause they were well-known – these days news outlets grab the nearest punter and put him or her on- amazing how many Ukraine, Hamas, Max experts there are- fling a cat in a crowded room and you’ll hit one for sure

  25. No one has yet mentioned the role of the subcontractor who supplied this door plug. As the supply chain becomes more diverse (that has lots of meanings, all true), it becomes more and more challenging to drive that design, fabrication, inspection and quality mentality upstream. As a former 20 year Boeing structural engineer, I still place this one squarely on those folks. But I will also not be surprised if they find something causal from the sub-k. Glad Bob found the door.

  26. Is there any chance that the “plug” door that exited the fuselage into a 300 knot slipstream might have taken out the left horizontal stabilizer on the way to Bob’s backyard? Russ, excellent post. Thanks!

  27. Someone else said this after a previous incident followed by endless fact-free interviews with ‘experts’: “those who actually know something aren’t talking and those who don’t won’t shut up”.

  28. While Boeing’s current error trend cannot be solely attributed to its generally predominant white male workforce, it is crucial to recognize that workforce demographics are shaped by geographical and industry-required skills and qualifications. Fundamentals such as historical hiring practices and regional or local talent availability contribute to the racial/ethnic composition of Boeing’s, or any other entity’s, workforce.

    However, it should be noted, for the benefit of those concerned about diversity, that error trends at Boeing existed long before the implementation of Boeing’s DEI initiatives. Despite the social, economic, cultural, and political influences, Boeing, like many others, is addressing these complexities through diverse initiatives to foster a more inclusive and competent work environment. So, discussions about errors should focus on systemic issues and organizational improvements rather than absurdly singling out whites or any other particular demographic group, dispelling any notion of white male supremacy within its workforce.

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