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

> 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.

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 ...".

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.

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.

There's a reason why Murphy's Law is so commonly acknowledged, though. When you've got a process like this that gets repeated over and over by a bunch of different people, you simply must recognize that that, if it's possible for someone to fuck up, then somebody will fuck up.

And a relatively straightforward corollary of that reality is that, when somebody fucks up, putting too much personal blame on them is pointless. If it weren't them, it would have been somebody else.

In other words, this "blame is due where blame is due" framing is mostly useful as a cop-out excuse that helps incompetent managers who've been skimping on quality controls and failsafes to shift the blame away from where it really belongs.