Flight Safety Information - August 7, 2024 No. 157 In This Issue : Accident: Korean A333 over China on Aug 4th 2024, severe turbulence injures 14 people : Incident: Horizon E175 near Portland on Aug 5th 2024, hydraulic problems : Incident: United B752 over Atlantic on Aug 6th 2024, hydraulic problems : Incident: TUI B738 at Brussels on Aug 6th 2024, cargo fire indication : Incident: Tassili DH8D at Oran on Aug 5th 2024, burst tyre on landing : Incident: France A359 over Pacific on Aug 5th 2024, smell of smoke from trolley : NTSB, Boeing have not been able to identify who removed 737 MAX 9 door plug : Hearing seeks insight into blowout on a Boeing jet that pilots said threw the flight into 'chaos' : Boeing to make design changes to prevent future 737 MAX 9 door panel blowout : Calendar of Events Accident: Korean A333 over China on Aug 4th 2024, severe turbulence injures 14 people A Korean Airlines Airbus A330-300, registration HL7584 performing flight KE-197 from Seoul (South Korea) to Ulaanbaator (Mongolia) with 281 people on board, was enroute at 10,400 meters (FL341) over China near Tianjin when the aircraft encountered severe turbulence for about 15 seconds causing a number of people on board to be lifted towards the cabin ceiling and thrown back onto the floor. The aircraft continued to Ulaanbaator for a safe landing. The airline reported the aircraft was enroute near Tianjin when the crew observed lightning and thunder. The inflight meal was halted and the passenger instructed to keep their seat belts fastened. 10 passengers and 4 cabin crew received minor injuries however. The aircraft departed for the return flight on schedule. https://avherald.com/h?article=51c128c2&opt=0 Incident: Horizon E175 near Portland on Aug 5th 2024, hydraulic problems A Horizon Airlines Embraer ERJ-175 on behalf of Alaska Airlines, registration N663QX performing flight AS-2020 from Seattle,WA to Redmond,OR (USA), was climbing through FL270 out of Seattle when the crew reported a hydraulic problem and decided to divert to Portland,OR (USA). The crew requested a hold to make sure their gear got extended correctly and continued for a safe landing about 50 minutes after leaving FL270. A replacement ERJ-175 registration N645QX reached Redmond with a delay of about 3 hours. The occurrence aircraft is still on the ground in Portland about 18 hours after landing. The FAA reported: "Horizon Air Flight 2020 landed safely at Portland International Airport around 3:05 p.m. local time on Monday, August 5, after the crew reported a hydraulic issue. The Embraer E175 departed Seattle-Tacoma International Airport, and was headed to Roberts Field Airport in Redmond, Oregon. The FAA will investigate." https://avherald.com/h?article=51c1158d&opt=0 Incident: United B752 over Atlantic on Aug 6th 2024, hydraulic problems A United Boeing 757-200, registration N19136 performing flight UA-119 from Edinburgh,SC (UK) to Chicago O'Hare,IL (USA) with 181 people on board, was enroute at FL340 about 100nm south of Keflavik (Iceland) and about 800nm northwest of Dublin when the crew decided to turn around and divert to Dublin due to hydraulic problems. The crew advised that their operations were normal and they would be able to vacate the runway unless something changes, the crew requested runway 28R but was told to expect runway 28L. The aircraft continued to Dublin for a safe landing on runway 28L about 2 hours after turning around. The remainder of the flight was cancelled. The aircraft is still on the ground in Dublin about 4 hours after landing and is not estimated to depart until the next day. https://avherald.com/h?article=51c1250c&opt=0 Incident: TUI B738 at Brussels on Aug 6th 2024, cargo fire indication A TUI Airlines Belgium Boeing 737-800, registration OO-TUK performing flight TB-2252 from Heraklion (Greece) to Brussels (Belgium) with 123 people on board, was on approach to Brussels' runway 25L when about 7 minutes prior to estimated landing the crew received a cargo fire indication for the forward cargo hold. Upon contacting tower the crew reported the fire indication had just gone out after about 5-6 minutes being on and queried whether emergency services would be attending to the aircraft. The aircraft continued for a safe landing on runway 25L and stopped on the runway, the crew advised the indication had come back on and they wanted to evacuate. The aircraft was evacuated via slides. There were no injuries. Emergency services subsequently found no trace of fire, heat or smoke. The airline reported a potential fire indication in a cargo hold, the aircraft was evacuated, there were no injuries. Emergency services did not detect any trace of fire, heat or smoke. https://avherald.com/h?article=51c11e9d&opt=0 Incident: Tassili DH8D at Oran on Aug 5th 2024, burst tyre on landing A Tassili Airlines de Havilland Dash 8-400, registration 7T-VCN performing flight SF-2202 from Algiers to Oran (Algeria), landed on Oran's runway 25L but burst a tyre. The tyre was replaced and the aircraft was able to continue its schedule, flight SF2353 to Adrar (Algeria), however with a delay of about 3.5 hours. An investigation has been opened to determine the causes of the repeated incidents, also see Incident: Tassili DH8D at Rouhrde Ennous on Aug 3rd 2024, burst tyres on takeoff. https://avherald.com/h?article=51c118a2&opt=0 Incident: France A359 over Pacific on Aug 5th 2024, smell of smoke from trolley An Air France Airbus A350-900, registration F-HUVB performing flight AF-29 from Papeete (French Polynesia) to Los Angeles,CA (USA), was enroute at FL390 over the Pacific Ocean about 600nm north of Papeete when the crew decided to return to Papeete reporting the smell of smoke from a trolley. The aircraft landed safely back in Papeete about 4.5 hours after departure. The aircraft is still on the ground in Papeete about 16 hours after landing back, the flight to Los Angeles as well as the onward sector to Paris Charles de Gaulle (France) were cancelled. https://avherald.com/h?article=51c1127e&opt=0 NTSB, Boeing have not been able to identify who removed 737 MAX 9 door plug WASHINGTON (Reuters) -The National Transportation Safety Board and Boeing have not been able to determine who removed a door plug in a new 737 MAX 9 Alaska Airlines 737 MAX 9 that suffered an in-flight emergency in January, the board's chair said on Tuesday. NTSB Chair Jennifer Homendy told reporters Boeing needs to make significant improvements to its safety practices. "The safety culture needs a lot of work (at Boeing)," she said. "It is not there from the evidence itself, from what you see in the interviews. There's not a lot of trust, there's a lot of distrust within the workforce." The Federal Aviation Administration has also said Boeing must improve its safety culture and practices and directed it to address quality issues before the agency will allow the planemaker to boost 737 MAX production. Boeing did not immediately comment. The NTSB has said the 737 MAX 9 was missing four key bolts. Boeing has said required documents detailing the removal of the door plug during production of a 737 MAX 9 that failed during the in-flight emergency were never created. Boeing has provided a list of 52 prior cases of a door plug removal since 2019. Boeing's senior vice president for quality, Elizabeth Lund, said the planemaker has now put a bright blue and yellow sign on the door plug when it arrives at the factory that says in big letters: "Do not open" and adds a redundancy "to ensure that the plug is not inadvertently opened." Homendy said the NTSB has not been able to interview the door plug team manager, who has been on medical leave. Earlier this year, the NTSB had to press Boeing to get the names of the 25 employees who worked on the door plug. The NTSB has conducted some interviews and obtained some written statements. "I have some concerns because each of those written statements end with the line -- I have no knowledge," Homendy said. "It's the same actual line. So I have some questions about that." https://www.yahoo.com/finance/news/ntsb-boeing-not-able-identify-192357801.html Hearing seeks insight into blowout on a Boeing jet that pilots said threw the flight into 'chaos' Boeing factory workers say they were pressured to work too fast and asked to perform jobs that they weren’t qualified for, including opening and closing the door plug that later blew off an Alaska Airlines jet. Those accounts from inside the company were disclosed Tuesday, as federal investigators opened a two-day hearing into the blowout, which further tarnished Boeing’s safety reputation and left it facing new legal jeopardy. A Boeing door installer said he was never told to take any shortcuts but everyone faced pressure to keep the assembly line moving. “That’s how mistakes are made. People try to work too fast,” he told investigators for the National Transportation Safety Board. The installer, along with other workers, was not named in probe documents. The panel that blew off the Boeing 737 Max in January was made and installed by a supplier, Spirit AeroSystems. It was removed at a Boeing factory so that workers could repair damaged rivets, but bolts that help secure the door plug weren’t replaced. It’s not clear who removed the panel. Another member of the Boeing door crew said workers got no special training for door plugs and should not have been asked to open or close the panels. Boeing workers at the factory in Renton, Washington, have “been put in uncharted waters to do everybody’s dirty work because no one wants to touch it,” the second worker told investigators. He said Boeing's safety culture is “garbage. Nobody's accountable.” The workers’ accounts were among more than 3,000 pages of documents released by the NTSB as it began a two-day hearing into the Jan. 5 accident, which left a gaping hole in the plane and created decompression so violent that it blew open the cockpit door and tore off the co-pilot’s headset. “It was chaos,” the Alaska Airlines co-pilot told investigators. The captain said it was so loud that he couldn’t communicate with flight attendants. On an intercom, he heard them talking about a hole in the plane. He decided to land the plane as quickly as possible. The accident on flight 1282 occurred minutes after takeoff from Portland, Oregon, as the plane flew at 16,000 feet (4,800 meters). Oxygen masks dropped during the rapid decompression, a few cell phones and other objects were swept through the hole in the plane, passengers were terrified by wind and roaring noise, but miraculously there were no major injuries. “This was quite traumatic to the crew and passengers,” NTSB Chair Jennifer Homendy said as the hearing began. “We are so sorry for all that you experienced during this very traumatic event.” The NTSB said in a preliminary report that four bolts that help secure the panel, which is call a door plug, were not replaced after a repair job in a Boeing factory, but the company has said the work was not documented. During the hearing, safety board members are expected to question Boeing officials about the lack of paperwork that might have explained how such a potentially tragic mistake occurred. The safety board will not determine a probable cause after the hearing. That could take another year or longer. It is calling the unusually long hearing a “fact-finding” step. Boeing and Spirit executives said turnover since the coronavirus pandemic has left the companies with less-experienced workforces. Elizabeth Lund, who has served as Boeing’s senior vice president of quality — a new position — since February, said before the pandemic most new hires at Boeing factories had aerospace experience, often in the military. Now, she said, "considerably more of our employees did not have that aerospace experience.” Spirit Senior Vice President Terry George said that five years ago, 95% of the company's factory employees had worked with sheet metal, but now it is 5%. They company has increased training for tasks such as drilling holes and installing fasteners in aircraft bodies, he said. A representative of the machinists' union said Boeing cut back on inspections and training over the last several years. Lund said the company has significantly increased training since the Alaska Airlines blowout, and that the company is trying to improve quality as it focuses on “lean manufacturing.” “Can I make one suggestion?” safety board member Todd Inman interjected. “Sure, please,” Lund replied. “Stop talking about leaner and quality and start talking about safer manufacturing,” Inman said. Lund also said Boeing is working on ways to prevent door plugs from being closed if they are not firmly secured, but she could not say when that redesign might be completed. Boeing production of Max jets dropped below 10 per month after the blowout and remains under 30 per month, Lund said. The Federal Aviation Administration has set a limit of 38 per month until it is satisfied that Boeing's manufacturing process is producing safe planes. Later Tuesday, witnesses were expected to testify about the FAA’s oversight of Boeing. FAA Administrator Mike Whitaker has conceded that his agency's oversight of the company “was too hands-off — too focused on paperwork audits and not focused enough on inspections.” He has said that is changing. The accident led to several investigations of Boeing, most of which are still underway. The FBI has told passengers on the Alaska Airlines flight that they might be victims of a crime. The Justice Department pushed Boeing to plead guilty to a charge of conspiracy to commit fraud after finding that it failed to live up to a previous settlement related to regulatory approval of the Max. Boeing, which has yet to recover financially from two deadly crashes of Max jets in 2018 and 2019, has lost more than $25 billion since the start of 2019. Later this week, the company will get its third chief executive in 4 1/2 years. https://www.yahoo.com/finance/news/witnesses-tell-federal-safety-board-213857604.html Boeing to make design changes to prevent future 737 MAX 9 door panel blowout Summary • NTSB releases 3,800 pages of reports, interviews • Boeing's executives testify on quality improvements • FAA oversight criticized • Systemic issues at Boeing's factory highlighted by FAA inspector WASHINGTON, Aug 6 (Reuters) - Boeing said on Tuesday it plans to make design changes to prevent a future mid-air cabin panel blowout, opens new tab like the one in an Alaska Airlines (ALK.N), opens new tab 737 MAX 9 flight in January that spun the planemaker into its second major crisis in recent years. The National Transportation Safety Board and Boeing said officials still have not determined who removed and reinstalled that plane's door plug during production. Advertisement · Scroll to continue NTSB completed the first of two days of hearings Tuesday that lasted nearly 10 hours into the mid-air emergency that badly damaged Boeing's reputation, led to the MAX 9 grounding for two weeks, a ban by the Federal Aviation Administration on expanding production, a criminal investigation and the departure of several key executives. Investigators have said the door plug in the new Alaska MAX 9 was missing four key bolts. Advertisement · Scroll to continue Boeing, which has vowed to make key quality improvement, faced extensive questions about the production of the accident MAX 9 and lack of paperwork documenting the removal of the door plug. NTSB Chair Jennifer Homendy on Tuesday criticized the planemaker's safety culture, asking why it had not made improvements earlier and said it must takes steps to improve. "The safety culture needs a lot of work," Homendy said. Boeing's senior vice president for quality Elizabeth Lund said the planemaker is working on design changes that it hopes to implement within the year and then to retrofit across the fleet. "They are working on some design changes that will allow the door plug to not be closed if there's any issue until it's firmly secured," Lund said. Lund said two Boeing employees who were likely involved in the opening of the door plug have been placed on paid administrative leave. The board also released 3,800 pages of factual reports and interviews from the ongoing investigation. Boeing has said no paperwork exists to document the removal of four key missing bolts. Lund said Boeing has now put a bright blue and yellow sign on the door plug when it arrives at the factory that says in big letters: "Do not open" and adds a redundancy "to ensure that the plug is not inadvertently opened." A flight attendant described a moment of terror when the door plug blew out. "And then, just all of a sudden, there was just a really loud bang and lots of whooshing air, like the door burst open," the flight attendant said. "Masks came down, I saw the galley curtain get sucked towards the cabin." Doug Ackerman, vice president of supplier quality for Boeing said Boeing has 1,200 active suppliers for its commercial airplanes and 200 supplier quality auditors. Lund said Tuesday Boeing is still building "in the 20s" for monthly MAX production - far fewer MAXs than the 38 per month it is allowed to produce. "We are working our way back up. But at one point I think we were as low as eight," Lund told the NTSB. Last month, Boeing agreed to buy back Spirit AeroSystems (SPR.N), opens new tab, whose core plants it spun off in 2005, for $4.7 billion in stock. The hearings are reviewing key issues, including 737 manufacturing and inspections, safety management and quality management systems, FAA oversight, and issues surrounding the opening and closing of the door plug. FUSELAGE DEFECTS Jonathan Arnold, Aviation Safety Inspector at the FAA, said a systemic issue he witnessed at Boeing’s factory was employees not following the instructions. "That seems to be systemic where they deviate from their instructions. And typically, tool control is what I see most," Arnold said. Lund said before the Jan. 5 accident, every 737 fuselage delivered to Boeing by Spirit AeroSystems had defects. "What we don't want is the really big defects that are impactful to the production system," Lund said. "We were starting to see more and more of those kinds of issues, I will tell you, right around the time of the accident." Homendy at one point expressed frustration with Boeing. "The safety culture needs a lot of work (at Boeing)," she said. "There's not a lot of trust, there's a lot of distrust within the workforce." Boeing executive Carole Murray described various problems with fuselages coming from Spirit AeroSystems in the run-up to the accident. "We had defects. Sealant was one of our biggest defects that we had write-ups on," she said. "We had multiple escapements around the window frame, skin defects." Michelle Delgado, a structures mechanic who worked as a contractor at Boeing and did the rework on the Alaska MAX 9 aircraft, told NTSB the workload is heavy and requires working long hours. "In order for me to not have to deal with a worse situation tomorrow, I'd rather work a 12 to 13-hour shift to get it all done, for my sake, so I don't have to deal with people the next day," he told NTSB. Also in June, the NTSB said Boeing violated investigation rules when Lund provided non-public information to media and speculated about possible causes. Last month, Boeing agreed to plead guilty to a criminal fraud conspiracy charge and pay a fine of at least $243.6 million to resolve a Justice Department investigation into two 737 MAX fatal crashes. https://www.reuters.com/business/aerospace-defense/us-transport-safety-board-hold-hearings-boeing-737-max-9-mid-air-emergency-2024-08-06/ CALENDAR OF EVENTS • Asia Pacific Summit for Aviation Safety (AP-SAS 2024), Aug. 13-15, Beijing, China. • Asia Pacific Airline Training Symposium - APATS 2024, 0-11 September, 2024, Singapore • Aircraft Cabin Air International Conference - 17 & 18 September - London • 2024 Ground Handling Safety Symposium (GHSS) - September 17-18, 2024 - Fort Worth, TX • 2024 ISASI - Lisbon, Portugal - September 30 to October 4, 2024 • DEFENCE AVIATION SAFETY 2024 - 2 OCTOBER - 3 OCTOBER 2024 - LONDON • International Congress of Aerospace Medicine ICAM 2024 in Lisbon, Portugal, 3 - 5 October 2024 • Aviation Health Conference back on Monday 7th and Tuesday 8th October 2024 • Safeskies Australia Conference, Canberra Australia - 16th and 17th of October 2024 - www.safeskiesaustralia.org • 2024 NBAA Business Aviation Convention & Exhibition - Oct. 22-24 (Vegas) • Sixth Edition of International Accident Investigation Forum, 21 to 23 May 2025, Singapore Curt Lewis