“Is it safe, Pop?”
Ava my granddaughter is 9. I was so proud of her confident stride and big smile as she boarded the plane to Phoenix unescorted earlier this month. But my phone alerted me of an urgent text as soon as I got home. A Boeing 737 Max 9 had been forced to make an emergency landing. A chill ran down my spine as I scrambled to find out if it was Ava’s flight — it wasn’t.
But there were four unaccompanied minors on the Alaska Airlines flight that triggered that text, after a door plug on the left side of the airplane dramatically malfunctioned at around 16,000 thousand feet. Thankfully no one was hurt. But the incident has understandably rattled travelers and prompted calls for more regulation and oversight. The Federal Aviation Administration temporarily grounded some Boeing 737 Max 9 airplanes in the immediate aftermath of the accident and quickly opened a formal investigation.
Thankfully no one was hurt. But the incident has understandably rattled travelers.
Following a series of internal inspections, Alaska Airlines CEO Ben Minicucci revealed the carrier found “some loose bolts on many” of the other Boeing 737 Max 9s in its fleet. Clearly, this is not just an isolated “quality escape,” as Boeing CEO Dave Calhoun obliquely noted in the days after the accident.
Notably, this is also not the first Boeing plane to have safety issues recently. Just last week, a Delta Boeing 757 lost one of its wheels as it was about to take off in Atlanta. But in my 45 years as a licensed aircraft mechanic, FAA safety inspector and accident investigator, I have never felt so disturbed about an accident. I literally wrote the book “Why Planes Crash” — I thought I’d seen it all. I was wrong. Here’s why this accident is the straw that broke the camel’s back for me.
No fatalities and no serious injuries resulted from the emergency on Alaska Airlines Flight 1282. This wasn’t a case of pilot error or severe weather. No, this accident was shocking to me because of how absurdly simple and avoidable it was.
At the heart of this story is a bolt that was either not installed or was installed incorrectly at one of the world’s largest manufacturers of commercial airplanes. Boeing literally set the standard for quality and safety in manufacturing. It has backup systems, checks and double checks to avoid this sort of potential catastrophe. Indeed, I have spent my entire life designing, building and implementing safety management systems. They make up the very foundation of my confidence in the aviation industry. The perception that these systems don’t work at Boeing has not surprisingly shaken traveler confidence in the entire industry.
One thing I have learned as an accident investigator is that the real cause of an accident is rarely found at the site of the accident. Aircraft accidents almost always have a latent cause — present but needing conditions to become active, obvious or completely developed. And what was the latent cause of this accident? Let’s start with the last people who could have prevented the accident, the person who installed or closed the door plug.
Did the person who installed the Alaska Airlines door plug think the bolt wasn’t important? Maybe wasn’t needed? I don’t think so. According to new reporting from the The Air Current, there were nonconforming rivets on the brand-new fuselage when it arrived at the Boeing factory in Renton, Washington. (The fuselage was manufactured by Spirit AeroSystems in Wichita, Kansas. In a statement, Spirit Aerosystems thanked the Alaska Airlines crew, noting “our primary focus is the quality and product integrity of the aircraft structures we deliver.”) To facilitate the repair of these rivets, the left door plug reportedly had to be opened or removed.
The Renton facility knows how to manufacture and assemble complex aircraft to the approved specifications. But when a nonconforming part is discovered, even experts have to shift their strategy and abandon the standard production assembly line mentality that does not always take into account how individual parts could ultimately affect the safety of the aircraft and the lives of the passengers.
These types of repairs require analytical problem-solving skills as well as trained and licensed airframe and powerplant mechanics who can assess and understand the impact the repair will have on the operation of the entire aircraft. They also require a second set of eyes to thoroughly inspect the work.
A distinct and identifiable separation between the tactical assembly line mentality and the more strategic certified repair station mentality must be reinforced at Boeing, and it must be strongly enforced by the FAA. Until then, Boeing will continue to be vulnerable to Calhoun’s cryptic “quality escapes.”
I urge Boeing to assess and mitigate this vulnerability, and I call on the FAA to increase surveillance and intensify its enforcement in this area. Only then will my confidence in Boeing be restored. Only then will I be able to watch Ava once again confidently board an airplane unaccompanied with a smile on her face. Because only then can I tell her it is truly safe.
