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

(www.ntsb.gov:443)
165 points starkparker | 1 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. ghushn3 ◴[10 Jul 25 23:27 UTC] No.44526847{3}[source]▶
This is absolutely incorrect. It runs counter to every high functioning safety culture I've ever encountered.

The system allowed the human to take the incorrect action. If your intern destroys your prod database, it's because you failed to restrict access to the prod database. The remediation to "my intern is capable of destroying my prod database" is not "fire the intern" it's "restrict access to the prod db".

Even the best trained humans will make errors. They will make errors stochastically. Your systemic safety checks will guard against those errors becoming problems. If your safety culture requires all humans to be flawless 100% of the time, your safety culture sucks.

So no, this isn't a fault with a human. Because this was a possible error, it was inevitable that at some point a human would make that error. Because humans never operate without errors for extended periods of time.