More 737 Max issues! Panel blows out in Flight of Alaskan Airline 737 Max 9

[stever219]

22 hours ago, hairystick said:

They just had a depressurisation - this caused a lot of things to be sucked out of the hole.

Alledgedly the "secure" cockpit door opened and loose stuff left the cockpit as well. Checklists included...

 

Crew put on oxygen masks (don't want those 2 people passing out) which also have comms headsets to talk with ATC.

 

After all that, getting back on the ground & being swamped with emergency services, etc, etc, missing the checklist item to pull the CVR breaker has been overlooked.

It seems pointless having a 2hr recording time in today's digital storage media environment. Resetting these devices to 24 or 48hrs (or something in this range) would be easy and simple to do.

Is the 737 MAX not fitted with a glass cockpit, like the A320 for example, where checklists, including those for emergencies, are displayed on-screen as part of the ECAM or EICAS (can’t remember offhand which is the Boeing version)?  Also would not the QRH and/or checklists be available in the crew’s Electronic Flight Bags?  You might think that, with a successful outcome like that the crew might have wanted to keep the evidence for the inevitable investigation, even if the odd rude word or phrase was uttered in the heat of the moment.

[NoSG0]

Re CVR/FDR etc

 

They should all be 25hr, and the batteries should all be extended life.  Flotation buoys of some type that register the last known gps location in case of a catastrophic water incident. 

 

Also why are these not retroactive to already existing and flying aircraft? So a plane built 5-10 years ago which has a cvr still only needs the 2hr?

 

Yes cost, ask the relatives of still missing aircraft how they feel about that.

[alt-92]

5 minutes ago, NoSG0 said:

They should all be 25hr, and the batteries should all be extended life. 

Not according to the FAA who have stuck to 2 hours.

 

NTSB wants 25, like EASA/EUROCAE already have mandated.

5 minutes ago, NoSG0 said:

Also why are these not retroactive to already existing and flying aircraft? So a plane built 5-10 years ago which has a cvr still only needs the 2hr?

Yep, pretty much that. No retrofit mandate.

If you're really unlucky, you might even see a 30 minutes unit.

[Alan P]

33 minutes ago, stever219 said:

Is the 737 MAX not fitted with a glass cockpit, like the A320 for example, where checklists, including those for emergencies, are displayed on-screen as part of the ECAM or EICAS (can’t remember offhand which is the Boeing version)?  Also would not the QRH and/or checklists be available in the crew’s Electronic Flight Bags?

Yes it has a glass cockpit, but no Electronic Checklist or EICAS on any 737 variant. Once again, because big customers like Southwest and Ryanair don't want to foot the costs of retraining thousands of pilots in new type rating procedures. EFB checklists are available for reference but most operators use the paper QRH unless they have authorisation to use the EFB for inflight procedures from their national authority.

 

Normal checklists are usually on a laminated, double sided card, and reflect operator-specific procedures. I expect that's the one that went bye-bye when the flight deck door blew.

[11bravo]

14 hours ago, Alan P said:

Yes it has a glass cockpit, but no Electronic Checklist or EICAS on any 737 variant. Once again, because big customers like Southwest and Ryanair don't want to foot the costs of retraining thousands of pilots in new type rating procedures. EFB checklists are available for reference but most operators use the paper QRH unless they have authorisation to use the EFB for inflight procedures from their national authority.

 

Normal checklists are usually on a laminated, double sided card, and reflect operator-specific procedures. I expect that's the one that went bye-bye when the flight deck door blew.

Had a current MAX pilot on another site refer to this jet as just the old 737 with new TV's.     As noted above though, I don't think the blame for the lack of new (or even "not as old" tech) falls on BA, they are simply responding to what their largest customers demand.    Don't like it?  Write a strongly worded letter to Ryan, WN or the carrier of your choice. 

 

I found the report that the checklist flew out the cockpit door during the event to be pretty comical though.    I also found it surprising that the high security door blew open during a relatively low enegy depressurization event .  Wonder if was left unlocked for some reason?  Or maybe BA figured if there's a gaping hole in the fuselage, the last thing the pilots have to worry about is some drunk / disgruntled passenger trying to get into the cockpit. 

[Alan P]

19 hours ago, Alan P said:

One of the door panels is designed to blow out in the event of depressurisation to equalise the pressure between the cabin and flight deck.

@11bravo as previously noted. If it didn't equalise the pressure between compartments, structural failure could/would result. See what happened with the Turkish Airlines DC-10 when the cargo door blew out.

[11bravo]

59 minutes ago, Alan P said:

@11bravo as previously noted. If it didn't equalise the pressure between compartments, structural failure could/would result. See what happened with the Turkish Airlines DC-10 when the cargo door blew out.

I get that part, just figured there would be a blow-out panel or some sort of pressure relief valve, not the entire door blowing open, especially given that this wasn't a true "explosive" decompression.   

 

The only good thing about this (beside highlighting an inexcusable QC failure on Spirit / BA's part) was that no one was killed and the jet wasn't lost.   BA got amazingly lucky on this one.   That plug could have sheared off the vertical / horizontal stab and the outcome would have been much different.   I'd suggest that if this jet was lost, it would have been the end of the MAX program (and possibly BA's commercial airplane business).      BA has one last chance to get their house in order and start focusing on the basics, instead of their focus for the last couple of decades (increasing shareholder value).  I hope they make good use of it. 

Edited January 13 by 11bravo

[JohnT]

Another Boeing problem on a 737 cracked window. I imagine anything will get reported so no respite for Boeing

 

https://www.bbc.co.uk/news/world-asia-67968526

[hairystick]

On 1/13/2024 at 10:45 AM, Circloy said:

Are Boeing trying to be too clever by using plugs where doors would otherwise be fitted but are not required by the customer. Should the fuselage structure not extend through?

No.

If there is a "max-seating" configuration (squeeze the punters in!!!) then to meet the 90 seconds to evacuate the plane, that extra emergency exit door will need to be fitted.

 

 

Edit: There seem to be some "other" things discovered by the grounding of the fleet...

Edited January 14 by hairystick

[11bravo]

Never really understood why they opted to eliminate an emergency exit.   I get that from a regulatory standpoint it's not required but from a safety standpoint, having these openings fitted with functional emergency exit doors vrs "plugs" would still save live in the event of a catastrophic ground fire that required immediate evacuation.    Why not just keep these exits functional, regardless of seating layout?    Does the cost savings really trump the increase in safety that these would provide?

[kiseca]

I can't imagine it functioning well as an emergency exit when there's a seat right in front of it that's not on an extra wide "emergency exit" gap. Don't emergency exit doors open inwards and then have to get thrown out the door? Then once the door is out of the way, passengers need to clamber over the row of seats to get to the door, also making it more awkward to get on a slide, there's no room for a flight attendant to watch and help passengers exit through that hole.

 

I'd assume if they left the door in place and then put a seat in front of it like it appears to be from the images, it would hinder passengers exiting from that point. It may trap them, injure them or simply make them too slow when exiting to pass certification.

 

I don't know what the seat plans look like that makes that point an impractical place to have an exit row in some configurations but I'm expecting that making it a permanent door would have a knock on effect in seat arrangement options.

 

EDIT: also, if this is quality control problems, is there any guarantee that a door mounted there would be any less likely to make a bid for independence than the plug was? I'd expect that if the plug is capable of vanishing outwards, so is the door that replaces it?

Edited January 14 by kiseca

[Dave Swindell]

7 hours ago, kiseca said:

I can't imagine it functioning well as an emergency exit when there's a seat right in front of it that's not on an extra wide "emergency exit" gap. Don't emergency exit doors open inwards and then have to get thrown out the door? Then once the door is out of the way, passengers need to clamber over the row of seats to get to the door, also making it more awkward to get on a slide, there's no room for a flight attendant to watch and help passengers exit through that hole.

 

I'd assume if they left the door in place and then put a seat in front of it like it appears to be from the images, it would hinder passengers exiting from that point. It may trap them, injure them or simply make them too slow when exiting to pass certification.

 

I don't know what the seat plans look like that makes that point an impractical place to have an exit row in some configurations but I'm expecting that making it a permanent door would have a knock on effect in seat arrangement options.

 

EDIT: also, if this is quality control problems, is there any guarantee that a door mounted there would be any less likely to make a bid for independence than the plug was? I'd expect that if the plug is capable of vanishing outwards, so is the door that replaces it?

Boeing offers 3 optionsfor that position in the 737-900 Max

Door plug as fitted with Alaska, the plug is a semi-permanent fitting and is covered by normal interior panels, the only indicatiion of it's position from the inside is the slightly larger window spacing. Normal 3 row seating can be fitted with full row pitch flexibility. Cheapest option to pruchase, but expensive to convert into an operable emergency exit.

De-activated emergency door, again a semi-permanent fitting but looks like a door on the inside with the emergency slide cover protruding into the cabin space - this precludes the fitting of the outboard seats in rows in the vicinity of this door, much more expensive option to pruchase but cheap and easy to activate to a fully functioning emergency escape door.

Fully functional emergency exit door, requires an exit gangway to the doors inside and cabin crew located here during landing & takeoff as far as I'm aware.  Required fitment for certification for high density seating. These doors open outwards and pivot forwards or aft through 180 degrees to lie parallel to the fuselage side. The overwing emergency exits are hinged on the top side and open outwards and upwards.

When purchasing the 737-900 max new from boeing the customer has to weigh up their likely future requirements for the aircraft, if they intend to use it for high density seating they have to fit the activated emergency door, if they don't intend to use the aircraft initiaally for high density seating they have the option of choosing the de-activated door which may limit the possible seating configurations but can easily be upgraded if a high density seating arrangement is required in the future, or they can choos the door plug which gives maximum flexibility for seatng configuration but will be costly to upgrade to an activated emergency exit if required for high density seating.

The door plug is supposedly bolted and locked in the closed position with locking bolts secured by split pins, the functioning emergency doors have a much more complex operating and locking system, the same as the other doors on the aircraft which have flown millions of hours without dropping off.

[dambuster]

28 minutes ago, Dave Swindell said:

The door plug is supposedly bolted and locked in the closed position with locking bolts secured by split pins, the functioning emergency doors have a much more complex operating and locking system, the same as the other doors on the aircraft which have flown millions of hours without dropping off.

The functioning emergency doors in these locations have the same mechanism but are activated by an operating handle. These are emergency doors only so do not work like the normal entry/exit doors. When the door handle is moved it lifts the door 4cm to clear the stop pads and rollers. It then needs a push to open, and hinges at the bottom to lie against the lower fuselage, a bit like a cargo door in reverse. 
 

One point that has been mentioned in the Alaska accident is that the aircraft was flying through some turbulence just prior to the plug opening. This supports a theory that with no locking bolts to prevent upward movement of the door, and without the maximum internal/external pressurisation differential, the door moved upwards in the turbulence the 4cm needed to disengage from the stop-pads.
 

Peter

[NoSG0]

The door/plug at the NTSB. Thanks to OP on pprune. That is a few years of bubble wrap popping for me.

 

https://www.pprune.org/accidents-close-calls/656760-alaska-airlines-737-900-max-loses-door-flight-out-pdx-49.html#post11576255

Edited January 15 by NoSG0
Typo

[stevehnz]

21 hours ago, 11bravo said:

Does the cost savings really trump the increase in safety that these would provide?

 In the USA anyway, yes, if the book I've just read, Flying Blind, The 737 Max tragedy & the Fall of Boeing, by Peter Robison is to be believed, not a lot has changed.

Steve.

[Dave Swindell]

16 hours ago, dambuster said:

It then needs a push to open, and hinges at the bottom to lie against the lower fuselage, a bit like a cargo door in reverse. 

I knew that, don't know why I said it opened like the other doors, it wass late and I was knackered...

 

16 hours ago, dambuster said:

The functioning emergency doors in these locations have the same mechanism but are activated by an operating handle.

What I was trying to explain was the mechanism for locking the door in position was different - the arrangement for transferring the pressurisation loads and guiding and hinging the door plug or emergency exit door are the same, but the door plug is locked in position using 4 bolts passing through the hinges and guides which prevent any upward movement when fitted, whereas the emergency exit door is locked in position by the door operating handle.

Neither the door plug nor the emergency escape door are a new design for the Max, they are a carry over from the NG series.

[JohnT]

By chance I was reading up on the North American F-100 Super Sabre and came across a photograph in the Osprey Air Combat book of the factory production line.  Next to the line hangs a very large notice stating for all to see :-

 

"Quality must be built into a product.

It cannot be inspected into it."

 

Maybe Boeing need to run off a few !  Production line, design office, sub contractors etc

[NoSG0]

Eeesh. I know they will fix it but...eeesh

 

From the ntsb flickr account

https://www.pprune.org/accidents-close-calls/656760-alaska-airlines-737-900-max-loses-door-flight-out-pdx.html#post11577784

 

 

[hairystick]

On 1/18/2024 at 4:45 AM, JohnT said:

Maybe Boeing need to run off a few !  Production line, design office, sub contractors etc

"Head office", ALL CEO / board / executives' offices too!

 

Quality products begin at the top. If their leadership cannot influence the production workers...

[dambuster]

This seems to be a case of poor design thinking. If the requirement is to plug the gap where a door is not required by an airline, then why use something that can be opened? Would it have been possible to produce a different mechanism to replace the lower hinge, using the same fuselage fittings, that still enabled the plug to be dropped into position but then secured more robustly? At the very least someone should question what was the need for the lift assist hinges on a non-functional door? My understanding is that they are required on the emergency exit to prevent the door falling back once activated, which you obviously would not want in an emergency evacuation situation. Making the plug removal ‘easy’ in that it only required four bolts to be removed and providing ‘lift assist’ would encourage use of this as an access to the fuselage during any maintenance where the interior fittings were removed. 
 

Peter

[Dave Swindell]

4 hours ago, dambuster said:

This seems to be a case of poor design thinking.

The design has been in service since 2006 in over 500 737-900er's without any issues.

The issue appears to be recent poor asssembly, quality contol and inspection processes during manufacture.

[dambuster]

Latest news is that the FAA have called for inspections of door plugs on 737-900ER aircraft as there have been issues noted apparently with these same bolts by airlines that took the initiative to inspect following the Alaska incident. 

Edited January 22 by dambuster

[NoSG0]

https://www.flightglobal.com/safety/faa-recommending-737-900er-door-plug-inspections/156576.article

 

Sigh.

 

I really hope that all involved can figure this out quickly and with a proper fix.

[bentwaters81tfw]

And now more faults found. Hopefully information from an official source will come to light;

https://www.dailymail.co.uk/news/article-13046873/Boeing-finds-new-problem-737-Max-planes-worker-spots-mis-drilled-holes-fuselage-lead-delays-delivery-50-new-planes.html

[dov]

Hallo

The issue above, @bentwaters81tfwmentioned, is a logical issue, when too many options are packed into one design!

If a design is overloaded with options, it ís a nightmere in production and assembly!

It is simply unreasonable for every subsequent worker to create such overloaded and confusingly optimized drawings.

Typical issue of a dead cash-cow.

The workers are simply overwhelmed as a result.

The management certainly has no practical experience in production and assembly.

The management certainly has no idea what it means to work against the clock with such rubbish on overloaded drawings.

This is how employees become slaves.

Such designs should be reworked and made lean and safe for anyone who works on this matter.

Easy to estimate in future maintenance that the people who have to work on this a/c wish the evil to their creators.

This matter was for 20 years long my matter on an other public transport system!

 

Happy modelling