FOIA Response From the FAA Shows That the FAA Didn't Actually Investigate Boeing QA Manager Whistleblower Mitch's Whistleblower Report
I've gotten back a troubling Freedom of Information Act (FOIA) request response from the FAA that shows again that the FAA just goes through the motions (if that) in whistleblower investigations, rather than what you would expect them to do if they worked for you rather than for Boeing--be all over investigating fraud and noncompliances at aviation companies like white on rice. You can download or view the entire response on the new FOIA Response Page.
I put in the FOIA request on 4/18/18 and got this response faster than any of the others I've submitted so far. I requested that any documents concerning the 25% 787 oxygen bottle failure rate that Boeing QA Manager Whistleblower Mitch reported to them. They returned their seriously deficient investigative report and related emails that were redacted except for who sent them and who received them. The only positive note is that they disclosed the entire investigative report, not just limiting it to the investigation of the 787 oxygen bottle whistleblower report item.
Here is Mitch's Whistleblower report, which was part of the FOIA response so you can understand the FAA's investigation report. Click on the "expand" icon to view the entire page:
As you can see, Mitch reported three items for investigation. The 787 oxygen bottle squib failures, Boeing South Carolina's failure to ensure part serial numbers were recorded correctly during production and failing to notify Boeing customers that their Airplane Readiness Log (ARL) lists were suspect as a result of those errors, and the "lost" defective 787 parts that were likely installed on random 787s in service today. What follows is what the FAA thinks is an actual investigation of those issues:
Note that during the investigation that Boeing lied to the FAA that all the missing defective parts were lost rather than likely being installed on random 787s, totally leaving out the most likely way those parts disappeared as noted in my 5/9/18 blog on the subject.
As you can see, the FAA substantiated Mitch's report of lost nonconforming parts, but that seems to be only because 53 parts had been lost and/or Boeing volunteered to actually investigate the 176 parts that Mitch told them were closed out as lost without any investigation of where they ended up. The FAA appears to have completely ignored the most serious part of Mitch's disclosure--that the defective parts were likely installed on 787s now in service in their defective conditions.
And you can note the FAA's failure to fully respond to my FOIA request by reading the "Corrective Action" for allegations 1 and 2 concerning the "lost" nonconforming parts. The report states that the FAA issued a Formal Compliance Action to Boeing, which had a due date of 3/31/17, and after review of Boeing's corrective action response, they would know when the ECD of closure and verification of the Formal Compliance Action would be. The due date of that FCA was over a year ago, yet is not included in the response. Maybe they are hiding behind the fact I didn't specifically request info on that item in the report in my FOIA request. One more FOIA request to write I guess.
But what is most troubling about the response to this whistleblower report item is the FAA's investigator(s) acceptance of everything Boeing management told them, without any investigation themselves. They reviewed Boeing's documents of their so called "investigation" instead. They did not investigate the factory for the "lost" defective parts being out on the production floor unidentified or installed on 787s.
This is the FAA's specialty--Boeing biased so called "investigations" of whistleblower reports, as the FAA has done at least since 2002, when they closed out my 382 item report with only a superficial investigation of only 5 to 8 percent of those 382 items while ignoring 92% of them and refusing to investigate the main item I wanted investigated and replaced--the Boeing QA managers responsible for the 382 noncompliances in my report, and Boeing inspectors' rollerstamping inspections off as complete rather than actually doing them as required as I had witnessed myself when I was an inspector at Boeing.
Time and time again, including in this investigation of Mitch's whistlebower report, the FAA has placed blind trust in Boeing management to fix things that those same Boeing managers were at fault for intentionally allowing or ordering themselves.
The next item in the FAA investigation report, "Allegation 3" concerning Boeing's failure to investigate the 25% 787 oxygen bottle squib failure rate, is even more poorly handled than the "lost" defective parts issue that the FAA never investigated themselves to see if they were being installed on 787s, as Mitch saw they were himself.
First off, as you can see above, they "investigated" nothing. They just interviewed Boeing personnel and looked at only the documents they were given by Boeing. The People they likely interviewed were probably Mitch's corrupt QA Superintendent and the remaining likely similarly corrupt QA Managers that worked for him, as all halfway ethical QA management had been purged from Mitch's former management at the time of the investigation, I believe.
They took it on misplaced faith that Boeing QA management and the squib supplier were investigating the issue. No proof that the issue was actually being investigated and when that investigation actually began was included in the report. Boeing Powerpoint Rangers could certainly whip up a relatively real looking fake investigation Powerpoint and related documentation overnight. It's unknown how much notice the FAA investigation team (if it was more than one person) gave Boeing QA management of the team's visit.
And, as the report above shows, the FAA investigators bought whatever documentation Boeing produced about the issue hook, line, and sinker.
Then, just based on that one visit, the investigative team called it all good, didn't substantiate Mitch's reported issue, and closed the issue out. No FAA personnel will be following up to ensure that the 787 oxygen bottle squib failures are corrected, and will not be ensuring that Boeing addresses the thousands of defective 787 passenger oxygen bottles that may be installed in the delivered fleet. This is the quality and depth of FAA investigations when life sustaining equipment on airplanes are suspected to fail up to 25% of the time. It's almost criminal level incompetence and abrogation of their basic regulatory and investigative role over the safety critical aviation industry, in my opinion.
And Boeing QA Manager Whistleblower Mitch reviewed the FAA investigative report and pointed out that there are quite a few misleading and incorrect statements made in the relatively short investigative report description of the "investigation" of the issue.
The portion of the report that reads: “The PSU electrical circuits are tested twice…and in the event of a failure, the PSU is removed…After removal, BSC personnel discharge the emergency oxygen bottles and there have been some cases where the squibs failed,” is misleading and incorrect per Mitch.
He states that the squibs that failed were not due to them failing the electrical circuit test on 787 airplanes. Most of the squibs in question were taken straight out of stores (an inventory purge) and were being discharged due to the part numbers being rolled, so they were no longer the latest version for use on the aircraft, but they were still conforming parts. Others were from mechanics damaging the plastic housing of the PSU. If they chip a corner or scratch the PSU, they throw them aside and grab a new one. Again, there was nothing wrong with the PSU oxygen system, just the plastic PSU housing was damaged. The FAA is trying to mislead and minimize this issue, Mitch says.
As for, “…the FAA confirmed BSC is aware of the squib failures...,” Mitch says that Boeing is not denying the 25% squib failure rate, they are just trying to cover it up.
And Mitch says, ”...and (Boeing South Carolina) is actively investigating the issue,” from the report is incorrect. He says the squibs are still in BSC MRSA. He's talked to the Boeing people that would be doing this investigation in Everett and BSC and none of them know anything about this.
And Mitch also says that the “Preliminary BSC investigation findings have attributed squib failure to wire harness damage occurring during storage, handling, and installation” section of the report is also incorrect. Mitch did the preliminary investigation of the squib failures, and he oversaw the unpacking, handling and disassembly of the PSUs after they were pulled from stores and brought in from the field. He says that the PSUs are in oversized boxes, packed in thick foam, and are very protected in their shipping boxes, and it is physically impossible for the wiring to be damaged in storage or in transportation because they are so well protected. I've seen similar packaging of such pricey supplier built components myself, and about the only thing that could probably damage such parts nested in perfectly shaped high density foam within sturdy wooden steel banded crates is a nuclear strike or similar powerful explosion. They are seemingly packaged to withstand crashes at highway speeds of the trucks they are transported in.
Mitch states that early on, his team did receive 3 or 4 bottles from the field where the wires had been cut, but he assured that didn’t keep happening and those 3 or 4 were set aside for future action. He says that the 75 squibs that failed to fire were fresh out of stores and had never been handled by mechanics at all.
So there you have it. Boeing is trying to cover up the nature and extent of these 787 passenger oxygen bottle failures from the FAA, and it appears they have succeeded, as the FAA intentionally did no investigative action themselves other than accept, without any corroboration on their part, Boeing's investigation, an investigation that came up with the wrong preliminary cause as Mitch notes. Who knows if either Boeing or the supplier continued their alleged so called "investigation" of the squib failures after the FAA investigative team left the factory.
This obviously incompetent FAA investigative team also breached Mitch's statutorily protected whistleblower confidentiality due to them sending his whistleblower report to Boeing with all of his personal information unredacted. Then his whistleblower report was printed on a Boeing "public" office printer by the Boeing manager that received it from the FAA and was left there for an unknown but significant amount of time for other Boeing personnel in the office to see.
On to the FAA investigation's report on their "investigation" of "Allegation 4:"
Mitch says that the FAA report's key words in their botched investigation of his above allegation 4 concerning Boeing's failure to notify customers of ARL errors are, “when an error in the ARL...is found…" Mitch says that that is the real problem--BSC is not really "looking” to find all of the many ARL errors in the first place, so 787s are delivering with many incorrect part numbers and serial numbers on the ARLs than what are the part and serial numbers actually installed on the delivered airplanes.
Mitch gives this quick "Reader’s Digest version" of the problem: At the Boeing Everett Plant (as a comparison) they have around 30 “ARL Inspectors” that are assigned to go out and put eyes on every serialized part on the airplanes to verify that the recording of the serial numbers are complete, accurate, and match the equipment installed.
At Boeing South Carolina, however, there are 3 “ARL Administrators” that are “responsible” for the ARL accuracy for all the airplanes and airplane sections built there. It must be noted that all Boeing 787s, even Everett built and delivered 787s, have a large Boeing South Carolina built content, including entire sections of the airplanes that Boeing Everett inspectors are not allowed to inspect at all for quality and conformity upon receipt in Everett. Therefore, Boeing South Carolina deficient work as detailed in the last three or so blogs is almost surely not fixed at all in Everett, including any ARL mistakes from BSC.
With FAA oversight as incompetent as noted above, getting the serious issues reported to them by whistleblowers fixed through the FAA investigative processes is largely impossible. When the FAA lets the "fox" (Boeing management) watch the hen house instead of the FAA, and then only asks the "fox" how the chickens are doing when reports come in that the chickens have all been eaten, you have the situation noted here, where Boeing Quality System corruptions as noted above are pretty much unrepairable.
In both Everett and BSC, the mechanics are responsible for recording the serial numbers as they install the parts/equipment. In Everett, however, there are inspectors that lay eyes on every part to check the accuracy of the part serial numbers as noted. In Everett, those inspectors discover thousands of errors each year and they are able to correct them on the spot.
At BSC, however, they take the mechanics' words for the accuracy of the recorded serial numbers. The ARL Administrator sits at a desk and does what is called an "Engineering bump." Basically, they run a report listing all 1815 serialized parts per airplane and compare the length and format of the serial numbers, and not the accuracy of them.
As an example, if the format of the serial number is supposed to be "123A4-1," but the number in the record is "A1234," then it is flagged and corrected, but as long as the format matches, the bogus serial numbers pass on to Boeing customers undetected and uncorrected. The example serial number could be "968Z3-9," and it would pass as correct even though it isn't remotely close to the installed part's serial number.
Mitch's team found mechanics that had created a list of serial numbers from several airplanes back on the production line and were just copying and pasting the same serial number list to different 787 line number build records. Mechanic's were putting “NA” in serial number boxes and just making up numbers, all in the interest of “going faster."
Mitch says that Boeing isn’t lying when they say they correct the errors when they find them. What they are leaving out, however, is that the system they have in place at BSC is set up for failure and will not find many of the errors in the ARL log Boeing customers receive.
Mitch says this really gets complicated if you want to know the reason the ARL accuracy is important. He says that a person needs to understand what the recorded serial numbers are actually for, and why they are so important and the dependency that the customers and the FAA have on complete and accurate build records.
One example Mitch likes to use is the recent recall of many of the airbags in cars and trucks. Because the manufacturers had accurate build records, they were able to identify which vehicles were affected by the defective air bags and were able to notify the owners of those vehicles of the recall. Imagine if they didn’t know which vehicles those defective airbags were used on. Mitch says that is the case at BSC--they have no idea what airplanes most of the serialized equipment is installed on. He says this will not pose a problem unless there is a major recall of some type or if there is some type of catastrophic accident that would require an investigation of the build records. Unfortunately, it will be too late at that point.
There you have it. As you can see above, the FAA really screwed the pooch (as they normally do in my experience) in their so called "investigation" of Mitch's whistleblower report, just as they also did in 2002/2003 with my report to the FAA about the rampant Boeing QA fraud that I witnessed during my career at Boeing.
Everyone loses with such bungled FAA investigations. Especially the flying public who doesn't know about these issues and therefore can't use the existence of such existing unaddressed problems to inform themselves on which airplanes they choose to fly on.
Boeing QA Manager Whistleblower Reveals That Thousands of Defective and Scrap Parts Likely Have Been Installed on Boeing 787s, Including Two Entire Fuselage Sections
Today, in the third of many revelations, Boeing QA Manager Whistleblower Mitch reveals that thousands of defective and scrap parts likely have been installed on Boeing 787s that are in service today, including two entire fuselage sections, both of which had significant skin delamination which Boeing Engineering deemed unrepairable. Those two structurally deficient fuselage sections quite likely may be flying around on two different and unknown 787s today, imperiling any passengers and crews that fly on them.
Mitch found this out when his Boeing QA upper management retaliated against him by re-assigning him to be QA Manager over the 787 factory MRSA (Material Review Segregation Area) for his ethic of doing his QA Manager job with the integrity required for that position per Boeing's FAA approved QA procedures. The QA Superintendent he reported to actually docked him on his annual performance ratings for actually following Boeing QA procedures instead of "working in the gray areas" of those procedures, whatever that means.
The Boeing 787 factory had four different MRSAs and each one had their own lost/stolen defective and scrap parts list to deal with when Mitch started his MRSA QA Manager role. There were over 1800 lost/stolen defective and scrap parts on the list when Mitch started, and he was told there was another 1000+ MRSA parts' nonconformance records that were closed out, largely without the required investigation to find them, prior to his taking over the factory MRSA QA Manager role that also are likely to be installed illegally on Boeing 787s. This is product substitution on steroids.
MRSAs are areas where defective and scrap parts are stored to keep Manufacturing from taking those defective/scrap parts and installing them on an airplane in place of an out of stock conforming part. They are usually locked caged areas to prevent the “do anything to complete the job on schedule” Manufacturing Mechanics, Leads, and Managers from purposely stealing the defective/scrap parts therein to use in place of an SOS (out of stock) part to complete an assembly so that a Boeing QA inspector can buy it off as a completed job, or "bean," as known internally at Boeing.
This use of defective parts in place of conforming parts issue is all the more serious on the 787 program, with its heavy use of composite parts that may be delaminated internally and appear as though they aren't defective with the naked eye.
In this Boeing age of “just in time” inventory, where Boeing has only the minimum amount of parts for production on site (which are delivered as late as possible to minimize the extra costs of buying and storing parts before they are needed), when a defective part is written up on a Nonconformance Record (NC/NCR) or scrapped altogether, that often generates an SOS parts situation on the production line that prevents a job from being completed, or many jobs from being completed that are dependent on installation of that one defective part in the MRSA.
Because unethical Boeing Manufacturing personnel have historically stolen defective and scrap parts from MRSAs to complete work on Boeing's production lines, the MRSA system of locked cages or rooms monitored by QA was developed.
In his MRSA QA Manager role, Mitch and others witnessed the MRSAs being raided for parts for use on 787 production airplanes. They found parts that had been painted red and put in the MRSA scrap bins out in the production areas being used by Manufacturing. Mitch found dozens of parts that had mysteriously “walked off” from the shelves in MRSA cages after he was directed to issue keys to the MRSA to the First Line Manufacturing Managers.
That is like handing crack cocaine to an addict. There is almost nothing so depraved of ethics at Boeing than a Manufacturing Manager who is solely rated on how many "beans" his crew sells to QA on a shift. They almost always (in my experience) have equally corrupt Manufacturing Leads and even a few "regular" Mechanics that do their dirty work, like covering up defects, and stealing defective and scrap parts (or getting them from the boss who has the MRSA key) and installing them.
Boeing QA Manager Whistleblower Mitch and I have a lot in common. We both battled to do our jobs despite our management wanting us to do otherwise. Apparently we both were born with a defect that can get you easily terminated or retaliated against at Boeing--a core of integrity and ethics.
When Mitch was assigned as the manager of the factory MRSA, he insisted that each lost/stolen nonconforming part be fully investigated to determine their final disposition and to assure there were no nonconforming parts on the 787s out in production or in service per the requirements of the applicable Boeing Process Instruction (BPI). This put him in direct conflict with his Boeing QA senior management.
He was given two days by his Quality Leadership to close out over four hundred of the lost or stolen defective part Nonconformance Standard Operating Instructiions (NC-SOIs) that documented the nonconforming condition of each lost or stolen MRSA part. He refused to just buy those records off as his management wanted him to do and instead he insisted that all defective parts that disappeared from the MRSA be investigated, as the QA system required for obvious reasons.
As a result, Mitch was denigrated, ridiculed and told to just close the records without any search for the missing defective parts. Again, he refused to close them without a complete investigation. Later, he was made aware of a large number of NC-SOIs that had been previously closed out by other QA Managers without an investigation of where the parts went. He was told by his senior QA management to not worry about them, as they had been "addressed."
The noted lost/stolen defective part NC-SOIs were all bought off on the same day, by the same two people and they all were marked “no” where the form asks if the airplane/production area was checked, inventory was checked, etc. They hadn’t looked anywhere for the parts, but they completed the NC-SOIs with "787 Lost Part" forms as the authority to do so.
Most of the defective/scrap parts that were lost/stolen were not structural 787 parts, however some of them were very structurally significant and would cause a safety issue if they were installed without the repairs as documented on the NC-SOI’s being accomplished first. But it should be noted that many non-structural defective parts can be a safety issue if installed on an airplane as well.
Examples of parts that were lost/stolen and subsequently closed out as noted were dozens of wing to body stub fittings (bathtub fittings) that attached the wings to the fuselage that had mill steps on the machined surface. If there are mill steps on a milled surface of such a heavily loaded structural part, there is a good likelihood it will develop stress cracks over time. If the cracks go unnoticed, they would propagate through the entire part, making the part structurally unsound. Engineering deemed them unacceptable for use, but they disappeared from the MRSA and were nowhere to be found with no evidence they had been repaired per their NC-SOIs.
The lost/stolen defective/scrap parts also included stringers, frames, and other structurally significant parts.
Also of note are the two scrapped "47" (see diagram below) fuselage sections that were lost/stolen. These were entire rear 787 fuselage sections on which the 787 tail, with its crucial horizontal and vertical stabilizers, is later attached to the airplane. The 47 sections that “disappeared” and are likely components of two possibly imperiled 787s now in service are identical to the one pictured here:
This diagram (item #47) shows where it is located on the airplane:
Both 47 sections had significant delamination in the outer barrel and were deemed “scrap” by Engineering. Both 47 sections have no traceability of where they are, and are consequently quite possibly installed on delivered airplanes, as noted. Here are the two rollerstamped 47 section 787 Lost Part Forms. As you can see, there was no effort to trace where they were or which 787s they were possibly installed on:
Look at all the areas they checked off that they didn't look, including the airplanes they could have been installed on! Also note they didn't even fill out items 4 through 6 either "yes" or "no." This is what "rollerstamped" paperwork looks like. Notice that the Senior Manufacturing Manager (which is 2nd level or higher, I believe) and the Inventory (MMO) Manager signed this off without doing the required checks. These two 787 fuselage sections weren't small or insignificant parts as shown in the picture above.
The forms above are just the authority for QA to close out the open NC-SOIs shown on the forms. But, as detailed here, Boeing QA Managers don't have a choice whether or not to close out those NC-SOIs without accountability of where the parts ended up. They must do so or face retaliation, up to and including termination for doing the right thing.
There also were countless CRN (current return) cables (critical for lightning strikes) that were damaged, defective or otherwise not suitable for use that went missing with no traceability of their final destinations. Every commercial airplane is struck by lightning an average of twice a year and the 787s with defective CRN cables installed on them could be at risk when they are inevitably struck by lightning.
There were also Aft Pressure Bulkheads that came in from the supplier with Open Nonconformances (ONs), but were stolen from Receiving Inspection and installed on airplanes without the ONs being worked.
This is an especially egregious case of Boeing fraud if they were taken and installed on airplanes in their defective state, as it was an Aft Pressure Bulkhead whose repairs were done incorrectly by Boeing and rollerstamped off as acceptable by QA that caused the JAL Flight 123 Boeing 747 to crash, killing 520 people. Apparently Boeing has learned little since it caused that horrendous crash decades ago.
Mitch also discovered that over 150 keys to the MRSA cages had been issued out. He performed an audit of the keys and found that Manufacturing had been issued keys to the cages. He had all of the locks on the cages changed and he issued keys just to his QA team for MRSA access in an attempt to keep nonconforming parts under control, and to meet the MRSA parts control requirements, which are shown in the following document that Mitch emailed to Manufacturing and QA personnel:
A few days after he changed the locks, he was directed by his Superintendent to issue keys to all of the First Line Manufacturing Managers. Within a week, Mitch and his team found that parts were again being taken from the MRSAs without authorization, and also found parts out in production areas that used to be in the MRSA scrap bins. Mitch’s Boeing Quality Leadership showed very little concern with their responsibility to control nonconforming parts, to put it mildly.
That's because such QA Managers work at the direction of corrupt "bean counting" Manufacturing Managers and Manufacturing Team Leaders, in my long experience at Boeing.
The following case, in which QA Manager Whistleblower Mitch reported his QA Manager to Boeing HR for an ethics investigation in late 2016, shows that Senior Boeing QA Management not only lacks the required independence from the Manufacturing organization they are supposed to independently oversee the work of, but they actually perform unethical/illegal acts for the Manufacturing organization they effectively report to.
In this case, Mitch's Senior QA Manager and another QA Manager worked with Manufacturing personnel to steal a hydraulic tube assembly from the MRSA scrap bin so that mechanics could install it on an unknown line number 787 now in service. Hydraulic tube and hose assemblies fluidly power most of the most safety critical systems on a Boeing airplane, like the primary flight control actuators, the landing gear actuators, the thrust reversers, and the leading/trailing edge flap actuators.
This brings new meaning to former Boeing Commercial Airplanes' CEO Alan Mullaly's "Working Together" slogan of his time. Boeing Manufacturing and QA are working together, yes, but they are even working together to do bad things occasionally, as this case shows. Here is the redacted statement Mitch gave to the HR Generalist who investigated the case:
Here is the text from the investigation statement above for easier viewing:
"My name is (Mitch). My BEMS ID is XXXXXX. I am a Quality…Manager…I work in (building and area of building) and my manager is (Mitch’s Manager’s name). I have over XX years of Company service.
I submitted a complaint to HRG (HR Generalist name) on Saturday…(in late)…2016, after hearing that (Mitch’s Manager’s name) released a part from the scrap bin. The part was some sort of hydraulic tube.
On Thursday,…(month and day)…2016, (witness name) told me that (Mitch’s Manager’s name) retrieved the part from the scrap bin. (Witness name) spoke up and told (Mitch’s Manager’s name) he couldn't do that. (Mitch’s Manager’s name) argued with (Witness name) until (Witness name) got involved. (Witness name) took the part from (Mitch’s Manager’s name) and placed the part on his desk to work on the following day.
When (Witness name) returned the next day, the part was gone. (Suspected perpetrator name) or (suspected perpetrator name) took the part from (Witness name's) desk and attempted to wipe off the red paint per (Mitch’s Manager’s name's) instruction. (Suspected perpetrator name) or (suspected perpetrator name) then gave the part to (Mitch’s Manager’s name). (Mitch’s Manager’s name) gave it to Quality Manager (name).
(Witness name) further stated that, when he looked on the aircraft later, he discovered the part was installed and it was pink, since all of the paint was not removed.
I called (Mitch’s Manager’s name) on Friday,..(Month and date)…2016, to discuss another matter and during that conversation, I asked him about the part. During our short conversation, I told (Mitch’s Manager’s name) that I had heard rumblings that he pulled a part from the scrap bin and gave it to the floor. (Mitch’s Manager’s name) replied, “Yes I did. I gave it to (QA Manager name). Don't worry about it. We've got it covered.” That was the end of the conversation, as I felt uncomfortable pushing him too hard on why he did that. He rates my (Performance Management) PM. We have not spoken about this issue again.
Parts are scrapped in one of two ways, either on Defective Part Reorder Tags (“DPRT”) or the part is written up on an NC. BPI-1193 governs this process. For DPRT, the part has to meet five criteria, two of which are that the part costs under $1,000 and Boeing caused the defect. With DPRT, the part goes straight into scrap without Engineering or MRB disposition. With an NC, the part doesn't meet the five criteria for DPRT and there is a disposition to scrap the part. The part in question was scrapped via a DPRT. There was an issue on the floor with the part in question. That is why it was scrapped by the Manufacturing Manager.
When Quality receives a part on DPRT, we ensure the documentation is completed, we paint the part red, and we throw it in the scrap bin. The scrap bin is located inside the MRSA cage, which is kept locked. (Mitch’s Manager’s name) has access to the cage as the (Quality) Senior Manager.
The part should have never been removed from the scrap bin. All Boeing BPIs are written to instruct teammates as to what they can do, rather than what they cannot do. There is no documentation stating parts can be removed from scrap bins. For the last XX years at Boeing, this phrase has been drilled in my head: “If it doesn't say you can, you can't.” In addition, common sense tells you that parts that were scrapped should remain in the scrap bin.
It is possible that (QA Manager name) generated an NC to cover it after the fact. However, this would also be improper, since teammates are not permitted to remove parts from the scrap bin. For an NC to be proper, it would have had to be written before the part was placed in the scrap bin. BPI-1149 contains specific language regarding releasing parts from MRSA. For a part to be released on an NC, it must contain a unitized tag that was generated on the floor. This BPI deals only with parts on NCs. This is the only vehicle that allows parts to be released from MRSA.
I do not know the affected line number or relevant SOI. There is no documentation tracking the part from the scrap bin to being installed on the aircraft.
My team is concerned about being held to certain standards when upper management is not. My team follows Boeing processes. They are asking me what I am going to do about (Mitch’s Manager’s name)."
End of investigation excerpt.
There you have it, a Boeing Senior QA Manager taking a scrapped defective part from the MRSA and giving it to one of his QA Managers who then gave it to Manufacturing, who installed it on an unknown 787 that is now out in service. Note that hydraulic systems are extremely high pressure systems, up to 5000 PSI or so, that are even more vulnerable to even minor damage than are lower pressure systems, as the hydraulic tube wall is stressed much more due to the high pressures involved.
Also note a key phrase from Mitch's statement, "all Boeing (Process Instructions) BPIs are written to instruct teammates as to what they can do, rather than what they cannot do.
A few days after he changed the locks, he was directed by his Superintendent to issue keys to all of the First Line Manufacturing Managers. Within a week, Mitch and his team found that parts were again being taken from the MRSAs without authorization, and also found parts out in production areas that used to be in the MRSA scrap bins. Mitch’s Boeing Quality Leadership showed very little concern with their responsibility to control nonconforming parts, to put it mildly.
Mitch then met with the Boeing FAA Liaison Manager, the Process Subject Matter Expert, his manager, and the Compliance Manager and all agreed that the requirements were for them to do their due diligence in trying to find the lost/stolen nonconforming parts, and if there was no traceability as to where they were, they would need an Engineering and Quality review to determine the potential impacts if the parts were installed unrepaired on an airplane and then present all of their findings to the FAA with a “self disclosure.”
Mitch’s Quality Director however decided Boeing would not be disclosing anything to the FAA, and Engineering decided they wanted nothing to do with this embarrassing Boeing QMS (Quality Management System) failure. So, Mitch was left being pressured again to just buy the NC-SOIs off without any investigation of where the parts were to make them go away. He wouldn’t do it, so his management deemed him the “problem” in keeping the NC-SOIs from being bought off without the required investigation.
Mitch wasn't fired, but suffered other actions against him by his Boeing QA senior management for trying to do the right thing. Over the past six years, his QA management's pressure and penalties for Mitch to stop following QA processes and to stop putting QA process failures in writing anywhere has been on a constant increase.
He's been banished to 2nd shift, denied an opportunity for 3rd shift, his Performance Management Reviews (PMs) were lowered for following procedures, he was ambushed with a 60 Day Action Plan his management didn’t have the balls to look him in the face to tell him about, false rumors about him were spread around by his QA management which were then documented on his PM and his score lowered because of it, he was blocked from being offered a position back in his home state, he was blocked from a job offer in another Division, and on and on.
But such retaliation on the job is not the only thing that can happen to you if you attempt to do your QA job at Boeing. Mitch was QA Manager over the factory MRSA, and another QA Manager ran the other MRSAs. The other QA Manager was also being pressured to just close out the NC-SOIs without the required investigation like Mitch was. He pushed back and demanded an investigation be completed. He was placed on a PIP (Performance Improvement Plan) for not getting the NC-SOIs closed out fast enough. After another QA Manager rollerstamped the NC-SOIs off, he was terminated.
This issue of "lost" and stolen defective and scrap parts' installation on now compromised 787 airplanes again shows how utterly broken Boeing's quality system still is, over 15 years after I reported that to both the FAA and Boeing in 2002/2003. Unfortunately, as Boeing has regulatory captured the FAA, Boeing's quality system will only devolve even more over time, IMO, as Boeing controls the FAA, and not the other way around as it is supposed to be.
It also must be noted that their isn't really a direct Boeing procedure on how QA is supposed to investigate "lost" and stolen defective and scrap parts. Why not? That's because nonconforming and scrap MRSA parts are NEVER supposed to be lost or stolen, so no procedure exists for that scenario.
This proves the most likely thing by far is that the thousands of noted defective and scrapped parts are actually installed on 787s in service today, rather than just being "lost." As Mitch rightly notes, such parts just don't disappear into nothingness or walk off themselves. That means that in the vast majority of cases, the noted thousands of defective and scrapped parts were actually stolen by Manufacturing (with QA help in some cases as noted) to install on production 787s. That means almost every 787 in service today could have one or more of these defective and scrap parts installed on them, including the noted two fuselage sections, an unknown quantity of Aft Pressure Bulkheads, and other safety critical parts.
Boeing QA Manager Whistleblower Reveals That 787s Have Foreign Object Debris (FOD) That Is a Safety of Flight Issue That Boeing Has Refused to Fix
Today comes the new revelation from Mitch, our Boeing QA Manager Whistleblower, about more wrongdoing by Boeing management that has allowed Foreign Object Debris (FOD) to remain on 787s now in service despite Boeing having known about this 787 FOD problem for at least five years, and has let hundreds of 787s deliver with this FOD condition.
This 787 FOD condition was reported to the FAA by whistleblower Mitch over eight months ago as his management refused to do anything about it in the delivered fleet and at Boeing in Everett, Washington and North Charleston, South Carolina 787 factories.
Here is Mitch's whistleblower report to the FAA:
August 16, 2017
DOT - FAA
c/o (FAA Name)
800 Independence Ave. SW
Washington DC 20591
Dear (Name) and (name),
As you may recall, I filed case (number) with the FAA against The Boeing Co. After receiving their response for the issues I reported, I found that they have provided disturbingly false information to the FAA and OSHA and appear to be attempting to misrepresent and minimize the safety concerns I identified. It is my understanding that it is against Federal Law to provide the Government with false information, so I wanted to include my objective evidence to show the inconsistencies and false information provided by Boeing to the FAA and OSHA. Please see attached Response summary, my affidavit and copies of my supporting documents.
Also, as I was reviewing my records for those issues, I came across another issue I felt you should be made aware of. I fought this issue but was unsuccessful in getting the correct actions taken. It bothered me for a very long time, but I had no recourse in getting it corrected at the time.
We discovered that when the floor boards were being installed on the passenger deck, the fastener’s threads holding down the floor boards were being peeled off by the E-nuts, allowing metal slivers (up to 3” long) to be created and fall on top of wiring, electronic boxes and the Electronic Equipment (EE) Bays. Quality Leadership decided to allow the metal slivers (FOD) to remain above the cargo areas without cleaning it up as they felt it would cost too much and take too much time to remove the ceiling cargo liners to have the metal slivers removed. My fear is that these metal slivers will migrate and cause electrical shorts or possibly a fire on one of our airplanes.
I have attached e-mails and a picture as evidence of the issue. This picture is just one of many examples of the 100s and/or 1000s of fasteners we found with this condition across numerous different line numbers at BSC. We also found that there was a layer of slivers lying on top of some of the cargo liners, wire bundles and electronic equipment that had fallen from the screws. Leadership had NC’s written and LE deemed the areas “use as is” (UAI). The metal FOD was allowed to remain on those airplanes identified in the attached.
End of FAA whistleblower report.
As you can see in the picture above that was sent as part of Mitch's whistleblower report to the FAA, the FOD is titanium metallic curls peeled off of the threads of the BACS12LM 787 floor panel attach fastener when it was installed. These metal curls detach and fall on anything below--cargo compartment ceiling panels, wiring, electronic boxes and the everything in the Electronic Equipment (EE) Bays of every 787.
Mitch says Boeing Quality Leadership knew about this E-nut FOD for over five years but did nothing to have the FOD removed or to correct the issue. Engineering at Boeing provided a “use as is” disposition on the Nonconformance records (NC’s) for the E-nut FOD, which is beyond their authority to do.
Had it not been for Mitch's complaint, Boeing would still be delivering airplanes with loads of this metal FOD floating around in the power panels, electronic equipment bays, black boxes, flight control modules, etc.
Mitch received a letter from the FAA stating they substantiated this complaint and are taking appropriate actions. And they appear to be doing so, at least for airplanes in production at Boeing at the time of Mitch's FAA whistleblower complaint and after.
The FAA did their own inspections and found E-nut FOD in every 787 they inspected at Boeing's Everett, Washington and North Charleston South Carolina Factories.
The FAA issued a DAI (Designated Airworthiness Inspection) to Boeing, forcing them to clean all airplanes in production on their Everett and North Charleston 787 production lines, as the FAA identified this FOD condition as a safety of flight concern.
The DAI caused Boeing to miss a scheduled 787 delivery in Everett. The FAA so far inexplicably has not released an AD (Airworthiness Directive) to all airlines/operators with 787s to have those airplanes in service inspected and the FOD removed. With that in mind, you may not want to fly on any 787s in service until such an AD is released by the FAA and this safety critical FOD issue is finally removed from the in-service fleet.
The FAA had to force Boeing to do the right thing and assure certain in production 787s are safe from this FOD by issuing the DAI, but have so far not addressed 787s in service, as noted.
Boeing QA management was unable on multiple separate occasions to do the right thing itself, despite Mitch trying to get them to do so again and again.
As noted, this FOD was a result of the new E-nuts Boeing is using on the floor boards. When the titanium fasteners are inserted into the E-nut and tightened down, the E-nut peels a sliver of titanium off the threads of the fasteners. The slivers range from .5 inches to over 3 inches and were found in the wiring, electronic boxes and all in the EE bay. The FAA did finally it appears, but it was five years after the issue was first discovered by Boeing.
Again, Boeing Quality Leadership knew about this FOD and chose to allow it to remain rather than have the cargo panels removed and the FOD cleaned up. The E-nuts had been leaving FOD for over 5 years and Boeing had done nothing to properly address it or to assure the safety of the flying public from its effects on in-service 787s.
More background on this story is that this issue with the E-nut FOD had been going on for over five years, as noted. During that time, Boeing Liaison Engineering and Quality were trying different things to try to address it. Engineering and Quality decided to try to wet install the fasteners thinking the sealant would catch the slivers and then when it dried, the slivers would be held by the sealant. This practice had been going on for some time I guess. They discovered that not only did the sealant not catch the slivers as they thought, but they were applying the sealant on numerous planes without Engineering approval or authorization. So essentially, they were applying more “FOD” to address FOD without authorization and it didn’t work as anticipated.
Another process they tried was to pre-torque the fasteners before they installed them on the plane. They created a fixture with E-nuts installed. They had someone sit and install and remove hundreds and hundreds of fasteners to “eliminate the slivers they created before installing them.”
The spec allows reuse of the fasteners up to five times, so the thinking was to “use it” the first time by “removing the slivers” and then the 2nd use would be the first install on the plane. So, without verifying this theory, they ran with it and started installing the 2nd use fasteners on the planes. After who knows how many line numbers, they found that the fasteners produced slivers every time they were torqued.
They took a sample of fasteners (after they were doing this on the plane) and tested them. They found that the fasteners produced slivers up to the 5th time they were torqued. By this time, several planes had been assembled using this method.
From my understanding, Boeing is still trying to figure out how to rectify the problem with these fasteners. So far, they have just thrown Band-Aids at it with no real plan on how to fix it. I would think that after six years, Boeing could have come up with a redesign like using nut plates or other proven industry designs. Apparently that would have cost Boeing too much money, so they instead chose to let 787s deliver with this FOD, as noted.
Hopefully the FAA will continue to follow through on Mitch's whistleblower report, and force Boeing to finally do the right thing and pay for airlines to fix this FOD issue ASAP, rather than what Boeing frequently seems to do--the cheapest thing, as in this case, where they essentially did nothing effective to permanently rectify the issue. Such a fastener should have never been approved for use on any Boeing airplane, IMO.
As ethical Boeing QA managers like Mitch have shown, a few QA managers at Boeing still try to get their upper management to do the right thing, even though trying to do so often fails and just brings retaliation down upon them, like being blocked from better jobs within Boeing, being moved to late shifts with few duties, and retaliatory bad annual reviews. On one such review, Mitch was faulted for not working in the "gray areas" of procedures rather than the procedures themselves.
As I have experienced as a Boeing QA Inspector for almost ten years, it's the same with QA inspectors at Boeing who try to actually do their jobs instead of just mostly pretending to do them. They are punished for doing their jobs by being put in the most undesirable parts of the factory, put in make work jobs to keep them off of the production line, and extreme efforts to find reasons to terminate their employment, all of which I experienced myself when I insisted on doing my QA Inspector job at Boeing.
That's it for this latest revelation about Boeing QA issues. As noted above, you may want to avoid flying on 787s because of this and other previous revelations concerning that model, at least until these issues are finally fixed.
The Last Inspector