Yep, biggest new thing here is discussion of witness marks showing no evidence of the bolts, and photo before the rivet repair showing that at least two of the bolts were present, and photo after the rivet repair during installation of the insulation showing at least 3 bolts missing.

So this all just serves to confirm that report, and what people suspected for a while; the bolts were just missing, removed for removing the door plug for the rivet rework and never reinstalled.

> removed for removing the door plug

there was apparently two (identical) procedures -- one for "removing" the door plug and one for "opening" the door plug -- but only one of them actually called for paper-work and quality inspection after it is done.

It seems they decided to "open" the door plug instead of "remove" it to work on the sealing issue? -- and thereefore documentary record of the work performed and inspection thereafter is lacking.

It would be useful IMO to explore what led the team to prefer "opening" versus "removing" -- and if the subtle difference in documentation requirement was a consideration in preferring one over the other -- and if that points to deeper pervasive culture issues that leans towards less work rather than give safety and quality the primary importance.

I don’t think there were two approved procedures.

I think there was an approved procedure (“removing the plug”) and a deviance from process, justified with ad hoc semantic games.

I doubt this was intentional? It sounds more like mistakenly applying the procedure for opening a normal door, which requires no followup, to opening a door plug, which does.

lol of course it was intentional.

what the Spirit mechanics had to do was a RMV, they knew this, because the Boeing eng rep told them so, but they didn’t like this, so they marked it in the system as an OPEN but performed the work of a RMV, to avoid the additional quality checks a RMV would require. And then they fucked up the RMV but didn’t know and no one else did because it was marked as an OPEN so no one checked the bolts.

this was very intentional. the Spirit mechanics thought they were hot shit and didn’t need to follow the stupid, slow process. and they abused the system to allow them to file the work as more innocuous than it was. because they didn’t need anyone checking their work, or whatever they were thinking.

My experience in across a range of technical and consulting roles has been that junior folk understand the need gor their work to be reviewed and checked, because they know that they are inexperienced. Good senior folk want their work to be checked because they are experienced enough to know that they are fallible. It is the mid level folks (especially those who are promoted above their competence to senior roles) who think that they are good enough not to need hheir work reviewing.

This is my experience as well, but it’s usually not those promoted above their capability but those who were passed over and then grow resentful that end up causing the issue. An otherwise competent, but now bitter, middle aged guy on the third shift (or otherwise with less supervision than usual) who is going through a divorce or some other major life stress is the scenario I see most often. They fall behind, they come in to catch up, they have to leave unexpectedly for a family medical crisis, they fall further behind, and so on and so on and before you know it, a perfectly rational person is doing stuff like half-assing the QA checks and it seems almost normal.

But you’re right. It’s not the black belts you have to watch out for it, it’s the browns.

Are Spirit employees allowed to file records in CMES?!

Are Spirit employees not accountable for their work?

Ironically that anonymous insider account is more insightful than the 100+ pages of this report.

Yeah, this is a preliminary report, they only report direct factual findings that they have collected so far, and as they mention in this report, they haven't yet examined the electronic manufacturing records that the insider was referring to.

The NTSB is not quick to jump to conclusions; they are very thorough, and they collect and sort through a lot of evidence. It's not surprising that there's information out sooner that says more for such a high profile incident; but once the NTSB final report comes out, it will be quite detailed and thorough, and cover all of this and more.

It's a preliminary report, they deliberately avoid including conclusions that might be reversed later but would do harm by inclusion at this stage.

Where are you seeing a 100+ page report?

The report is 19 pages.

Can someone explain to me why this door plug wasn't actually a plug that physically stays sealed from cabin pressure? That seems like a sensible failsafe?

Probably because it reuses parts of the design of the emergency door so it can be swung out of the way for maintenance. The emergency door uses this complex designs of stop pads and guide rails etc to have “plug” characteristics (which did hold out for 3 months without being properly secured) because a true plug door would have to swing inwards, which isn’t an ideal property for an emergency escape, and I’d guess it might need more room reserved internally.

It's also done this way so a real emergency exit can be installed instead of the plug if the airline (or another airline that buys the plane) decides to increase seating capacity. It would be really inconvenient (not to mention mechanically questionable) if you would have to weld additional stuff onto the fuselage to accomplish this, so the parts that are connected to the door frame are already there...

Good point. Boeing (737) has the door open to the outside. The Airbus (320) the door opens to the inside.

I can remember when I was small my Mom mentioned that doors of buildings in the US are mandatory to open to the outside, a rule that does not exist in Europe AFAIK. So there you have it, you have a significant higher chance of crashing in a Boeing, but when it happens, your can leave the plane 2 seconds faster.

Nope, you are wrong on both accounts. OP is referring to the emergency exit and why it would make sense to make them fail save. These doors are located above the wings. Your picture shows the normal entrance door. This door is gigantic and has all sorts of safety procedures to keep them closed.

Boeing opens the emergency exit to the outside and we all know that they will just pop out during flight every time they forget to bolt them. Airbus has a fail save design: unlock, pull in, then throw it out. No way you can open these during flight, with or without bolts.