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.
Brave Boeing QA Manager Whistleblower Comes Forward, Exposing that in a 787 Hull Breach, Only 75% of Passengers' Oxygen Masks May Work.
"Mitch," a brave whistleblower from Boeing QA Management has contacted me about several QA issues he witnessed in his Boeing management role--issues he was retaliated against by his management for trying to fix.
This whistleblower's first revelation revealed publicly anywhere is, that if you or your loved ones fly on any Boeing 787, you only have approximately a 75% chance of surviving in an emergency if you require emergency oxygen.
That's right. Approximately 25% of 787 passenger oxygen bottles will likely fail and not give you oxygen in an in flight emergency, as the squib/firing pin that fires to release oxygen to your mask that drops down won't fire and release life preserving oxygen through the tubing to your mask. So if a depressurization occurs as happened with the Southwest 737 yesterday killing a woman occurs at altitude, you have approximately a 25% chance of injury or death by asphyxiation on a 787.
And, if you are unfortunate enough to be on a 787 during an in flight emergency requiring oxygen masks and you are unlucky enough to be in a seat served by one of the defective "dud" oxygen bottles whose squib doesn't fire and release oxygen, you won't be injured or die alone. The passenger(s) next to you will die of asphyxia or be brain damaged from lack of oxygen at the same time, as there aren't individual oxygen bottles for every 787 passenger.
According to the Boeing QA Management Whistleblower, Each PSU (Passenger Service Unit, which is above your head when you are seated, where your lights, fasten seat belt indicator, and A/C nozzles also are on most airplanes) oxygen bottle serves 3 passengers in most cases. There were several different bottle sizes and types that had their squibs fail to fire when tested by Boeing.
The Boeing QA Management Whistleblower is not sure of all the other places these discrepant oxygen bottles are used, but they are mostly used in the PSU’s for passengers, they believe. However it is possible that the pilots' and flight attendants' oxygen bottles may be affected as well. Here is a picture of the 787 PSU showing the usually hidden passenger oxygen bottle that are unlikely to give passengers oxygen in approximately 1 out of 4 cases:
Boeing QA Management Whistleblower Mitch's disclosure here should give pause to any flier considering flying on Boeing 787s, at least until this specific safety threat is finally investigated, fixed, and the fix is ultimately verified.
So, as noted above, don't count on the person next to you on a 787 having a non-defective and working oxygen mask when your defective oxygen bottle doesn't release oxygen. That's the kind of fate no one sane wants to share with anyone else.
For the past 2 years, Boeing has known that at least 25% of the Passenger Emergency Oxygen bottles in the Passenger Service Units (PSUs) above the passenger seats on 787s will not operate in the event of an emergency.
The whistleblower's group at the time, Boeing MRSA (Material Review Segregation Area, which is where QA keeps defective or suspected to be defective parts and assemblies to ensure they can't be taken by Manufacturing and installed on airplanes until they are reworked/repaired, as they sometimes are at Boeing if not locked up. Sometimes they are even taken without authorization when they are locked up in such cages) discovered during a discharge of oxygen bottles in 2016 that 25% of the squibs on the O2 bottles failed to fire as designed when the activation electrical charge was applied.
The squibs did not fire so there was no oxygen released. After Boeing failed to take action to determine the root cause and correct the fleet after almost a year, the Boeing QA Manager Whistleblower reported this safety concern to the FAA and OSHA via a Whistleblower complaint.
Thus far, no actions have been taken to correct this safety issue, and QA Manager Mitch's career at Boeing has been destroyed by his Boeing Quality Leadership for his insistence on following Boeing's FAA approved QA procedures in his attempts to assure the safety of the flying public by fixing this and other safety issues.
According to the FAA, Boeing Everett reported a higher failure rate than Boeing South Carolina did, but yet, the flying public remains unaware and are being left in harms way by Boeing, the FAA and OSHA.
This brave whistleblower has ample documentation to support this particular safety concern, as well as other safety issues. Here is the text minus identifying info of their Whistleblower complaint to the FAA:
December 13, 2017
DOT - FAA
1601 Lind Ave. SW
Aircraft Certificate Service
Systems Oversite Division
Renton Wa, 98057-3356
Dear ( FAA name),
As you may recall, I filed case (case number) with the FAA against The Boeing Co. In my initial complaint, I disclosed a safety concern dealing with the emergency oxygen equipment on the 787s. In my most recent complaint, (case number), I provided information regarding (another 787 safety issue).
It appears that the oxygen issue was not identified properly nor investigated. Next is a quick history that explains my concern. In an effort to dispose of damaged PSU panels and other panels that contained oxygen supply equipment, we (MRSA) separated the plastic panels from the oxygen supply systems (metal) in order to send the parts to separate reclamation locations. In dealing with the oxygen supply equipment, we were required to discharge the pressurized oxygen bottles in order to send them off to reclamation.
During the discharge process in (Boeing Area) (July 2016), it was discovered that 25% of the squibs responsible for releasing the oxygen did not activate (fire). There were 300 oxygen bottles of varying sizes and shapes that we needed to discharge. Out of those 300, 75 squibs (25%) did not discharge when activated by the equipment. The discharge equipment was set up to mimic the airplane.
The 75 squibs that did not fire were removed from the oxygen bottles and were quarantined in MRSA (August 2016) for failure analysis. The failure analysis has never been performed and no corrective actions have been taken to correct in-service airplanes. When I left, the separated defective squibs were still located in the “explosives” area in MRSA.
There were an additional 200 PSU panels and oxygen bottle assemblies quarantined in MRSA for failure analysis and testing. I am aware the local FAA located the 200 oxygen bottles and panels in MRSA due to my initial complaint, but only wrote them up for not being marked correctly for scrap, they missed the fact that they were the ones set aside for failure analysis. No action has been taken to determine why the squibs are failing and no actions have been taken to insure the flying public is safe.
My concern is that Boeing has had data for well over a year that shows 25% of the emergency oxygen bottles currently in service will not operate in the event of an emergency. So far it has been ignored and gone unaddressed. I feel it is imperative the defective squibs not go unaddressed any longer. I wanted to make you aware of my concern in hopes that you can help drive the appropriate actions to assure the aircraft being delivered and those that have already been delivered are safe.
I believe Boeing’s failure to properly address known defective emergency equipment and knowingly leaving the flying public at risk should be reviewed as well.
Attached, please find supporting documents.
(Boeing QA Management Whistleblower)
Cc: (Two names)
End of whistleblower complaint.
The FAA has so far not acted to eliminate this 787 safety threat per the Boeing QA Manager Whistleblower. Because of his concern that 787 passengers and perhaps even crews are in danger of dying or being injured in a 787 depressurizing event at altitude, he has decided to go public with this so far unaddressed safety threat here at this time.
I submitted a FOIA today to the FAA requesting all of their records on this serious safety issue. When I receive anything in response from the FAA is anyone's guess. Just like Boeing, they seem to hate showing their dirty laundry, so to speak, without an act of Congress. I'll keep you posted as time goes on.
The above document unfortunately shows what I experienced when I went to the FAA with my whistleblower report of QA management driven fraud throughout Boeing Commercial Airplanes. Reporting anything to the FAA is exactly the same as reporting it to Boeing management itself, and is just as ineffective, in my experience.
In fact, this Boeing QA Management Whistleblower told me that another worker at Boeing reported to him that they had found his FAA whistleblower complaint above on top of a Boeing printer. Whomever at the FAA gave this QA Manager whistleblower's complaint to Boeing management should be terminated, at a minimum, IMO.
Boeing QA Manager Whistleblower Mitch insisted on trying to have the defective squibs analyzed for failure analysis and all the appropriate actions taken to assure the fleet was corrected and the flying public was safe, but rather than getting the support he requested from his Boeing QA management, he was removed from the investigation and the investigation was stopped.
And, this may just be the tip of the iceberg. Hopefully this will get the reliability of all oxygen bottles/generators looked into on all Boeing models in service. Considering the importance of these oxygen bottles and generators to prolonging life in an emergency, you would think there would be some robust oversight of the reliability of them by the FAA and/or Boeing. As this case shows, that is obviously not the case. If it was, the FAA and Boeing would have the ongoing test data to prove that these oxygen bottles/generators are reliable to the degree such life saving equipment should be, in the very high 99th percentile.
A Boeing apologist on the Facebook post of this blog actually wrote that passenger and flight attendant oxygen masks functionality isn't a concern, as the pilots would always detect a hull breach at altitude, immediately don their own oxygen masks, then immediately dive to an altitude to where others on the plane can breath without supplementary oxygen.
This is false. That isn't what actually happens in real world hull breach situations:
In 1999, a Learjet 35 with two pilots and four passengers on board, operated by SunJet Aviation, stopped responding to air traffic controllers enroute from Orlando, Florida to Dallas, Texas. An F-16 fighter was dispatched to intercept the Learjet about an hour and a half after departure, and found it unresponsive to radio communication. The jet looked undamaged, but the windows seemed to be dark and blocked with ice or condensation, and no flight control surfaces moved as if a pilot was controlling them. The fighter pilot had to go back to their Air Force Base.
About three hours into the Learjet's flight, two additional F-16 fighters intercepted it, and found the exact same situation the first F-16 pilot had found. They had to break contact and refuel. About 40 minutes later, two more F-16s were dispatched, along with the two refueled F-16s, and they followed it until it ran out of fuel and spiraled down, having to leave because the fighters were at their limit of endurance just before it crashed. It impacted at near supersonic speed just outside Mina, South Dakota, killing all on board.
The NTSB investigation found that the probable cause of the accident was incapacitation of the flight crew members as a result of their failure to receive supplemental oxygen following a loss of cabin pressurization, for undetermined reasons. In addition to the deaths of the two pilots and three passengers, Payne Stewart, the famous golfer, died in the accident.
In 2000, a chartered Beechcraft Super King Air with one pilot and seven passengers on board, departed Perth, Western Australia, enroute to Leonora, Western Australia.
During the flight, the aircraft climbed above its assigned altitude. When air traffic control (ATC) contacted the pilot, the pilot's speech had become significantly impaired and he was unable to respond to instructions. Three aircraft intercepted the Beechcraft but were unable to make radio contact. The aircraft continued flying on a straight heading for five hours before running out of fuel and crashing South-East of Burketown, Western Australia. The accident became known in the media as the "Ghost Flight".
A subsequent investigation concluded that the pilot and passengers had become incapacitated and had been suffering from hypoxia, a lack of oxygen to the body, making the pilot unable to operate the aircraft.
The last and most similar to a possible 787 hypoxia induced crash is that of the 2005 crash of Helios Airways Flight 522, a Boeing 737-300 flight enroute from Larnaca, Cyprus to Prague, Czeck Republic.
All 121 people on board, consisting of both pilots, four other crew members, and 155 passengers, including 22 children, died in the crash. All recovered body autopsies showed that the passengers and crew were alive on impact, and many burned alive in the crash. Three bodies were never recovered.
It was found that a ground maintenance engineer had left the pressurization system in "manual" mode after a pressurization check after inspection for a possible leak in the right aft service door, when it should have been set back to "auto" mode after the inspection.
As the 737-300 climbed, the pressure inside the cabin gradually decreased. As it passed through an altitude of 12,040 feet, the cabin altitude warning horn sounded. The warning should have prompted the crew to stop climbing, but it was misidentified by the crew as a take-off configuration warning, which signals that the aircraft is not ready for take-off, and can only sound on the ground.
Shortly after the cabin altitude warning sounded, the captain radioed the Helios operations center and reported "the take-off configuration warning on" and "cooling equipment normal and alternate off line". He then spoke to the same ground engineer that had left the pressurization system in "manual" mode and repeatedly stated that the "cooling ventilation fan lights were off". The ground engineer asked "Can you confirm that the pressurization panel is set to AUTO?" However, the captain, already experiencing the onset of hypoxia's initial symptoms, disregarded the question and instead asked in reply, "Where are my equipment cooling circuit breakers?". That was the last communication with the aircraft.
Two hours and 14 minutes into the flight, two Greek F-16s were dispatched to intercept the 737-300. They intercepted it and observed that the first officer was slumped motionless at the controls and the captain's seat was empty. They also reported that oxygen masks were dangling in the passenger cabin.
25 minutes later, a flight attendant, Andreas Prodromou, entered the cockpit and sat down in the captain's seat, having remained conscious by using a portable oxygen supply. Prodromou held a UK Commercial Pilot License, but was not qualified to fly the Boeing 737. Crash investigators concluded that Prodromou's experience was insufficient for him to gain control of the aircraft under the circumstances. Prodromou waved at the F16s very briefly, but almost as soon as he entered the cockpit, the left engine flamed out due to fuel exhaustion and the plane left the holding pattern and started to descend. Ten minutes after the loss of power from the left engine, the right engine also flamed out, and just before 12:04 the aircraft crashed into hills near Grammatiko, Greece, 25 miles from Athens, killing all 121 passengers and crew on-board.
It is quite amazing that Boeing, a manufacturer of at least one commercial airplane that tragically crashed killing all on board because of hypoxia of the pilots and others possibly capable of taking over flying the plane, treats oxygen bottle and oxygen generator functionality so cavalierly as in the 787 "one in four oxygen bottles is a dud" situation described above. Extreme negligence on the part of Boeing, indeed.
Boeing had to separate the "loss of oxygen" idiot light in the cockpit from the same idiot light being used for a relatively minor fault as a result of this crash.
So, as can be seen from all of these airplane crashes, things don't always happen the way the Boeing apologists think they should in such incidents, with deadly results. That's why the pilots, the rest of the crew, and the passengers deserve functioning oxygen bottles/generators in a hull breach like occurred in the noted Southwest Airlines incident.
Another incident that shows what can happen when emergency equipment like the noted 787 passenger/crew oxygen bottles not functioning in an emergency happened only three days ago on an American Airlines flight from Hawaii to South Carolina, with a planned stop at Dallas-Fort Worth Airport.
American Airlines passenger Brittany Oswell died after the flight, during which she suffered an embolism and went into cardiac arrest, according to a wrongful-death lawsuit filed against the airline by Oswell's husband and parents.
The suit alleges that Oswell began to feel unwell while the flight was near Los Angeles and fainted after becoming disoriented and slurring her speech. A doctor who was a passenger on the flight talked to Oswell after she regained consciousness and determined she was having a panic attack, the suit alleges.
According to the suit, within three hours of the doctor's initial conversation, Oswell vomited and defecated on herself in the bathroom. The doctor then examined Oswell and told flight attendants to let the flight crew know it should land the plane at the nearest airport so Oswell could receive further medical attention.
Brad Cranshaw, the attorney representing Oswell's husband and parents, told The State that the doctor asked for an emergency landing three times, but the flight crew never attempted one.
The lawsuit alleges the doctor tried to use medical equipment on the plane, but the equipment didn't work properly. Oswell's breathing and pulse stopped about five minutes after the doctor went to the cockpit to speak with the pilot, according to the suit, which says the doctor then made three unsuccessful attempts to use a defibrillator on Oswell.
Oswell was taken to Baylor Medical Center after the plane landed in Dallas-Fort Worth, where she was diagnosed with brain damage and an embolism. Oswell was removed from life support and declared dead three days later.
As the suit alleges, because the defribrillator malfunctioned, the woman died because of severe brain damage, whereas if the defribrillator was tested regularly and functional on the flight, she would have had a real chance of survival. The refusal of the pilots to make an emergency landing was a separate issue that reduced her chances of survival still further.
This is a real life present day example of why you can’t compromise when it comes to emergency life supporting equipment like the emergency medical equipment on this American Airlines plane and the oxygen bottles on 787s.
During an emergency, it’s too late to find out the equipment your life depends on doesn’t work. You are dead. Boeing and the FAA can make all the excuses they want, but at the end of the day, they have solid objective evidence as noted above showing 25% of the 787 oxygen bottles don’t work when tested.
Instead of taking it seriously, Boeing and the FAA seem to be working very hard to minimize this safety issue and sweep it under the carpet. They have 75 squib/oxygen bottle assemblies that were pulled straight from stock that failed to function as designed.
Instead of taking 3 or 4 days to analyze the 75 failed squibs and make a solid, provable conclusion, Boeing would apparently rather spend two years (and counting) trying to “make it go away” and justify their actions for not taking action on the 787 passenger safety issue.
This is not only a violation of countless processes and procedures, but it is a violation of the public's trust in both Boeing and the FAA to do the right thing when safety issues like these arrise.
The public rightly expects all emergency equipment to work, without question. Knowing there is this so far uninvestigated question with the 787 oxygen bottles should be enough for Boeing to do their due diligence in making sure there is not an issue that could cost up to 60 to 70 lives or brain damaged passengers per decompression event, per airplane. But, apparently in the interest of Boeing’s profitability, this issue has so far gone unaddressed. Apparently Boeing continues to justify its lack of action with cost concerns instead of doing its due diligence in finding the root cause of these failures and ensuring they cannot recur in an in-flight emergency. There is absolutely no excuse for this issue to have gone this long without action, period.
The 787 is the first program to use the oxygen bottle/squib combination for emergency oxygen support for passengers. The other Boeing airplane programs have different types of systems, i.e. the 777 uses oxygen generators, 747 used compressed gas tanks at one time. All have different requirements and are activated in different ways.
On the 787, the oxygen bottle/squib assemblies are for passenger use only. The Pilots and Flight Attendants have their own separate oxygen supply that they turn on by a manual valve, not by a squib. Some are portable tanks that allows them to move around and assist a few individual passengers that need oxygen for whatever reason, without having to activate the entire system as would be needed in a hull breach.
So, the passengers and the flight crew are serviced by different systems. However, as seen above, the pilots aren't always able to get their masks on in a depressurization event. But even if one does, and the plane is still under the control of an alert pilot, if 25% of the passengers are found dead or brain damaged after the landing, can such a landing be considered a success? Obviously not.
Even if the noted suspect passenger oxygen bottle/squib combinations went through all of the required approvals, testing, and certifications that they must go through to be approved for use on 787s, they went through those steps initially, 7 to 15 years ago. But it doesn’t just end there. Over time, other influences come into play at the manufacturers, like process revisions, management changes, employee changes, etc. It can’t be a “one and done” process, as this case shows. Periodic retesting must be done, especially when they fail as often as is noted above.
These 787 oxygen bottle failures are rightly a major concern of Boeing Quality Manager Whistleblower Mitch, who reported them to the FAA, and then to me when that effort apparently failed. It also a major concern of mine now, as well.
"Mitch," the Boeing QA Manager Whistleblower, prays that we don’t wake up one morning to headlines about how 787 passengers died and/or were brain damaged from lack of an emergency oxygen supply, like the sad news of the woman that just died because the American Airlines emergency medical equipment didn’t work.
Mitch's sole purpose in his Boeing life as a Quality Manager was to assure that the airplanes Boeing delivered to the public are safe in all aspects, not just in a particular area. Such ethics driven QA Managers are not tolerated at Boeing, as Mitch's case and other QA Managers' cases have shown. He has suffered severe retribution from his Boeing management because he fought trying to protect all of us in the flying public.
Never in Mitch's decades at Boeing has he seen such disregard by the Boeing Quality Leadership in assuring the planes being built and delivered are safe. This 787 oxygen bottle failure rate issue is just one of many issues and concerns he has with Boeing Quality Leadership. There are more that are just as concerning, if not more so, that I will detail here soon.
I am so thankful that Mitch, the brave Boeing QA Manager Whistleblower, decided to turn to me for support in getting this existing deadly serious (literally) safety issue addressed and corrected.
Share this post with everyone you know and love. It is critical that you warn your friends and loved ones to avoid flying on Boeing 787s until this serious safety threat is actually investigated and ended.
This yet again proves that you, the taxpayer and air traveler is not being served by the FAA, as you are required to be by the law. As Boeing management has long ago regulatory captured the FAA you actually pay for, it is Boeing that controls the FAA, not you or your so called representatives in the Federal Government. Write them anyway, and ask them to investigate and end the puppet relationship of the FAA to their Boeing management puppeteers so there can finally be assurance that safety issues like this will always be investigated and fixed.
Remember to share this with any of your friends and loved ones, especially if they have booked travel on a 787 or are considering doing so. They may well breathe much easier if you do so. Certainly much easier than they will potentially breathe in a 787 emergency requiring oxygen masks to actually function.
On a different issue, longtime site visitors may want to know that I have finally become a President and CEO of a corporation! Not exactly my goal in life, but the corruption at Boeing and the FAA that I witnessed kind of forced me (as any ethical person would be) to do so in furtherance of this unusual personal hobby of mine.
I am President and CEO of the Foundation Against Roller Stamping Fraud (FARS-Fraud.org for short, and very much less funny sounding, and more relevant as well, as the fraud at Boeing and the FAA that I expose is fraud against the Federal Aviation Regulations, or FARS for short), which you can visit at www.farsfraud.org right now, if you wish. It's just a stub site now that I started only to get public donations for my FOIA requests of the FAA and other agencies, as well as website costs and social media advertising costs to get this information in front of as many air travelers as possible.
All you will see there now is the propriety logo of the site, taken from the "Post-Its From the Edge page," and the "What is Rollerstamping" page, the Briggs and Stratton powered rollerstamp that my corrupt QA Lead at Boeing used to brag that he used to buy off unlimited production records in record time for any corrupt Boeing QA Inspector/Lead or Boeing QA Manager. He is retired now, but his metaphorical lawnmower engine powered rollerstamp still lives on as an icon for all Boeing QA fraud, past and future, here and on the noted Foundation page. It is just an idea at this point, not yet realized, that quite likely may never be followed through on. I just love the irony that I am President and CEO of my own corporation, exposing the fraud of other Presidents and CEOs of corrupt gigantic corporations like Boeing and their Vast Network of Fraud supplier network.
I will never use any money raised by the Foundation for personal use, if I ever complete the site. It has probably cost me more money than I will ever raise through it for FOIA and website costs anyway. The FARS-Fraud Foundation will not be limited to Boeing and their FAA's various frauds. It will be used to expose Boeing's Vast Network of Fraud as well, such as General Electric/CFM, whose engine's defect killed a lady yesterday as noted.
At one time when I was allowed to inspect 737 CFM engines on receival at Boeing in my job as a Precision Assembly Inspector at Boeing's later absorbed into Everett and Renton Propulsion Systems Division, most of them had obvious defects that I wrote up, even serious ones such as missing safety devices and missing core section attachment bolts.
Don't forget to comment on this post, if you wish to, by clicking on the little "Comments" blue link at the top or bottom of this post, or if you wish to contact me privately for any reason, click here or on the "About/Contact Me" navigation button at the very top of the page and fill out the "Contact Me" form at the bottom of the page.
You don't have to enter your name or contact info if you want to remain anonymous to me for some reason. I'm especially interested in hearing about your own experiences with Boeing and/or FAA fraud, or their other crimes, ethical breaches, or other type of misconduct.
The Last Inspector