Boeing Aircraft

Purely a guess by a nerdy engineer. I replayed what he said at the punch line six times but could not understand it. He said something like "but we can't blame the fasteners ^%$#??* the technician who forgets to put them in". Almost like that small section within that sentence was edited to smear the audio.... WTH!

I still wager they knew exactly what and who caused the problem at their first inspection after the incident.
 
Purely a guess by a nerdy engineer. I replayed what he said at the punch line six times but could not understand it. He said something like "but we can't blame the fasteners ^%$#??* the technician who forgets to put them in". Almost like that small section within that sentence was edited to smear the audio.... WTH!

I still wager they knew exactly what and who caused the problem at their first inspection after the incident.
Sounds like to me, "but we can't blame the fasteners AND the technicians who forgets to put them in"

When doing some sort of incident investigation, doing a root cause analysis or a "5 Why", you have to arrive at a system failure and not point the finger at an individual, in this case the technician that likely forgot to put the bolts in. You need a robust system of checks and verifications that eliminates random errors. Because people can and do make errors and a robust system accounts for that. That's why pilots use a check list for everything. In the video, the speaker talked about an impact wrench or robotic tool that can record torque data. So I am guessing if the door requires X number of bolts, there would be an electronic record that shows X bolts being properly torqued.
 
Keeping torque and rev data on record for a variety of different bolts during a process or series of processes? Those records are kept for astronauts doing that type work but for maintenance, installing or replacing door plug bolts or any of a zillion varieties on airplanes??? Guaranteed they know what happened and who screwed up. Bureaucracies, big business and unions protect their own. Might look for extra fasteners (errrah aviation caps screws) laying around in a coffee can. Of course the common tater on the video couldn't bring himself to use such a sophomoric term as "bolt". Jeez of course they are a freaking bolt! Maybe aviation cap screw doesn't sound technical enough. Cripes, a "fastener" can mean most anything!! Pins and collars even more cryptic. Yet the super generic term "fastener" is where he ended up. LOL
 
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Sure, some unmotivated factory assembly line work forgot the bolts. So he gets fired. The problem isn't solved though. You replace him with a DEI unmotivated factory worker and the same problem is likely to happen again. You have to change the system. The system has to be able to check and eliminate random errors or variation. A QA/QC person who comes behind the worker and signs off on the job, for instance. An automated recording/report of the torque values is good too. On drilling rigs, we use both torque and number of turns for analyzing/verifying screwing together drill pipe, casing and tubing. Another way is for the worker to pull out his phone and take a photo or video of the completed, installed door, showing the proper number of bolts installed.
 
The assembly worker or maintenance worker or inspector has either a paper or electronic tablet with a diagram and specs with check offs for those specific bolts for that specific job. Either by hand tool, likely a mechanical torque wrench or an electric drive with adjustable torque limiter those bolts are torqued down to specs in a specific order. That worker, at whatever level he works, assembly or maintenance, initials or checks off that operation then goes to the next. The engineer in the video seemed to hint that there was a common way for the tool itself to digitally record all that data. Or that those tools are in common use in the assembly or maintenance of aircraft??? All the entities involved will be finger pointing somewhere else- they protect their own. Lucky this time. Next time maybe catastrophic consequences. Not that long ago, IIRC, a model group of large commercial jets in one of a major carrier's fleet, were discovered to have loose, damaged or missing main engine support bolts. Not only does the individual have to be held accountable, the whole chain of command has to be. But these cultures protect their own.
 
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The real problem seems to lie with the Georgia plant and takeover by executives with almost no technical knowledge
Very similar when I worked for Sears Roebuck. Attending the Diehard 500 they had a tire changing competition (1997 off rd so). Sitting at the table I asked what version Coats tire changing machines they were using. I used them in the early 70’s so didn’t know the later models.

One of young managers of the Sears Tire store responded with “what’s that?” I said the machine the teams are using. His response was “don’t know, I’ve never used one!”

And we wonder why companies eventually fold.
 
The real problem seems to lie with the Georgia plant and takeover by executives with almost no technical knowledge
Another problem is the management encourages everyone to further their education. So now the effort is to gain another degree to climb the ladder.
 
Ron Rodgers is a former USAF instructor and test pilot, and also a retired United Airlines pilot. I think he has an electrical engineering degree too. His narration is low keyed to somewhat boring, but the topics are interesting and the guy knows his stuff.

 
Ron Rodgers is a former USAF instructor and test pilot, and also a retired United Airlines pilot. I think he has an electrical engineering degree too. His narration is low keyed to somewhat boring, but the topics are interesting and the guy knows his stuff.

Bingo
 

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