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hey guys Oscar coms here with the iso
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901 group today we're going to talk
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about Five Lessons that we can learn
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from the Boeing 737 max9 door
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failure on January the 5th
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2024 a Boeing 737 Max 9 door fell off at
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16,000 ft in the air talk about a
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non-conformity let's talk about
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it all right so let let's talk about
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just what what happened in this incident
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at a high level and then we'll talk
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about the Five
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Lessons so on January the 5th 2024 at
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50:07 p.m. Alaska Airlines flight number
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1282 took off from the Portland
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International
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airport okay they were heading to
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Ontario California and they
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had 71 passengers on
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board now they had reached altitudes of
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16,000 ft when the door fell off they
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call it a door plug but
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basically it's a plug for a empty space
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for a um exit that they don't use so
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they use what they call a door plug
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which is basically a door so the door
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fell off all right and this is for a
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Boeing 737
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max9 which had only been in
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operations in October 31st 2023 now
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that's very important right because the
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Boeing 737 Max 8 is the one
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responsible for um two plane crashes and
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so the max 9 is the improved
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model the um two plane crashes killed
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like 356
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people um back in
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2018 all right so this is the improved
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model in
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2024 and the door is falling
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off so what is a door plug so a door
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plug is really meant to be a permanent
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seal of additional unused exits that are
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designed on the plane right so they call
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it a door plug so can you imagine you
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being on this plane and you guys are at
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16,000 ft and the door falls off and so
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you can imagine just all the pressure
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and and all of those other issues going
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on so luckily no one was killed no one
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was
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severely
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injured but it made the
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news and it was very traumatic for
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everyone involved
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including um the passengers of course
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the
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crew um Alaska
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Airlines and also um
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Boeing and also people on the ground
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were impacted so we'll talk about it so
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let's talk about the Five Lessons that
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we can can learn from this incident so
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the first lesson is that we need to
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understand that nonconformities have
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impacts right nonconformity the the
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non-conformity in this case is the door
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failure the door falling off this door
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fell into the yard of a of a
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teacher right so it fell on the on the
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all the way down to the ground over
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16,000 ft and landed in the yard of just
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a unsuspecting person in her backyard
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now what if she was out there doing
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something or you know of course that
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door could would have killed someone if
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if that door would have landed on
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someone Alaska Airlines they had to
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ground 65 of their 737 max9 airplanes so
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could you
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imagine the disruption in all of the
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flights and all the money lost um the
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money that they had to
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spend they grounded the flights all of
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the flights to perform
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inspections now we're going to talk
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about that
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later now the FAA grounded
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170 737 max9 globally so now we have
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this one incident not only impacting
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Alaska Airlines but impacting all
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Airlines globally okay now that's pretty
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important so sometimes we need to
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understand that our non-conformity in
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our company can
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impact someone globally can have a
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global impact guys sometimes I know we
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don't think about that so
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nonconformities
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are more than paperwork sometimes we
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think about nonconformities is just
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being paperwork or why do we have to
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fill out this form we're filling out the
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form guys because we are trying to
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document our non-conformities we're
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trying to really understand the impacts
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of the
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non-conformity um if there are similar
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nonconformities that have occurred
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because if it happened if you had a
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non-conformity on a certain part chances
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are and you ship that out to
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previous customers and you found this
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non-conformity chances are you have that
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nonconformity in other on other parts so
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we need to think about just in other
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areas if we're talking thinking about
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processes right because nonconformities
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are more than just product related many
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non-conformities product
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non-conformities stem from processed
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nonconformities guys so we we have to
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take nonconformities series it's not
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just
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paperwork and then we also as I
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mentioned we have to make sure that when
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we have a nonconformity now just like
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they're doing here they grounded all of
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the 737 Max
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NES because that door
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failure could occur on those planes as
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well because similar model same design
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everything of that nature so we have to
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keep that in in mind when we are um
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looking at our nonconformities all right
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the second lesson we can learn from this
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incident is that your supply chain can
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damage your brand and cause your company
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money your your suppliers it could just
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be one supplier that could have a
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quality failure on their end and you're
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using their
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product providing their product to your
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customers just like these airlines are
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doing the airline is using Bo purchases
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Boeing
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planes to use in their airline to fly
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their customers so same thing for you
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you purchase material parts from a
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supplier to use in your production or
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sometimes to provide that directly to
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your customer so your supply chain can
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damage your brand and can cause your
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company money
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now let's keep in mind that the the
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passengers involved in this incident you
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know when they're riding the
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plane they are customers of Alaska
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Airlines right so Alaska Airlines is the
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one that has to deal with all of these
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um claims insurance claims injuries
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things of this nature right and also
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they took the hit to their image and to
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their company as well so so did Boeing
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because Boeing has been in the news
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quite quite a bit lately for several
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quality issues now we don't
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underestimate the importance of vetting
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your suppliers right that's how you can
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prevent some of these things vetting
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your suppliers doing Supply
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evaluations doing supplier audits going
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on site to evaluate your suppliers go
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visit their floor you know forget just
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getting a piece of paper or ISO
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certificate or you know filling out a
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questionnaire sometimes especially on
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those critical suppliers you need to get
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up and go to their location and see
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what's really going on for yourself it's
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very important all right guys let's talk
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about our third lesson that we can learn
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from this Boeing incident don't don't
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assume just because your supplier is a
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big company that they don't have quality
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issues I hear that all the time well you
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know they're a big company you know we
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they don't respond to us they won't um
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answer our um questionnaire or no this
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is your
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supplier you have to go vet your
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supplier do your inspections on your
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supplier do your evaluations on your
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supplier and just because they are a
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large company does not mean that they
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don't have quality issues and when they
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have those issues it's going to impact
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your
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company so often sometimes the larger
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companies are the ones that you really
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have to pay attention to because they
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become a bit complacent sometimes right
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and so you just cannot assume because
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it's a large company that they will not
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um give you problems and cause risk in
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your supply chain chain so lesson number
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three don't assume just because your
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supplier is a big company that you don't
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have to monitor them fourth lesson
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receiving inspections are
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crucial crucial guys now this Boeing
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plane was delivered to Alaska Airlines
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on October 31st
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2023 so Alaska Airlines did not they
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probably didn't feel like they needed to
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do do a heavy receiving inspection right
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a very thorough one because this is a
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brand new plane um it was had gone
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through final inspection by Boeing
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before it was
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delivered so they didn't probably feel
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the need to to do that well we we should
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always make sure that that we're doing
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thorough receiving inspections at all
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times especially on critical things now
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after the incident on January the
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5th um Alaska Airlines they performed an
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inspection a very thorough inspection on
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all 65
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planes you see sometimes we get caught
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up well we don't have time to do this or
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everything should be good already you
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know Boeing checked it now you see
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Alaska Airlines after the incident they
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found the time they found the money to
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slow down and do an inspection on all 65
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planes guys sometimes foresight can be
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2020 you know we say hindsight is 2020
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no you can slow
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down and have some foresight and catch
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things also foresight can also be 2020
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let's focus on doing that moving forward
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let's focus on changing this whole
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Paradigm that oh that was hindsight is
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2020 no make foresight
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2020 all right so these visual
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inspections they're good but sometimes
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you have to go beyond visual inspection
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you have to make sure that you are
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performing um
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validations um
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tests sometimes you you may need to even
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do destructive testing or nondestructive
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testing you know sometimes you may need
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to tear things apart that you receive CE
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to get behind the panels make sure all
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the bolts are tight yeah that was one of
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the things that United United Airlines
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which is another customer of
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Boeing um United performed inspections
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on their plane and they found some loose
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boats on that same door so they're still
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investigating why this this all happened
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but sometimes you need to do more than
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just a visual inspection when you
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receive things guys so let's make sure
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we do that
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lesson we can learn is active leadership
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counts it's one of the big things we
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talk about in ISO all the time is
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leadership now after the incident the
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Boeing CEO Mr Dave
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Calhoun he had the time to to hold an
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all employees safety meeting and what he
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told him in that meeting is that when it
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comes to the safety of our products and
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services every
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decision every action matters and when
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serious accidents like this occur it is
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critical for us to work
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transparently with our
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customers and Regulators to understand
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and address the causes of the event and
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to ensure that they don't happen again
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now that sounds great but I want to know
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if Mr Calhoun is having these types of
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meetings
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um frequently I understand he's a CEO so
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you may not don't have time to have
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these types of meetings all the time but
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how
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often is he having these types of
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meetings before we have this incident
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see guys a lot of these things we have
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to be proactive it's one of the seven
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habits of hly Effective People is being
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proactive not being reactive have these
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leadership discussions and and and all
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employees on debt discussions before we
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have a
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problem so I want to encourage you to
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ensure that your leadership in your
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company is fully
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engaged is fully demonstrating
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leadership when it comes to Quality now
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in his statement he mentioned that when
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it comes to the safety of our products
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and services well I mean yes safety is
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an issue but this is most likely a
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quality problem quality issue could be a
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process
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issue right maybe have the safety
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incident occurred because poor quality
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so here he's putting the emphasis on on
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safety of products and services where
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probably should have focused on the
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quality of products and
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services all right guys so those are
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five lessons that we can learn from the
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Boeing 737 max9 door falling off now you
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didn't think you could learn something
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from that right I gave you five things
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that we all can learn so guys let me
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know what you think about for one the
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the Boeing incident in general let me
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know what you think about that and let
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me know what you think about these five
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lessons that that I've um summarized
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here and maybe you have some lesson
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that you can take away from the incident
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feel free to drop your comments or your
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notes below hey guys take a second like
00:16:39
the video subscribe to our Channel share
00:16:42
this video somebody needs to hear what
00:16:45
we're talking about Oscar Colmes here
00:16:48
with the iso 901 group helping
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organizations improve their operations
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and reduce their risk talk to you soon
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now
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bye-bye
