You probably might have seen the frightening video from the Alaska Airlines flight from Portland, OR where the flight’s unused emergency door blew out at 16,000ft and caused a gaping hole in the fuselage. At that height, due to pressure difference, items were sucked out and dropped to earth. Thank heavens, no person was sitting next to the door and everyone was wearing seatbelts (listen to safety instructions, always!). The root cause of the issue is still unclear and the NTSB is investigating fully. We are not concluding any problems with the aircraft as most information is not privy to us. Journalists have documented interviews & reports on their culture extensively. The Boeing 737 Max series is marred with poor manufacturing quality & compromised design choices.
What can we learn: Have a high Quality Inspection (QI) for your manufactured products. Design choices will have an impact on the product’s Reliability. Use the Robust Ready framework to evaluate if the design balances Cost, Features, Reliability, and Time-to-Market. Operators play a role in ensuring Reliability – any alarms or anomalies must be reported to the Maintenance team for inspection.
It is also worth noting that the airline records show they had previous warnings about small losses in cabin pressure that were left unresolved. This is a hard lesson in the fact that most sudden catastrophic failures that “come out of nowhere” have been giving a “tell” that they are going to occur. There are no “small” problems or indicators when it comes to complex machinery. Everything is a health indicator, and all catastrophes have precluding symptoms. In many post mortems I have seen the clues needed to direct us to the issue before catastrophe were observed and documented, often marked as “continue to observe” or “no fault found.” What percentage of your investigations end in “no-fault found?”
-Adam