tef,
@tef@mastodon.social avatar

there's a very convincing anonymous post from an alleged boeing engineer, talking about how a "quality escape" can happen

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

mcc,
@mcc@mastodon.social avatar

@tef I cannot stop thinking about this video from three months before the incident— breaking down two separate problems, requiring expensive recalls/repairs at the end of Max manufacturing, which the vlogger ascribes to Boeing spinning off parts of their operations to save money, then having quality problems because half of their manufacturing was now technically under a different company they're constantly struggling with. Check your anon post and sure enough… Spirit https://www.youtube.com/watch?v=SmJgweFmoxs&t=320s

mcc,
@mcc@mastodon.social avatar

@tef I am not a physical engineer but it's hard not to draw a line from a known incident where a minor but potentially dangerous systemic production issue is found and fixed at the last minute before ship and everyone breathes a sigh of relief, and then a separate minor but potentially dangerous systemic production issue causes a door to fall off an airplane in flight months later…

mcc,
@mcc@mastodon.social avatar

@tef …and not think of the Challenger investigations, and descriptions of a culture where near misses kept happening and rather than this sounding an alarm over "we have a lot of near misses, we need to find and address the systemic problems causing this" it lead to a mindset more like "all of these near misses have turned out perfectly okay, so it turns out the process works well"

tef,
@tef@mastodon.social avatar

@mcc i feel the most indicative thing about challenger is that the engineers knew about the o-rings

and the elaborate length someone went to tell feynman

inviting him over to dinner, and just happening to be working in the garage on the car, which had a broken o-ring

tef,
@tef@mastodon.social avatar

@mcc

... and these are the faults we know about the 737

tef,
@tef@mastodon.social avatar

the tl;dr is "door plug had to be removed for some other repair, and wasn't tracked properly, unlike the original repair"

plus, y'know "increasing shareholder value will always push things beyond the safety margin"

... and "having formal and informal QA tracking procedures with management only caring about the latter, due to metrics"

tef,
@tef@mastodon.social avatar

i'm reminded of how nasa kills astronauts every twenty years or so

it starts with a management culture ignoring known risks , who only learn caution after getting blood on their hands

and after twenty years, all the managers with a guilty conscience leave, and the new ones feel there's no risk as all the bad stuff happened ages ago

mattgrayyes,
@mattgrayyes@chaos.social avatar

@tef I thought of this too when I saw the door news initially!

tef,
@tef@mastodon.social avatar

a lot of people are pointing out that after the merger with mcdonald-douglas fundamentally changed boeing as a company

and well, the 737max does feel like the dc-10 all over again, callous management, doors popping off and explosive decompression

cstross,
@cstross@wandering.shop avatar

@tef McD-D learned better for a generation ater the DC-10 disaster; problem is, that was early 70s, so by the mid-90s the managers who remembered it had all left … and then the re-toxified McD-D merged with Boeing and essentially did a reverse management take-over.

cdamian,
@cdamian@rls.social avatar

@tef
This sounds like so many organisations ... often without the killing though.
@cstross

luis_in_brief,
@luis_in_brief@social.coop avatar

@tef ask any urban South Floridian about the cycle of hurricane awareness (including both preparedness and compliance with building regulations). It's been 30ish years since Andrew, so we're due again.

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