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Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

(www.ntsb.gov:443)
165 points starkparker | 2 comments | 10 Jul 25 20:51 UTC | HN request time: 0s | source
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thomascountz ◴[10 Jul 25 21:46 UTC] No.44525985[source]▶
> We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled.

A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.

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JoshTriplett ◴[10 Jul 25 22:27 UTC] No.44526384[source]▶
Also, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".
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mrandish ◴[10 Jul 25 22:38 UTC] No.44526480[source]▶
Agreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training.

In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.

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lobochrome ◴[10 Jul 25 22:49 UTC] No.44526570[source]▶
In the end - action matters. Somebody didn’t put the bolts back in.

Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.

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1. bobsomers ◴[10 Jul 25 22:54 UTC] No.44526614[source]▶
Modern safety analysis acknowledges that humans are fallible, and they are generally acting in a good faith way to try and do their jobs correctly within a given system they are operating in.

That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.

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2. xp84 ◴[10 Jul 25 23:00 UTC] No.44526659[source]▶
Super underrated point - and one that I am not sure the general public always keeps top-of-mind, as human imperfection should be the default assumption. The whole system of air travel is designed so that wherever possible, multiple f*ck-ups can occur and not result in a catastrophe. The success of people involved with anything touching on aviation safety is best measured as in "how many f*ck-ups can occur in the same episode and have everyone still walk away alive?" If you can get that number up to 3, 4 complete idiotic screw-ups one after the other, and the people still live, you've really achieved something great.