No matter how you slice it, no matter how they try to blame the QA procedures at Boeing (and yes, that needs to be addressed) at the end of it, 4 workers took 4 bolts out of the door plug on a 737 airplane, did some maintenance, and failed to put the 4 bolts that were designed to keep the plug in place back into the assembly. . This was workers simply not doing their job, plain and simple. 4 people who could not make sure that the job was completed. Either too uncaring to finish a job, or deliberately not doing it to harm the company (they are lucky no one was hurt or killed) This could have been any number of critical assemblies….landing gear, engine attachment points, wing bolts, tail bolts, rudder cables, rudder hinges, etc. elevator bolts, etc…all of which are critical to safe and continued flight.
At the end of it, it was negligence by those workers that failed to complete their job and caused the door to depart the aircraft. (and, one wonders, where were the workers who put the interior on the door…were they blind or also uncaring?). Yes, again, there should have been an inspection afterwards, but if they were doing their job, that inspection should not have been needed. When you do a job and there are parts (bolts, nuts, and cotter pins, in this case) left over, one would think that even union employees would ask questions…..
I spent 28 years in the AF working on munitions and it took me a few years to realize what was really important. Really bright people could learn how to do the job pretty quickly and less bright people took a lot longer but could still do the work. What the absolute critical mindset people had to have though was they had to care about what they were doing. If they didn’t care about what they were doing I did not want to work next to them or, later on, have them in my maintenance bays.
Obviously these technicians did not care. Thank God no one was seriously hurt.
This incident is an example of the growing competency crisis facing modern society.
These workers either couldn’t do the job correctly or couldn’t be bothered to do it correctly. And as America’s Indoctrination System turns out more and more of these barely functional brain donors the problem will only get worse.
well, 2 sides to every story. i’m not disputing yours at all, but offer my own experience. i was on a crew doing critical repair on a tank, as in tracked vehicle. in the middle of bolting it back together my boss came in screaming about “no overtime”. we went home. came back the morning to finish the job, tank gone. some jackwagon had signed off on it and issued it to the unit b/c the commander was screaming at him. of course he was screaming again when it went kaput in the middle of the operation. but yes, some folks just don’t give a crap about pride in their work.
Not quite the same thing in the middle of an assembly line.
Either way, how long does it take to put 4 small bolts through 4 holes and put nuts and cotter pins on? They aren’t even a torqued bolt,.
It’s ironic that DEI can be rearranged into DIE.
Threaded fasteners are the bane of all manufacturers of every type of equipment.
Where I worked, inspector were issued paint-pencils and they were required to draw a scribe mark across the parent material and the head of the fastener. It showed that they had actually looked at it and had touched it. The mark could also serve as a witness mark if the fastener started to back out.
Vehicles that went into the “repair loop” were an entirely different kettle of fish. Critical components like brakes, suspension, steering wheels and fuel system parts had to have a second sign-off by a member of management from a different department before the vehicle could be re-inserted into the normal flow of production.
These were bolts through a hole with a nut and cotter pin.
All they were, really, were retaining pins.
They didn’t have to be tightened to a torque or otherwise do anything but be a pin.
Of course, they had to BE THERE to work….
Start with a clean work area. No nuts and bolts ,no parts ,if you’re finished and it now has nuts ,bolts or parts, you are not finished. If I’m working with small stuff I sweep up before I start. A little spring can hide behind just about anything.
Not the first time something like this has happened… Space industry is just as bad with ‘shift change’ issues…
i heard from my learning partner that that i the reason NASA stopped its dynamic development after getting to the moon–they were forced to hire incompetents –diversity
An infamous story from general aviation:
In the process of engine maintenance, the prop had to be removed. The A&P removed the spinner and loosened the prop bolts. He left the bolts finger tight until ready to remove the prop. He replace the spinner and screws but again, only hand tight. He then called it a day and went home.
The big glaring sign hanging on the cowling had been somehow removed. The next morning the aurcraft owner took the plane to make a short cross country flight. During run up, he was surprised to see the prop fling off to walk across the tarmac.
Undoubtedly I got some details wrong. I first read of this years ago in IFR magazine.
Many, many years ago a friend who worked for a utility in vehicle repair and support told me about their work standards. Apparently, that generation of diesels in GMC trucks were somewhat fragile and it was not uncommon for one to be towed in, dead. The engine got pulled, disassembled, inspected and repaired which required several different people across multiple shifts. The rule was “every threaded fastener in an assembly will be present-no “partial assembly permitted” – and every fastener present shall be torqued to the proper specification without exception. Failure to do so will result in immediate dismissal.”
Years later, as an engineer in a completely different industry, I was faced with management who believed quality could be “inspected in” during the final stages of manufacture (not to mention how expensive it was to perform those multiple “inspections”). It took one multi-million dollar catastrophe to convince them that structuring the manufacturing processes to prevent such occurrences – making it easy to do the right thing, difficult, maybe even impossible for some operations, to do the wrong thing – was important. It was expensive and time consuming to redesign both the product and the production tooling used to manufacture it to comply with that philosphy but much, much cheaper in the long run.
It also required a change in hiring and training standards; as EdC (above) points out, if someone doesn’t care about the quality of work they perform or complying with standards that attitude can defeat stringent quality standards. If you don’t let those people in you don’t have to clean up after them.
I just read an article about a Boeing breaking a speed record, 820mph. Had a 250mph tail wind. I’d be really nervous on that plane.