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热度 31已有 1163 次阅读2024-1-23 04:43

显然是某波音生产线上人士在Leeham News上的发言:

Current Boeing employee here – I will save you waiting two years for the NTSB report to come out and give it to you for free: the reason the door blew off is stated in black and white in Boeings own records. It is also very, very stupid and speaks volumes about the quality culture at certain portions of the business.


…With that out of the way… why did the left hand (LH) mid-exit door plug blow off of the 737-9 registered as N704AL? Simple- as has been covered in a number of articles and videos across aviation channels, there are 4 bolts that prevent the mid-exit door plug from sliding up off of the door stop fittings that take the actual pressurization loads in flight, and these 4 bolts were not installed when Boeing delivered the airplane, our own records reflect this.


…As a result, this check job that should find minimal defects has in the past 365 calendar days recorded 392 nonconforming findings on 737 mid fuselage door installations (so both actual doors for the high density configs, and plugs like the one that blew out). That is a hideously high and very alarming number, and if our quality system on 737 was healthy, it would have stopped the line and driven the issue back to supplier after the first few instances.


…Now, on the incident aircraft this check job was completed on 31 August 2023, and did turn up discrepancies, but on the RH side door, not the LH that actually failed. I could blame the team for missing certain details, but given the enormous volume of defects they were already finding and fixing, it was inevitable something would slip through- and on the incident aircraft something did. I know what you are thinking at this point, but grab some popcorn because there is a plot twist coming up.


The next day on 1 September 2023 a different team (remember 737s flow through the factory quite quickly, 24 hours completely changes who is working on the plane) wrote up a finding for damaged and improperly installed rivets on the LH mid-exit door of the incident aircraft.


…Because there are so many problems with the Spirit build in the 737, Spirit has teams on site in Renton performing warranty work for all of their shoddy quality, and this SAT promptly gets shunted into their queue as a warranty item. Lots of bickering ensues in the SAT messages, and it takes a bit for Spirit to get to the work package. Once they have finished, they send it back to a Boeing QA for final acceptance, but then Malicious Stupid Happens! The Boeing QA writes another record in CMES (again, the correct venue) stating (with pictures) that Spirit has not actually reworked the discrepant rivets, they *just painted over the defects*. In Boeing production speak, this is a “process failure”. For an A&P mechanic at an airline, this would be called “federal crime”.


…finally we get to the damning entry which reads something along the lines of “coordinating with the doors team to determine if the door will have to be removed entirely, or just opened. If it is removed then a Removal will have to be written.” Note: a Removal is a type of record in CMES that requires formal sign off from QA that the airplane been restored to drawing requirements.


If you have been paying attention to this situation closely, you may be able to spot the critical error: regardless of whether the door is simply opened or removed entirely, the 4 retaining bolts that keep it from sliding off of the door stops have to be pulled out. A removal should be written in either case for QA to verify install, but as it turns out, someone (exactly who will be a fun question for investigators) decides that the door only needs to be opened, and no formal Removal is generated in CMES (the reason for which is unclear, and a major process failure). Therefore, in the official build records of the airplane, a pressure seal that cannot be accessed without opening the door (and thereby removing retaining bolts) is documented as being replaced, but the door is never officially opened and thus no QA inspection is required.


https://leehamnews.com/2024/01/15/unplanned-removal-installation-inspection-procedure-at-boeing/#comment-509962

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发表评论 评论 (12 个评论)

回复 huma 2024-1-23 06:48
可有点吓人、看样子坐飞机的时候得全乘系着安全带了,而且少去卫生间
回复 togo 2024-1-23 08:13
前一班把四个铆订螺栓给卸下来了,但是由于Paper Work太乱,太多问题记录把这个记录埋了。后一班以为普通检验,不需要卸螺栓,QA也没有检查。幸亏有加持,就这样没有锁定螺栓还飞了四个月才出事。
回复 晨枫 2024-1-23 10:09
这个算criminally negligent吗?
回复 伯威 2024-1-23 11:08
togo: 前一班把四个铆订螺栓给卸下来了,但是由于Paper Work太乱,太多问题记录把这个记录埋了。后一班以为普通检验,不需要卸螺栓,QA也没有检查。幸亏有加持,就这样 ...
俺看的机翻,前面说的是波音交付飞机时就没安螺栓?是吗?
回复 togo 2024-1-23 11:52
伯威: 俺看的机翻,前面说的是波音交付飞机时就没安螺栓?是吗?
八月三十一号在工厂,不知道是新机出厂还是旧机维修。
回复 大黑蚊子 2024-1-23 22:17
波音公司内部人士爆料——我将免费告诉你,不用等两年的NTSB报告:门为什么会脱落,在波音的官方记录里写得清清楚楚。这事儿不仅愚蠢至极,还暴露了公司某些部门的质量文化问题。
...言归正传...为什么那架注册为N704AL的737-9的左舷中段出口门会脱落?简单来说,正如航空界的多篇文章和视频所报道的,有4个螺栓是用来防止中段出口门在飞行中因承受增压而从门止装置上滑落的,而这4个螺栓在波音交付飞机时并未安装,我们的记录也证实了这一点。

...因此,这项本应只发现少量问题的检查工作,在过去的一年里,竟然在737中段机身门安装上发现了392个不合格项(包括高密度配置的实际门和像那个脱落的门塞)。这个数字高得吓人,令人警觉。如果我们的737质量系统运作正常,它应该在最初几次问题出现后就停止生产线,并将问题反馈给供应商。

...现在,说到那架出事的飞机,这项检查工作是在2023年8月31日完成的,确实发现了问题,但问题出在右舷门,而不是实际出问题的左舷门。我本可以责怪团队疏忽了某些细节,但考虑到他们已经发现并修复了大量缺陷,有些东西难免会被遗漏——在出事的飞机上,确实有东西被遗漏了。我知道你现在在想什么,但先别急,剧情即将反转。

第二天,也就是2023年9月1日,另一支团队(记住,737在工厂里的流转速度非常快,24小时就能换一批工作人员)在出事飞机的左舷中段出口门上发现了损坏和安装不当的铆钉。
回复 大黑蚊子 2024-1-23 22:18
...因为737的Spirit制造存在诸多问题,Spirit在Renton现场有专门的团队进行保修工作,处理他们糟糕的质量。这个特殊检查任务(SAT)很快就被当作保修项目处理。在SAT的沟通中发生了一些争执,Spirit花了点时间才拿到工作包。一旦他们完成工作,就会将其送回波音QA进行最终验收,但接着,恶意的愚蠢行为发生了!波音QA在CMES(正确的地方)中又记录了一条(带图片),指出Spirit并没有真正修复那些不合格的铆钉,他们只是“在缺陷上涂了漆”。在波音的生产术语中,这被称为“过程失败”。对于航空公司的A&P机械师来说,这等同于“联邦犯罪”。

...最后,我们来到了这个关键的记录,它大致内容是:“与门团队协调,确定门是否需要完全移除,或者只需打开。如果需要移除,那么就需要写一个移除记录。”注意:在CMES中,移除记录是一种需要QA正式签字确认飞机已恢复到图纸要求的记录类型。

如果你一直在关注这个情况,你可能已经发现了关键错误:无论门是简单地打开还是完全移除,那4个用来防止门从门止装置上滑落的固定螺栓必须被移除。在任何情况下,都应该编写移除记录,以便QA验证安装。但事实证明,有人(具体是谁,调查人员会感兴趣)决定门只需要打开,而在CMES中没有生成正式的移除记录(原因不明,这是一个重大的过程失误)。因此,在飞机的官方建造记录中,一个无法在不打开门(从而移除固定螺栓)的情况下检查的压力密封被记录为已更换,但实际上门从未被正式打开,因此也不需要QA检查。
回复 大黑蚊子 2024-1-23 22:23
看完这个,深吸了一口气,“我R尼玛,波音一笔屌糟”

赶紧在订票规则里加一条,不要波音飞机
回复 旺旺的考拉熊 2024-1-23 22:36
大黑蚊子: 看完这个,深吸了一口气,“我R尼玛,波音一笔屌糟”

赶紧在订票规则里加一条,不要波音飞机
具体一点,不要太新的波音飞机,当然也不能太老的,中间的还是可以勉强坐坐的,不然出行真的有点难
回复 雨楼 2024-1-24 00:25
不是说波音的分包把机身和门一起交付的。交付的时候为了方便运输,门(door plug)就固定在机身上。注意是固定,不是安装。
然后估计波音内部程序的问题,总装的时候就以为门已经安装好了。。。。
帝国雄风不再啊。
回复 清凉山 2024-1-24 20:09
阿航老总说在很多架飞机上发现了松动的螺栓,这也太可怕了
回复 清凉山 2024-1-24 20:12
旺旺的考拉熊: 具体一点,不要太新的波音飞机,当然也不能太老的,中间的还是可以勉强坐坐的,不然出行真的有点难
应该要求航司明确区分新老机型:以前的叫波音737,B737,新的叫麦道737,MD737或DC737

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