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10-18-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate the lack of required process audits at PSD, and the
resulting defects it allows shop to pass on, such as "calibrated arm" (process specification) torques on non-designated
torques.
...regarding requirement that Process Audits have to be done regularly
and that deficiencies have to be documented and corrected :
Good luck finding documentation. I understand that our PSD "Conforming
Product Team" may do something like process audits during their product audits, but these CPT reviews are a joke. I will be
old and much grayer when this team ever gets to auditing me. There is no way an audit with such a low frequency could ever
assure anything. Ask a BCAG QE to calculate the effect these audits have on the quality of products or processes at PSD at
their present frequency. These audits have less chance of affecting product quality than I do of winning the Lotto. Process
audits of sufficient frequency to assure process conformance to IRR (Initial Reliability Requirement) and AQL (Acceptable
Quality Level) values are the answer.
10-17-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please stop this corrupt practice for good. Tell us that we have to find
out what is actually discrepant and fix that, not just bend a tube to fit the discrepant structure and consciously deliver
that discrepant structure to our customers without even MRBing it as "Struc and Func," Tell us from now on that we have to
follow our procedures--not just change them to the corrupt way we want to do it to "add value" to our bottom line. Tell us
that, when a tube does not fit, that if the tube being out of tolerance is not the cause, that a structural inspection will
be done to find the discrepancy--not just to force the defects out the door to our unsuspecting customers as we are so
used to doing. They are expecting to get a conforming airplane--not garbage. And they expect that if something does not conform,
that it will be documented and approved by Engineering, not just given the "what they don’t know won’t hurt them"
treatment.
10-16-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The tooling people would just get in the way of the mechanics "pushing the garbage out the door." So they simply don’t
do them (the required structural conformance investigation), and just tell us, their underlings, to write a tag saying the
tube won’t fit, and have the tube shop make a special tube to fit the most likely discrepant structure. If we had any
guts as a QA department, and stood up to our masters, we would tell shop "no structural investigation, no tag," but we don’t
have any guts.
10-15-07 quote: This quote is also from my addendum (supplement)
to my first report (please check out the last few weeks quotes as I haven't updated this page in a while) (continued
from previous day's quote):
Section (section I.D.)--This section states that the inspector is supposed to tag the structure, if that is what is causing
the tube not to fit, or is to tag the tube if it is discrepant, or is to tag both, if both are discrepant, I believe. The
problem with this? As with almost every procedure ever written for Quality--we don’t follow it. Shop does not want to
do the required structural investigations to find out what is wrong with the structure. If they found something mislocated,
then they would have to fix it, which "wouldn’t support the delivery schedule."
10-14-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Comments about the written policy on tubing rejection and rework:
...see related sections (sections' I.D.s) which have more to say about the structural investigation that should be done
when a tube does not fit, but isn’t.
Concerning quoted requirement to fabricate the (modified) tubes when
authorized by an NCR )Non-Conformance Record):
Oh really? It looks like I was right! I hate it when that happens!
10-13-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
This illegal rework has been going on at PSD forever, so like alcoholics,
it’s easy for them to fall back on old crutches to get them through the tough times. Anyway, while talking to (Customer
Coordinator Inspector's name) about the new process, He told me that it wasn’t (our QA supervisor) that
had stopped the unauthorized "adjust/bend to fit" tube installation process--it was him. He had seen the tube mockup guys
bending tubes any which way they wanted without any authorization other than the "adjust tubing installations as necessary
to fit" drawing note, and had went to Engineering to confirm that bending the tubes was what they had meant by that note.
It wasn’t. So they were told to follow the old MRB process, as they should have been doing all along. I was relieved. (My
QA supervisor) having told shop to stop their unethical practices, of his own volition, did not fit his style or unethical
character. He would only do that if his hand was forced, as in the torque witness reinstatement, or in this instance. Now
his reputation was safe.
10-12-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Maybe they are making them themselves, but they apparently still tweak
them a little during installation sometimes to ensure a perfect fit, or to ensure all struts take the same NCR (Non-Conformance
Record) configuration tube, as Engineering will roll the part number after all strut positions take the same tube for (number)
consecutive airplanes. There is an incentive for them to tweak the odd tube that won’t fit to ensure a drawing change
will occur.
10-11-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
During the time I was inspecting the tube, (Customer Coordinator
Inspector's name) came into the area and he, (the tube shop mechanic), and I started talking about the new "tube won’t
fit" process. I told (the Customer Coordinator inspector) I thought they shouldn’t even have built the tube
until the tag was written. (The Customer Coordinator inspector) argued that they could build whatever they wanted
without paperwork, but they couldn’t install it without authorizing paperwork. Then I tried to pry (the tube shop
mechanic) for information about how they did the new process. I asked him if they were still "tweaking" production tubes
and putting them into the struts with this new process. He said they had stopped doing that about three months ago, and were
making the NCR (Non-Conformance Record) tubes "from scratch" themselves now. Of course, I could probably trust him about as
far as I could throw him on that, as my statement on the above PAR (Production Action Request) attests.
10-10-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
(Name) fixed the part mark, and I bought the tube build off. I still
had to write the revision authorizing it to be installed on the strut (I wrote NCR (Non-Conformance Record) (I.D. number) revision
10, I think, later to authorize it).
10-9-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I looked at the part mark of the tube--it was wrong. I also found out
that this tube I was inspecting was the one that I was just beginning to write the revision to the parent tag for, requesting
authorization to install it! More unauthorized rework at PSD. It would not be PSD we all know and shake our heads at without
all of this typical unauthorized rework, I guess. Manufacturing and QA Management love to live dangerously, thumbing their
noses figuratively at you every time they do something illegal to "maximize value" and/or "alter our processes to meet the
delivery schedule." I guess it shows how much they really care about your regulations.
10-8-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
This just in: I had the "opportunity" to work the (model I.D.) strut
shop...I stamped in on an NCR (Non-Conformance Record) revision request (for a tube that would not fit) on the call
sheet. I was beginning to write the revision, when Mr. (name), from the tube shop, came up to the desk I was at and asked
me to inspect a tube. He led me over to a strut, and told me that the tube installed was the one he needed bought off. It
was the infamous (part number) tube. He said that the material had already been bought on another tube inspection
record. I began to look at the installed tube, which tube shop had built to a...(former) NCR configuration. I checked the
bend data printout, I checked it for damage, and I checked for the correct fittings being installed--all I could really check
for in the installed condition. Of course, if I was in a real QA department, I would have told him he’d have to pull
it out of the installation before I could inspect it, but I was in a pretend QA department, and such a request would result
in me, not him, getting disciplined for not following the unwritten procedures and acting like I had some power to assure
quality, when the unwritten procedure said I should always defer to the mechanic’s wishes, even when they conflicted
with quality and safety.
10-7-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Also write us up if the tube mockup shop personnel should not be "inspecting"
tubes by operating the laser tracker machine, and us only "verifying" the printed report, and inspection should be operating
the machine to ensure valid data, with the possibly required certifications, of course.
10-6-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
If the old undocumented process of reworking already bought off production
tubes without authorization or such described checking, or the new undocumented process of reworking already bought off production
tubes without much authorization and with such described checking bothers you, then please write us up.
10-5-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The process works something like this, from what I know of it: If a tube
does not fit, like the frequently unfitting (part number) tube, instead of just writing a PAR (Product Action Request),
like they used to do, and getting the tube mockup shop to come out and bend the tube until it fits the installation, per the
"new process," the shop writes a PAR, and gets the tube mockup shop to come out and bend the tube until it fits the installation
(sounds like Deja Vu, huh?). Then, additional steps are performed in the new undocumented process that weren’t part
of the old undocumented process. Tube mockup then takes the tube that was reworked without anyone’s but shop’s
authorization, I guess, to their shop and they "laser tracker" it on their machine, "tweak" the tube, or manipulate the laser
tracker measurements [we wouldn’t know if they did this or not, as we do not do the laser tracker measurements of the
tubes, and we aren’t certified to operate the machine anyway (if certification is required), yet maybe the tube shop
personnel are not certified to operate the machine either, for all we know--you might want to check on this] until they get
the machine to spit out a report that states that the tube, after illegal rework, still conforms to the Catia bend data. Then
they bring it back out to shop and have us, line QA, bless the tube and/or it’s laser tracker report somehow, and shop
installs the tube.
10-4-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Just last week I saw them still use this bench to bend a (part number) production
tube per shop PAR (Production Action Request) (PAR I.D. number) (reference job (job number, control code (area) and strut
position). They are still bending these tubes like before, but a new undocumented process has been blessed by (my QA supervisor),
and therefore this new undocumented process is "legal"--not!
10-3-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The tube at PSD that this illegal bending is done most often to, but
is not by far limited to, is the (part number) pneumatic tube on (model I.D.) struts. In fact, the tube
shop has a special bench set up by the (model I.D.) strut line (adjacent to the "shop monitored" sealant freezer)
in which they did they illegal uninspected rework to this tube and others.
10-2-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Thousands of tubes are flying around on airplanes that may fatigue early due to this excessive uninspected bending, and
if they fail and the airplane is able to land, and the airline gets the part number off the ruptured tube and orders another
one from Boeing, they’ll be extremely angry when they find out it won’t fit the installation. Also, there are
untold numbers of systems that may be impaired by unknown ovality of system tubing that was bent excessively, without inspection
or required MRB authorization. Even though we do not inspect for ovality, but should (see item 55), a tube with half the required
tube diameter in the bend would be obvious to an inspector, if he ever had the opportunity to inspect this illegal rework.
I assume that PSD has notified you of these thousands of illegally reworked tubes on our airplanes due to the size of this
problem and the safety aspects of it, but if they have not, please consider this your notification.
10-1-07 quote: This quote is also from my addendum (supplement)
to my first report:
This is one problem that (our QA supervisor) has appeared to fix, but I’ll bring it up to give you a further
peek into the unethical world of BCAG. Our PIs (Production Illustrations) have had a general note to "adjust tubing"
to meet drawing requirements. This note was put there to allow the mechanic to adjust clamps, add shims, or loosen and re-clock
tube assys, C/T tubing installations. However, the tube shop interpreted it differently. To them it allowed them to bend any
production tube they wanted to in order to make it fit, bypassing the required MRB process that would have required fabrication
of an "-M" (Non-Conformance Record defined) tube, and the time consuming inspection of their tube bending on the NCO (Non-Conformance
Order) that fabricated the tube. It saved them a lot of time, and the Company a lot of money, so every one, but a few inspectors
like me, looked the other way. The problem with this? Tubes, bent to an unknown degree outside of engineering definition,
with no inspection at all, documented or otherwise, of this illegal rework.
9-30-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
Please make us rethink this whole situation with valid data, not lies
that work. Do not consider the fact of fireproof enclosures and fire suppression systems being on/in sections of the EBUs
(Engine Build-Ups) in your calculations. They are only backup systems. The valid witnessing of leakproof torques at
PSD by future (I hope) non-roller stamping inspectors should be a backup system unto itself, that is now missing, and should
ensure the 0 AQL. See the Exhibit AM email for an additional Engineering contact on the leak-proof torque issue. I think you
can see, by these emails and the (engineering specification) witness torque emails, that I suspected/knew of the
unethicality of our QA management long ago, and was checking up on them, Don Quixote fruitless style, trying to undo the horrific
damage they were doing, and have ultimately done, to our Quality System.
9-29-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
One additional lie in their bag of tricks they (Manufacturing and QA
Management) probably used in connection with getting the current system of "self-inspection" of these critical plumbing torques
instigated at PSD, was the ubiquitous lie of, that if we complied with the requirement, "it would shut PSD down." This is
the lie they use to get PSD exceptions to specs so we do not have comply with them. This leakproof torque debacle, while the
email doesn’t mention it, is one instance I’m sure it was used. They are probably using it now on the "do not
torque adjacent bolts on circular patterns" problem, trying to get (name), key engineer of the (engineering specification) spec,
to grant an exception for PSD (see Exhibit AH if you are interested). They are lying when they say this. If they were telling
the actual truth, this line would go something like this: "It would add significant time to our builds" or "It would slow
us down a little" or "We’ve been doing it so long now wrong, we need to cover our asses for past nonconformances we
shipped and make the spec say how we do it, not vice versa. If this gets out we’ll look like the people that put schedule
over quality and safety, like we are. If we have to pay the airlines for fixing all of the nonconforming product we shipped,
it would shut PSD down, or at least impact BCAG profits" or "It would inconvenience us" or "That safety requirement does not
fit in with PSD Lean plans--get rid of it."
9-28-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
Let’s take the (next) lie by our management that "justified"
omitting QA witnessing of leak-proof torques at PSD, "that there are too few inspectors at PSD." There are really not that
many of these leak-proof connections on an individual strut or engine, as our management probably told engineering and will
probably tell you. Have them count the few hundred critical fastener torques that we witness on an EBU (Engine Build-Up),
then have them count the number of leak-proof connections we torque on that same EBU. The number of critical leak-proof connections
we torque will probably be less, and in fact, much less, than the number of critical fastener torques we witness on
an EBU. How much extra time does it take for QA to witness a torque than if a mechanic does it without witness?
Almost no extra time. Is only thirty seconds more for the mechanic to call the inspector too much to ask to increase the
safety of the people on our airplanes, and the safety of mechanics at Prime Divisions that have deal with the spewing connections
we left loose at PSD, that did not wait to fail in service? They will probably try to tell you "just look at the big picture"--thirty
seconds on each connection would equal a huge amount of profit loss for the Company. Except shop does not torque just individual
connections in a system, then one more later. They are supposed to torque all connections in a system at the end of installing
that plumbing system, not to just install one tube at a time. (Our QA supervisor) told us in our...crew meeting that
recently seven gallons of hydraulic fluid leaked from a B-Nut (tubing) connection to the hydraulic pump during a wet
run of an EBU at Prime Division that supposedly was a witness torque at PSD. Whether it was a witness torque or not, or whether
it was loosened after inspection at PSD is anyone’s guess. (Our QA supervisor) seemed to imply it was a QA
escape, but I know anything (our QA supervisor) says in crew meetings should probably be taken with a grain of salt,
unless it jibes with his true unethical BCAG QA Supervisor nature. He only speaks the truth to us individually, behind closed
doors. Of course, what he said may have been true, and one of his "trained to roller stamp" inspectors may have bought that
torque, if such a witness on that connection existed. I have personally had to re-witness witness torques on hydraulic pump
unions on the 747/767 EBU line, where a PSD roller stamping inspector, (name), Lead Inspector, had "witnessed" the torques,
that were not obviously, by visual inspection, completely torqued, and would have similarly leaked at (Prime Division, in
this case the Everett factory). The current ineffectiveness of our management trained roller stamping inspectors is no reason
to let these critical 0 AQL leak-proof torques go uninspected. The effectiveness of our Quality System will ultimately be
restored, if you investigate per this report. I believe these torques can be done with only the current inspection force,
if they are made what they should be--a witness. So what if I’m slightly off and they have to hire even one more inspector?
Is the lack of their extra pay by their absence, due to the possible maintaining of the current lie-gotten "non-witness" leakproof
torque system at PSD, worth the lives of hundreds at a crash? Maybe to our management, but not to me. So much for the "there
are too few inspectors at PSD" lie.
9-27-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Let’s take the first lie by our management that "justified" omitting
QA witnessing of leak-proof torques at PSD, "the tight spaces make it difficult for an inspector to actually view the witnessing."
I have worked most everywhere at PSD over the years except much of the 777 EBUs (Engine Build-Ups), and I can unequivocally
state that there are no such tight spaces that make it difficult for an inspector to actually view the witnessing,
as all plumbing we install has been designed to be accessible by airline mechanics, and the viewing of these connections can
be done from multiple angles in nearly all cases. We don’t even have the obstructions that airline mechanics have to
deal with, at PSD--engines and cowling installed on the struts! The only place I can think of that would even be mildly "difficult"
to witness the torque of would be one (fire extinguishing) system B-Nut (tubing connection) just above the midspar
in the forward section of the 747 struts, and that would only be "difficult" to witness for the kind of inspectors at PSD
that inspect critical items with only a coffee cup in their hands. Our management will probably try to tell you we don’t
have this basic inspection tool at PSD, in order to maintain the cherished non-witness status of these torques, but we do.
It is the inspection mirror, and with it, and with the other, "should be" obligatory inspection "tool," a flashlight, it would
be very easy to witness the noted torque without even interfering with the mechanic. So much for the "the tight spaces
make it difficult for an inspector to actually view the witnessing" lie.
9-26-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
"The big reasons for not having line inspectors witness leak-proof torques
at PSD are that the tight spaces make it difficult for an inspector to actually view the witnessing, and that there are too
few inspectors at PSD?" Sounds like super-technical statistical QE (Quality Engineering) reasoning, doesn’t it? More
accurately, it is the best reason they could fictionalize in order to save PSD the minimal extra costs of the witnessing of
these torques, and for our QA Management to avoid "interruption of the lean manufacturing flow," their main goal (not the
goal to avoid defects in the product, like you might expect), that might result from a valid inspection regimen that would
ensure the 0 AQL (Acceptable Quality Limit) requirement.
9-25-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Do you think the exemption for PSD not to witness engineering required
leak-proof torques on the engines and struts was given because our mechanics make few, if any, mistakes, the engines don’t
need the plumbing systems we install to run (as (my QA Supervisor) would probably tell us line inspectors), or that
some huge, statistically valid study was done by QE (Quality Engineering) to show that the risk of a leaking connection to
ETOPS was minimal in relation to the inspection costs saved? Nope. Read Exhibit AL for the real, sad truth from the eyewitness
engineer that worked the PSD X-XX change, (name), of why this critical torque witness was axed for PSD--simple (non-statistically
valid) lies. What the last sentence of the first paragraph of the email shows, is the reasoning PSD QA used to probably accede
to their real bosses’ unethical, purely non-quality and non safety related wishes, Manufacturing Management. Lies.
9-24-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please investigate the lack of leak-proof torque witness at PSD. True,
(engineering specification), PSD (Process Specification Departure) X-XX section XX.X.X. (which may have been incorporated
by now, hopefully) exempts PSD QA from verifying leak-proof torques, "unless specified by the engineering drawing." However, (engineering
specification) page X Table X allows an AQL (Acceptable Quality Level) of 0 on leak-proof torques, which means,
that in addition to QA having to witness the mechanic do the torque, probably God would also be required to watch too, to
meet that AQL. We used to have to witness leak-proof torques that the values of were called out on the drawing, just like...bolt
torques, but they killed that requirement without cause (murdered it) near the time of the drawing designated critical torque
"no witness" debacle to compromise quality and safety in return for more profits and better "inspector-less" manufacturing
flow. See Exhibits AK for two emails from our management on the subject.
9-23-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote). This item might have some applicability to the recent explosion
of a 737 in Japan, with all of the passengers thankfully (but barely) escaping with their lives, mostly due to an alert ground
crew person at the airport gate it had just pulled up to noticing the leaking fuel from a puncutured fuel tank caused by an
omitted or misplaced washer on a fastener before the passengers could be engulfed by the resulting conflagration:
This item is almost Deja Vu to the (below) item. It is not that
major, unless you expect BCAG to build conforming products to the fastener level, which I think you might. It illustrates
again how screwed up (BCA) is to requirements that would allow us to build products with stable conformity from unit
to unit. It mainly has an effect on inspectors like me, who actually inspect fastener installations, and who don’t like
to guess what the configuration of the product should be when I inspect it. This item is one of the few situations where engineering
has not screwed up, and that common sense and (engineering specification) requirements, without modification, should
prevail. However they don’t, because shop does what they want, whether it is right or not, and inspectors don’t
care or don’t speak up because our corrupt QA Management will find us new jobs beside the freeway if we do: It has to
do with washer position on fastener installations. Many of our drawings show fastener installations where a bolt, a plain
washer, and a nut are called out without a specific head direction or washer position callout. The washer should go under
the nut, as it is uncountersunk, and no such washers should go under the head, right? Wrong per shop tribal knowledge and
build methods. No, the washer always is installed under the component, bolt head or nut, that gets rotated during installation,
per shop preference of which side to rotate. This shows how often shop reads their specs, as this might have been partially
true about 15 years ago, per the (engineering specification) spec. I don’t know if you want to write
us up for this or not. You are welcome to. It is mainly illustrative of the inability and/or unwillingness of inspectors to
attempt to politely enforce even basic fastener installation requirements like these for fear of the "is it critical!" berating
"yell" that (inspector's name) got from (my QA supervisor) in that crew meeting when speaking of missing "non-critical"
shakedown inspection buyoffs, and fear of the later "not supporting the delivery schedule" private meeting with (my QA
supervisor) to get your "award" for enforcing basic Engineering requirements, a CAM (Corrective Action Memo, any three
of which result in termination). See Exhibit AI item 1 for an email I sent to the keeper of the (engineering specification) spec
about this subject. He seems to think the drawing is deficient if it doesn’t state where to put the washer. The middle
sentence of his answer, I believe, is in error, as it should not be up to the mechanic where to put the washer. See the following
sections of (the engineeriung spec) for what shop should be doing in these situations, and what we would
be making them do, if we weren’t instructors, and were really inspectors allowed to inspect the product:...
...(Note about washer use requirements on painted parts) Nope, most of the parts we misplace the drawing washer on are
bare parts, and if such a primered part existed for which we needed to comply with this section by having a washer under the
head that we had to torque because of no access to the nut, then we wouldn’t just take the drawing plain washer, that
should always be under the nut, and put it under the head for protection of the finish. We should comply with the spec section
X.X.X above, and add an additional (correct washer) from Table XX, as required, and put it under the head, leaving the
plain drawing washer under the nut.
9-22-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
References:
NCR (Non-Conformance Record) (NCR I.D.) I wrote on the (A/P Model I.D.) APU (Auxiliary Power Unit)
due to prior inspectors had been buying the APUs off with the incorrect bolt head direction per (engineering specification) on
single pin joints on the APU mount (items 1 and 3), as shop had installed them. Items 2 and 4 had to do with the wrong washers
being installed on the bolts with the incorrect head direction. I believe I asked for a line check, or inferred one was needed
on the tag.
9-21-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I have noticed problems with our drawings matching the AMMs
(Airplane Maintenance Manuals)/PPBU (Power Plant Build-Up) Manuals. I think I heard a rumor once that we weren’t updating
our AMMs/PPBU Manuals (because of MRB (Rejection Tag) changes?). At least our drawings seem to be better than the AMMs/PPBU
Manuals, though you’d expect we'd want to have our customers see our best, not our worst. I’ve submitted one change
for an AMM (reference PCR # TBC-PCR-XX-XXXX-XXXXXX), though I’ve actually read very little from AMMs/PPBU Manuals, considering
how much is out there, so far.
Representative installations:
The (installation number) (Thermal Anti-Ice) duct installation on job (job I.D., model I.D., line number I.D.).
...Drawing (drawing number) sheet 5 has three views of link fasteners. The views seem to indicate a head (direction)
position is required (pictorially, which violates drafting standards), regardless of the position of the clamp-up bushings
(which violates (the design standard) and conflicts with the above two drawings), which matches (the engineering
specification) requirements. But drawings trump spec requirements, and fasteners are not supposed to be shown in detail,
so which direction the fasteners are supposed to be installed in the above (noted) drawings is anybody’s guess,
because there are lots of conflicting requirements. The only given is that these (noted) drawings are typical of the
quality and interpretability of our drawings at (BCA), where fastener installation requirements are concerned.
9-20-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Anyway, you can probably tell I have done a lot of research into this,
without much success in finding the "Holy Grail" of documentation, like I did on the MHIR subject. Maybe the fact that I actually
care about the products we build is the problem. I think the main problem is that our Engineering department is not complying
with the (design specification) documents, which are mandatory requirements, I believe, unless they get (an
approval) for a drawing departure to those requirements. What the kicker is is that the way we install these single pin fasteners,
per the Catia drawing picture sheet, with the (fastener) and (fastener) next to the bushing that slips into the
clevis, violates (design specification), Single Pin Joints, page XX Figure X-X requirements to install the clamp-up bushing
adjacent to the (fastener). That is done so, if the nut (loosens, the fasteners) will stay in place until the next
maintenance visit. Please check into this, and have our engineers fix it if required so we can build safe and duplicate from
unit to unit products, or let me know if I am all wet on this subject and missed something that allows this confused state
of drawing and spec to exist. If there is a problem, be sure the AMMs (Airplane Maintenance Manuals)/PPBU (Power Plant Build-Up)
Manuals are revised also, so everything is the same after maintenance.
9-19-07 quote: This quote is also from my addendum (supplement)
to my first report:
This item is not that major, unless you expect (BCA) to build conforming products to the fastener level, which I think
you might. It illustrates again how screwed up (BCA) is to requirements that would allow us to build products with stable
conformity from unit to unit. It mainly has an effect on inspectors like me, who actually inspect fastener installations,
and who don’t like to guess what the configuration of the product should be when I inspect it: It has to do with the
required head direction of fasteners, and the lack of definition of such by (BCA) drawings. (Design specification), section
XX.X, states to not show fasteners in detail, and to add a head side direction required flag note if a specific head direction
is required. Section XX.X.X. states to call out fasteners in one view only. (Design specification) section X.X.
states drawings are the basic means of communication between Engineering and other organizations, and must be clear, concise,
and subject to only one interpretation. (Design specification) section X. states to use (design specifications) two
dimensional drawing standards except where Catia (design specifications) series standards identify departures. Catia
design standards do not give any exceptions to the noted design standards. This mainly affects single pin joints per the following (engineering
specification) section:
a. Bolts used in single pin joints or in control systems shall be installed with the heads (direction) or (direction),
unless otherwise specified. All other bolts shall be installed with the heads (direction) or (direction) wherever
practical.
These single pin joint fasteners are mainly used in engine mounts, and in links that support duct installations. It is
shop practice to always put the nut and plain washer on the bushing side of the joint, regardless of the noted (specification)
requirements. Most of our Catia drawings do show the bolts installed this way, and if they don’t, shop writes ELRs (Engineering
Liaison Requests) to make them that way. There are no head side required notes per (the design specification requirements).
The Catia drawings show the fasteners as gotten from the (Catia) repository, and these fasteners are practically
shown in lifelike detail, bolt head and all. Therefore shop mechanics, and probably most inspectors, including, I know, (name),
Customer Coordinator, think these fasteners must be installed as depicted pictorially on the Catia drawing, if they care about
fastener installation at all. These Catia drawing(s) violate (design specification), section XX.X, that states to not show
fasteners in detail, and (there) is no exception to this in the Catia design standards I am aware of. There is also nothing
anywhere that states that fasteners must be installed in the direction depicted on the Catia drawing when they lack a head
direction note, that I am aware of. So we are building these critical single pin joints by simply "tribal knowledge," and
not any engineering requirement. And we are ignoring the only real engineering requirement we have, which is the noted section
of (the specification) that states these types of fasteners shall be installed with the heads (direction)
or (direction) (to prevent the (fastener) from falling out until the next maintenance check if the (fastener
loosens)). I think we should ignore the head direction shown on the picture sheet, unless there is a required head direction
note on the drawing, but I am a minority in that on these critical single pin joints. The part of the...spec section that
states that all other bolts shall be installed with the heads (direction) or (direction) wherever practical
is a joke, and shouldn’t even be in the spec. It is unenforceable by QA, even if the shop has a mile of room to install
fasteners per the requirement.
The chances of an inspector, considering the corrupted state of our Quality System, being able to enforce this part of
the section in such a case without being fired "for not supporting the delivery schedule," is about equal to the chance of
you accidentally running over and killing the real Easter Bunny on Easter morning.
9-18-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please investigate the following issue that makes all your efforts to
get BCAG jobs to comply with requirements for inspectors to witness drawing designated torques useless: On XX/XX/XX, I was
lent to the (model I.D.) strut area, as they were shorthanded. I stamped in on a torque inspection on the call sheet
for Dennis Harem,...strut mechanic. It was for torques on the (part number) clamps on the precooler ducting and
fan air valve. He did the first torque on the fan air valve clamp, then reset the torque wrench for the next clamp torque
value and began to torque it. I told him he had not shown me what the torque wrench was set to on the prior torque, and that
I would like him to torque it again and show me the setting. He went ballistic. He got up, reset the wrench, gave it to me,
then said angrily, "Gerry, why do you always treat us like children?" I said I thought he knew that I always would look at
the wrench setting on each witness torque. I had inspected many of his torques when I used to be assigned to the strut shop.
"Torqued," he angrily retorqued the fan air valve clamp and then did the other torques on the precooler ducting clamps. You
can see (now) what an ethical inspector has to go through. It was obvious to me from this incident, that the "witnessing of
drawing designated torques without looking at the torque wrench setting," and probably even without looking at the wrench
calibration date, was still going on strong by roller stamping inspectors at PSD that weren’t brave enough to stand
up to such abuse. So, you see, even after all of your work, without the reform of the line inspectors that roller stamp per
QA Management direction, most of your efforts will go to waste.
References:
See Exhibit AG for an email exchange I had with someone on the BCAG Torque Team that may be insightful from your perspective.
You can see that I, the lowly powerless line inspector, was trying to right the scuttled ship of witness torques at PSD even
9 months ago.
9-17-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please also investigate the following drawing designated torque problem
that illustrates how clueless we have been: We have always, since PSD inception, torqued almost all of the drawing designated
torques on the inlets, exhaust plugs and sleeves, QADs, generators, hydraulic pumps, you name it, anything with a circular
pattern, or even a multiple row installation like the (model I.D.) fan cowl chine, in a circular pattern, in violation
of (specification section) (referenced in the reference section below) that states not to successively tighten adjacent
bolts or nuts in that situation, and instead to first snug up all the bolts, snugging up opposite bolts all around, then tighten
all the bolts, applying the final torque to opposite bolts in a pattern similar to that shown in Figure X of the spec.
The reason? When you tighten adjacent bolts on a part like an inlet or exhaust sleeve, you chase a gap around the inlet
or sleeve, which gets larger and larger as you progess, and this gap gets pushed all the way around, getting concentrated
between the first and last torqued bolts. This probably overstresses the first torqued bolt, and structure in that area. Excessive
gap at that area also results. We never check the gap between the noted parts and the engine that I am aware of, so unknown
gapping conditions exist in service. This may also effect the "calibrated eyeball" inspected (basically uninspected) fit and
fair of these parts, also. If we haven’t notified you of the many thousands of discrepant installations that resulted
from this improper torquing of drawing designated torques, then please write us up. Who knows how many thousands of engines
have bolts rattling around in their inlets or exhaust installations because of this problem. Even your local uneducated auto
mechanic knows not to do this on the tires on your car, but we don’t care, as we only care, it seems, about what will
"push more garbage out the door" faster. This very recently came up as an issue at PSD, as (name), the thorough inspector
who still falsely believes (per the unwritten BCAG Quality System ) that he is an inspector, and not a mechanic instructor
on corporate welfare, (brought it up). He started making shop torque anything that fit the noted section of (the spec),
including inlets and exhaust sleeves, per the noted section. This made shop go ballistic, as you might know would happen per
my descriptions of their character so far. They did the usual, and instead of happily complying with the obvious spec requirement,
to make sure that products shipped from PSD from now on would conform to requirements, they immediately began an effort to
kill the spec requirement for PSD, just so our build times would not increase by the few minutes that building conforming
products would require. I found out (the inspector) was enforcing this by shop rumor. (My QA supervisor) knows
about this. But does he tell all his inspectors to make sure they make shop torque per the requirement? No. And you know only
too well why. See Exhibit AH for an email that shows the PSD "mechanic’s position" on this and other issues of torque.
It shows that pretty much only the build times are what they care about, not the safety of the people on board our aircraft.
9-16-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
By the way, I’ve heard rumors that the mandatory compliance date
you gave us for witness torque inspections to be added to the plans for drawing designated torques was XX/XX/XX, which we
missed. There are still probably many drawing designated torque inspections missing from all our program’s plans, as
our QA Planning department went AWOL again, and let M.E. (Manufacturing Engineering) add/revise all of the inspections, with
no oversight. Please write us up, if we missed your "drop dead" date. The evidence of non-compliance is in the (model
I.D.) completed records, and probably still out on the production floor in assorted partially worked/still to be worked
plans.
9-15-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
Please use extreme caution when approving any changes to the drawings
to delete drawing designated torques. Engineering, like QA, is under extreme pressure from shop management to delete any requirements,
no matter how safety related, in order to compress their build times, save cost, meet schedules, and as (my inspector
coworker) said, "to push more garbage out the door." Our QA Management has totally capitulated to their every unethical
whim, and Engineering may also. Do not allow any drawing designated torques that were on the drawings from inception of a
program, or drawing designated torques that were added because of problems found in service, to be deleted.
Use the same "fault tree analysis", or similar tools, that were used
in type design approval, when deciding if a torque should be deleted or not. Please do not consider the current extreme state
of ineffectiveness of our line inspection force as a reason to delete those torques. This report is meant to restore that
effectivity, with your help. An engineering change to delete torques that is presented to you with the reasoning that less
inspection will save BCAG money, in my opinion, should be rejected. Believe, me (I’ve witnessed this), that, while the
reasoning for most engineering changes to delete drawing designated torques may be dressed up with statistics and other manipulated
data and reasoning, the only driver behind these changes is to, as (my inspector coworker) said, "to push more garbage
out the door," without any real consideration of the consequences, because as (my corrupt QA supervisor) said, the
statistics say our products are fool-mechanic-proof and cannot crash because of uninspected manufacturing error.
9-14-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
We just recently, at the end of February, supposedly revised the last
program at PSD, the (model I.D.) EBU program, to have witness buyoffs for the drawing designated torques. (My QA
supervisor) finally told them they would have to comply with the witnessing of drawing designated torques. They immediately
wrote ELRs (Engineering Liaison Requests) to delete all the torque callouts from the drawings, as the QA witnessing of the
torques added some minutes to the shop build schedule, and those minutes were not an equitable tradeoff to shop in return
for the increased likelihood of safe flight benefiting (by correct levels of inspection of those torques) those people on
the airplanes on which their EBUs would be installed (if they even considered such a tradeoff at all, as build times, and
build times only, are what the shop leads and shop management seem only to consider).
9-13-07 quote: This quote is also from my addendum (supplement)
to my first report:
Torque witness: I believe you have us under the gun to fix our witness
of drawing designated torque debacle, which should be proof enough of the motivations and corruption of our QA Management
that created this debacle, that allowed untold numbers of critical torques to escape required levels of inspection.
You probably know, as I do, a "verify torque" inspection is pretty much
worthless. It only proves the mechanic can enter the correct value on the paper, and has little real relationship to conformity
of the product.
Just a week or two ago, on the (model I.D.) EBU (Engine Build-Up)
line, during torque witnessing, I witnessed the mechanic, (name), set the torque wrench to the wrong torque on two consecutive
separate torque value requirement torques, so these things were occurring all of the time to the critical torques we didn’t
witness during that period. The mechanic would just set the wrench to what he thought he set it to, do the torque, then write
the value he thought he set the wrench to on the job for inspection to "verify."
These incorrect torques happen on (BAC specification called out) torques
shop does without any form of inspection, even the required sampling inspection of these torques per (the specification),
all of the time.
9-12-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Also see why they never caught this problem there before shipping the
T/Rs (Thrust Reversers). I suspect they don’t check the product for handling damage between the final shakedown and
shipment (no required shipping inspection per (our QA Manual requirement). See Exhibit AF, for an email I wrote to (name),
CAU (corrective Action Unit) Investigator, complaining of the ineffective CA on this damage.
9-11-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please investigate all tags for the last year for similar bogus CAR (Corrective
Action Record) closeouts that purposely avoid repairing known defects at BCAG, and instead knowingly deliver those discrepant
products to our customers to simply avoid costs and, consequently, fatten profits at the possible expense of human lives.
Also please investigate the first example problem, and fix it, because we purposely did not. Have BCAG issue the necessary
SB (Service Bulletin) for the airlines to inspect for this damage and fix it before cracks develop in the frame or adjacent
parts. Check out Wichita, and find the tool that causes the damage and make us fix it so it won’t create these defects
anymore, as we are unwilling to spend the money to fix (it)without your help.
9-10-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
As I can’t write this up again due to the fact that not just banishment
to a make-work job in the office will result, but banishment from BCAG itself will likely result, please take care of this
discrepancy for me. While I don’t know if another El Al style crash will result or not if corrosion causes some damage
to these unprotected roller swaged bushings, Engineers put requirements on drawings and in specs for a reason, not just on
a whim, as QA seems to think by the way we enforce them. The noted problem is C/T (Common To) (the) (part number) installation,
C/T the (part number) spring beams, C/T the (part number) nested bushings. See the noted latter two tags
for references. Also see "flag" (in a circle) 8 on the figure on SB (Service Bulletin) 747-54A2152 revision 4 page 54 on the
upper half of the page entitled "Typical Spring Beam Lug Rework, Nested Bushing Installation," which states on page 60, step
10, to do a "bead sealant in swaged lip." The service bulletin is much more clear than the drawing and spec on this issue.
Do not stop with the write up of this installation. I suspect the same discrepancy exists on all similar bushing installations
on all of our struts. We, as QA, should not have the luxury, as we do now, to say which things on the drawing we will ensure
are (done) correctly, and which we will purposely ignore, even though we know they are not done correctly.
\9-9-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
I noticed, during a recent walk through of the strut shop, that the (model
I.D.) struts were missing the fillet seal again I had written up just before my banishment. From page 30 of my original
letter:
I also was writing up missing fillet seals from Wichita around the bushings in the strut to wing attach fittings. I found
this discrepancy while inspecting the rework of a damaged bushing per NCR (Non-Conformance Record) (NCR I.D.). Examples: NCRs (NCR
I.D.) and (NCR I.D.).
9-8-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Original letter, item 1, page 30: After I had written several up, they
started to come in in the condition they should have been received--with no damage, although one came in in which it was obvious
that unauthorized rework had been done to the damage in Wichita, prior to being received at PSD. The damage had been crudely
blended out, with no required rotopeen or MRB stamp (NCR (Non-Conformance Record) (NCR I.D.) items 7, 8, and 9).
9-7-07 quote: This quote is also from my addendum
(supplement) to my first report (continued from previous day's quote):
Anyway, I got tired of it, so I left routing comments on NCR (NCR
I.D.) laying out everything, why I knew the damage was as received, which NCR’s CARs (Corrective Action Records)
had been bought off in error with the wrong reason for the damage, and that I suspected tooling locators in Wichita for causing
the damage. I monitored the CAR to see if Wichita would finally get the message and fix the problem by putting the real reason
for the damage on the CAR. Nope. They simply cut and pasted the wrong reason onto that CAR from an earlier CAR, denying responsibility
again, which would result in no action to fix the problem, as PSD did not normally receive those T/Rs (Thrust Reversers),
and the Renton inspectors may not find the damage, as they were unaware of the NCRs that had been written at PSD on the problem.
I wasn’t about to give up yet. The CAR had not been finalized yet. I got the name of the Wichita investigator that had
written the bogus non-fix on the CAR, and looked her number up and called her. I told her everything I had written in my routing
comments and told her that I, a line inspector, had witnessed that the damage was as received from them. I asked her why she
had mentioned "skin quality" for this non-clad part in the CAR. By her answer I found out she had no idea where the damage
was on the T/R, yet they had denied responsibility for it anyway. I told her that I had attached marked up drawings to the
NCRs and that I gave accurate three point locations for each damage location. I asked her to look into it again, and I told
her exactly where to look for the object that made the damage. I told her it was probably a holding fixture in which the T/R
was placed during shakedown in which the holding points of the tool were damaging the T/R and the damage was covered by the
tool during the final shakedown, making finding it during the inspection impossible, or it was a functional test tool that
did it after shakedown, or it was a lifting fixture that did it after shakedown. She said she would look into it again and
the call ended. A time later I looked the CAR back up again and it had been closed out. Yep, it read the same as before, denying
responsibility. Nothing would ever be done to solve the problem, as I would see no more of those T/Rs at PSD, most likely,
in order to try and get effective and ethical CA again on the damage. What’s bad is that I knew that they, Wichita,
knew that they caused the damage. One of the T/Rs came in, shortly after my first NCRs on the damage, with the same damage,
except that a crude attempt had been made to do an illegal blend out of the damage, as no QA would have ever bought that blend,
as the surface was still very rough, even for a non-sonic edge area which this wasn’t, most of the damage was not blended
out, and no attempt was made to alodine or primer the "repair," or to MRB (Material Review Board) stamp it. I had gotten this
same illegal repair response from Wichita before when I was in (model I.D.) struts on my T/R hinge damage tags: (To be continued..)
9-6-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please investigate ineffective/corrupt CA (Corrective Action), which
is as good as no CA at all, on NCRs (Non-Conformance Records) at PSD due to turf wars with Wichita and who knows what else.
A prime example of this is NCR (NCR I.D.), on chronic and at times very significant damage to the (part number) inner
barrel frame on the (part number) (model I.D.) T/R (Thrust Reverser) that is built in Wichita. Related CAR (Corrective
Action Record I.D.) for the NCR, and/or a similar NCR (NCR I.D.) stated that the damage was done at PSD during
fitcheck, which I knew was not true due to the fact I caught the damage on the receival inspection job before PSD mechanics
ever touched the T/R. I was tired of writing tags on nearly every one of these Wichita T/Rs that would come in, and nothing
ever would be done about it, as Wichita would not accept responsibility for it and fix whatever was causing the damage at
their plant. I had even requested a line check of delivered units in the routing comments of these numerous tags for the discrepancy,
because I only saw a few of these T/Rs, which were usually direct shipped to Renton, when there was a suspected problem with
them that PSD needed to check on our fitcheck tool. So all of the ones I didn’t see probably had the same damage. (To
be continued tomorrow..)
9-5-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Here’s a new twist: A tag that had a good disposition, but the mechanic did it the way they wanted to do it, and
our inspector bought it, without getting the disposition changed to match the illegal rework! The tag was NCR (NCR (Non-Conformance
Record) I.D.). The disposition of the NCR stated to remove and replace some loose bushings on an engine. Instead, the mechanic
just reseated the old bushings and replaced a rivet that secured the bushings in place. See attachment "XXXXX.JPG" on the
NCO (Non-Conformance Order) for the NCR, (NCO I.D.), for proof--in the vendor’s own words.
9-4-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I wrote the revision, and also noted on the revision that there were
no instructions in the AMM (Airplane Maintenance Manual) to replace the clamps, so I had inspected the work to the AIPC instead.
I also stated that the rework instructions were in the (engine vendor) MM (Maintenance Manual), I believe. To make a
much too long story finally end, the disposition for my revision came back to state to remove and replace the newly discrepant
clamp per the AMM! Yep, same disposition as revision 0 that was incorrect, except the engineer had actually called out a section
of the AMM in his new disposition, whereas the whole AMM document number was listed in the original disposition and us line
inspectors were supposed to fish for the right section of the AMM to do the inspection to. I looked at the AMM section the engineer had called out. It only applied to Boeing tubes and clamps,
not the vendor's. Oh well. I had tried to get the message across in my revision that the vendor MM applied, not Boeing’s--to
no avail. I decided not to try again as that would likely be similarly fruitless, and just result in me inspecting yaks at
Boeing Siberia. I left the engineer to his permanent "wet paper bag" home, and moved on.
9-3-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Of course, the washer had been required for a purpose, and when the bolt
was torqued the uppermost clamp lug twisted with the bolt head due to friction, twisting the clamp into permanent deformity.
Of course, the vendor mechanic was in such a hurry they did not see this, or did not give a damn if they did, and the vendor
rep that signed off the work also missed it. I now had to write up the three new discrepancies on the NCR (Non-Conformance
Record), whereas if I had not inspected the work like my comrades my job would be much easier--like a roller stamping inspector’s
life was. (To be continued tomorrow..)
9-2-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The (engine vendor) mechanic had had to remove a bolt to get the damaged
clamp off of the tube. In that process they managed to drop the washer that had been under the bolt’s head. They then
slapped the new clamp on, probably in an extreme hurry, as instead of the new clamp being butterflied under or over the adjacent
clamp as the original clamp had been, they butterflied it’s lugs with the other clamp’s lugs in an interwoven
fashion, so that neither clamp would be completely closed when torqued down. Then they reinstalled the bolt, without the washer
they had dropped, and then torqued it down, probably with their calibrated arms. (To be continued tomorrow..)
9-1-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I looked at the lower replaced clamp and it was fine--per AIPC, at least.
Then I looked at the upper clamp that was replaced. The horrific scene that met my eyes justified in spades why I inspected
vendor rework when other Boeing inspectors did not. Even though the airplane was not in all likelihood going to crash because
of this one poorly installed clamp, it made you wonder what other more critical components of the engine the vendor mechanic
had worked on. (To be contiued tomorrow..)
8-31-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I did my usual inspection of the rework. I got the AIPC (Airplane Illustrated
Parts Catalog) pages from the Boeing Maintenance Document website that showed the vendor clamp installations. I noticed on
the AIPC figure part number listing that under the vendor tube P/N and/or the vendor/clamp P/Ns, that only a (engine
vendor) MM (Maintenance Manual) section was listed. No AMM reference was listed. That was why I could not find the removal
and replacement instructions for the clamps and tube in the AMM--they were not there--they were only in the vendor MM. (To
be continued tomorrow..)
8-30-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please, during your review of our NCRs, look for dispositions that don’t make sense in relation to the description
of discrepancy. The inspector, in these cases, should write an "unable to accomplish disposition" revision to the tag and
get the disposition revised. Except that rarely happens at PSD. I am one of the few, if only, inspectors that routinely write
revisions if the disposition is wrong.
Examples:
(NCR (Non-Conformance Record) I.D.), Revision 1, I wrote to correct the wrong disposition on a (A/P Model I.D.) T/R
(Thrust Reverser) damaged bracket.
Sometimes our Liaison Engineers are so clueless that writing a revision to get a disposition fixed is a useless endeavor.
Check out (NCR I.D.) revision 2, I believe. The discrepancy was on two vendor clamps C/T a vendor tube that had
damaged cushions. The revision 0 disposition stated to remove and replace the clamps per AMM (Airplane maintenance manual).
This tag epitomizes the danger of accepting vendor rework per the undocumented "tribal knowledge" PSD way, of just making
sure the vendor signature is attached to the tag, without any inspection of the rework itself. (To be continued tomorrow..)
8-29-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Another example from page 73:
On NCR (NCR I.D.) revision 3, a T/R sleeve was replaced by a (engine vendor) mechanic in my area without
the usual Removal Records and with the usual bypassing of me, as I would make them do the job right. (My QA Lead) told
me he would do the inspection of the rework.
Another example from page 203:
They didn’t come get me when they had finished installing the cotter pins and sealing them per the drawing. I guess
that I had asked too many questions, so they bypassed me and got another inspector.
I was bypassed on most T/R repairs in the shop probably because (name), the repair mechanic in the fitcheck area,
knew I would make him fill out removals and that I would actually inspect the rework/repair, making the finding of defects
in that work, and the resulting in the delay of shipment of the T/R (and more work for him) much more likely than if he got
a roller stamping inspector. (Name) is a good mechanic, but as most mechanics who have been at Boeing a while, has it
ingrained in his psyche that pretty much the only thing that matters is the shipment of the product on time. He does O.K.
work, and believes the Company’s (and (my QA supervisor's)) line that QA are pretty much extraneous personnel who
only get in the way of shipment of the product when they actually inspect it. He goes and gets (name), (my QA lead),
or (the most notorious rollerstamping inspector in the Division) when he doesn’t have time for me to
actually inspect the product, or wants to risk me finding discrepancies with such. I don’t think (name) does his
inspections anymore as I complained to (name), my lead, about him, a Wichita Corrective Action Unit inspector, doing
inspections at PSD, which I believed was improper per the Quality System, as Wichita stamps did not appear in our QA manual
as authorized stamps to inspect work with at PSD. It also was probably a violation of the union contract.
This does not only happen to me. Other inspectors suffer this same fate, and the product’s quality and safety also
suffers as a result, as a majority of the critical to safety (NCR rework and repairs), and last minute "slap it together to
get it out the door" work gets "re-routed" from those "thorough" inspectors, like me, who are assigned to do the inspections,
to those inspectors who are in essence only on corporate welfare, and only pretend to do a cursory inspection on these inspections,
if that, before they roller stamp the work. You’d think shop would have more care for the safety of the flying public
than they do. You’d think they would want the "thorough" inspectors, those who are labeled "thorough" only because they
actually do the inspections, to do the inspections for the safety of all those millions of people on our airplanes, and for
the opportunity to actually find out the mistakes that they had made, and all humans, no matter how careful, will inevitable
make, in order to improve their build quality the next time. But no. Only the quickest build of the product matters to them--to
get the quickest and cheapest built product out the door--be damned the quality of the product, no matter how safety related.
Quality only interferes with what they care about most--cost and schedule, because it is the reason people like me are around,
that only needlessly hold them up from making further cost and schedule improvements. Please ask (fellow inspector's
name) about this and ask (my QA Lead), (the fitcheck mechanic), and (the most notoriously rollerstamping
inspector at the Division) about why I am bypassed. The Manufacturing Leads should also be interviewed to find out why
they bypass certain inspectors. The one reason you won’t hear is that they are trying to get a competent inspector for
the sake of the product.
8-28-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate the bypassing of inspectors that try to do their jobs
per the FAA-approved procedures. I have been a victim of this in the fitcheck area since my return from banishment in the
office.
An example of this, from page 55, which I reiterate:
Anyway, I found that often the composite repair technicians would use the wrong composite material to lay up the repairs,
or would set their equipment to heat up or cool down the repair too fast during the cure, or record insufficient thermocouple
readings than the minimum required. I wrote NCR revisions on these items, as there was no way to fix the errors without ripping
out the repairs and starting over. This threw the composite repair mechanics for a loop, as that had never happened to them
before at PSD. One technician, the one who usually did the repairs at PSD, (name), (from) Renton EMF Composites shop
(shop I.D.), thereafter would go get my lead of the time, (name), to do the "inspection", as he didn’t like me
inspecting his work, and writing his mistakes up. (My QA Lead) came out to speak to me about the situation,
stating that he had known that composite repair technician for, I believe, a seemingly ridiculous amount of time, like 15
years, and that he "did good work", implying I should not be looking at his work at all, like him. I said that, "We don’t
buy off a mechanic’s work just by who he is, we buy off the work by inspecting the work itself, right?". (My QA Lead),
seemingly reluctantly, agreed. (My QA Lead) was always good at spouting occasionally that things should be done
per procedure, demonstrating, occasionally, quite a knowledge of those procedures, but when it came to actually performing
his own inspections per those procedures, he ignored them, revving up his "Briggs and Stratton" endowed stamp to the redline
in order to "support the delivery schedule." (One of the other QA Leads) didn’t even have that many ethics,
as he would tell you to ignore procedures, and then roller stamp. I had somewhat more respect, although it was in the negative
range, for (the other QA Lead), because at least, in a sick way, he was more consistent in not doing his job. Anyway, I believe
examples of the tags I wrote on these bad composite repairs was (NCR I.D.) and (NCR I.D.) Revision 1 and
Revision 2 on 737X T/Rs. I wrote bad cures up on the PSD repairs I inspected, even after consulting with (name), the
Auburn QA Lead that oversaw the inspectors that worked with (name), composite repair mechanic, whose work I was inspecting
on NCR (NCR I.D.), I believe. (The Aurburn QA Lead) said that his inspectors had stopped writing similar bad cures
up at the Auburn Site, as the disposition of the tags always came back "structurally and functionally acceptable" to engineering.
I knew that that didn’t absolve QA from having to write up the tags, as "structurally and functionally acceptable" meant
it was still a discrepant part, and the only organization that could allow such products to be used, by "structurally and
functionally acceptable" dispositions, was Engineering. I ignored his ignorant or careless method and always wrote bad cures
up at PSD, before the composite repair technicians bypassed me, because, as I stated earlier, it was always my ethic to get
discrepant items fixed, or documented, as required, once they came to my attention.
8-27-07 quote: This quote is also from my addendum (supplement)
to my first report:
This item is closely related to the (below) item, but is more related
to our AWOL QA Planning: Per the (document I.D.) document, unless they’ve changed things recently, all dimensions
on the installation drawings require mandatory inspections such as "inspect dimension. record actual dimension." Of course,
this rarely ever happens at PSD, with the few examples in the above item being the only instances of it I am aware of at the
moment. Look at the (job I.D.) 14th stage duct installation job on 747 and 767 (engine vendor) engines.
The drawings for that installation ((drawing I.D.) sheet 6 zones B2, B8, and C4) call out certain minimum dimensions
between the ducts and adjacent parts. Try to find the inspections for these dimensions on the plan, and you’ll most
likely come up empty. Then try to find the certified tools to inspect these dimensions, and you’ll come up empty also.
Please write us up for each instance of a missing required dimensional inspection from a job, and write us up also for lack
of tools to do these inspections. If you find discrepant dimensions on the production line due to this lack of inspections,
have us issue the necessary document to the airlines to fix the fleet.
8-26-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Another sad example is from the high-tech 737NG EBU (Engine Build-Up)line.
I was inspecting there as a substitute line inspector about a week ago (it’s 3/10/02 now), when (name), EBU mechanic,
wanted me to inspect a dimension. The power feeder wire bundle that we installed on the EBU had a dimension check inspection
on the job that installed it. XX.X" to XX.X" was required between the spacer under the upper W/B (Wire Bundle) clamp and the
end of the connector per drawing (drawing I.D.) sheet 52 zone B3 flag note D. If the dimension was wrong, then
shop had to adjust the spacer to the required dimension. (Name) got the "certified tool" that was used to do the dimension
check--Yep, a "yoyo", the same tape measure the carpenter that built your house (which was built to about the same level of
technology that a 737NG EBU is today, right?) used. I asked (name) if that, the yoyo, was what was always used to do
the inspection. He said it was. I let him just measure the dimension for me, as the measurement was useless. It was the end
of the shift, so when (name) went home, I went to MRSA (Material Review Segregation Area) and got QA’s 12", actually
certified, caliper to do the measurement, in a couple steps, with. That even did not give the accuracy required, as you couldn’t
measure with it parallel with the W/B. I guess the 737NG EBU line "Value Team" cheaped out, and whereas the 747/767 EBU line
had actual simulated raceway receptacles on the monorail skate with which to hook up the wire bundles to ensure they were
routed correctly for hookup to the real strut in Everett, the 737NG "Value Team" apparently thought they could get by with
a $1.99 tape measure from the local hardware store to ensure the power feeder was not preloaded on hookup to the strut, which
could make it fail in service...Even though all measurements that verify or control the conformance of Boeing products to
engineering, contract, or customer specifications are required be made with equipment with known accuracy, we just
ignore that (and other numerous requirements) to save a buck at the expense of A/P safety by endangering one of the
primary energy sources for the airplane in flight. (Does that mean we can we just get the specs for the tape measure
accuracy from Stanley Corporation and we meet the "known accuracy" requirement?) In addition, measurements performed on Boeing
products are supposed to be made with equipment that is traceable to national or international standards of measurement
or to accepted values of natural physical constants.---(Maybe tape measures are. I know Starrett, a maker of precision measuring
tools, makes tape measures!) (Sarcasm intended.) (Some additions to the last paragraph have been made to enhance clarity to
a non-FAA audience.)
8-25-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Please investigate the use of uncertified tools to inspect at the most
advanced aerospace company on the planet due to the Company is too cheap and/or unethical to give inspectors accurate tools
to inspect with, and inspectors keep quiet, and don’t speak up about it, as they are too cowed by our QA Supervisors
to speak up. This involves a valve in the TAI (Termal Anti-Ice)system on (model number) struts (the shut off
valve, I believe). There is an inspection on the TAI duct installation job that requires the line inspector to inspect a dimension
called out the drawing to make sure the valve, which is held in place in the system by only two (part number) clamps,
is clocked correctly radially in relation to the duct system axial centerline. The drawing calls out a dimension, with a certain
tolerance, from the center of the valve receptacle to either the lower flange of the upper spar fitting, or the upper spar
web (where to measure to depends on whether it is a (engine vendor configuration) or (engine vendor configuration)
strut). What calibrated tool does inspection use to inspect this dimension? Yes, you guessed it, an "uncertified" 6" scale.
What’s bad about it is that each inspector will get a different measurement depending on whether or not they hold the
scale perpendicular both ways to the spar, if that is where the drawing shows the measurement is taken from. I believe, if
I remember right, it is impossible to keep the scale perpendicular for the installation that requires measuring from the fitting,
as the fitting does not extend to the point directly perpendicular to the valve receptacle on the spar, so you have to "guesstimate"
the right measurement with the scale, not perpendicular to the spar, on top of the fitting flange. Another sad thing is that
I probably am the only inspector that knows there is a difference between the method of measuring the (engine vendor
configuration) or (engine vendor configuration) installations due to roller stamping inspectors who rarely
look at the drawing. When I used to inspect in the (A/P model I.D.) strut area before my banishment, I suggested
to the mechanics that they should have planning get a tool made to locate the valve (then us inspectors could use it to inspect
with). They didn’t request one. I knew that was my only way to get this resolved, because if I attempted to write a
pickup stating "unable to inspect dimension due to no certified tools exist appropriate to the task" or some such thing, that
would be the last pickup I would probably write. Anyway, please ask the inspector who is in the (A/P model I.D.) area
now if they’ll show you how they inspect this dimension. Then write us up for inspecting without certified tools. If
the inspector looks confused then runs to get a caliper, give them points for improvisation in your finding.
8-24-07 quote: This quote is also from my addendum (supplement)
to my first report:
This item is about unauthorized and undocumented rework of engines, that
are built by a separate TC and PC than ours, by BCAG mechanics who, in addition to being unauthorized to perform the work,
know next to nothing about their vendor assembly and test requirements (as if that would make it O.K.):
A good example of this is the (part number) fuel transmitter installation on the (engine vendor) engine.
The mechanics routinely removed part of the (engine vendor) wire bundle assembly so they can install and torque
the "U" channel component of the installation. I asked (name), EBU (Engine Build-Up) mechanic on 2/12/02, I believe,
why they removed the three (engine vendor) W/B (Wire Bundle) clamps from the vendor (part number) and
the (part number)brackets to do that job. He said that, If they didn’t, it was a real bitch to get that channel
installed and torqued, and they usually damaged the wire bundle in the process. I asked him if the job stated to remove and
reinstall that part of the bundle. He said no. He was right. Not even the drawing mentioned anything about removing and re-installing
that vendor installation. A tag or ELR (Engineering Liaison Request) should have been written to get drawing authorization
to remove and reinstall that portion of the vendor drawing installation, but at PSD, we hardly ever do what is right, we just
do what is cheaper, even if it is patently wrong. Please have us fix this problem. Have us authorize this illegal rework on
the drawing, so it is finally legal (after over a thousand engines, I believe). Please also check the AMM/PPBU (Airplane Maintenance
Manual/Power Plant Build-Up Manual) Manual, and see if the AMM/PPBU Manual requires removal of the noted part of the vendor
W/B during the fuel transmitter replacement. If not, please have Boeing issue an AD or SB to inspect those engines that have
had fuel transmitters replaced in service to look for the inevitable W/B damage. Tell BCAG they could have avoided all of
this if they had just followed procedures prohibiting unauthorized rework, if we’ll listen. Also have the airlines check
for those three clamps hanging loosely off of the wire bundle. PSD inspectors may not be looking for illegally removed and
not reinstalled vendor clamps during their shakedowns, especially the roller stamping ones.
8-23-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
I think I have demonstrated, by the (below) four examples, that
line QA at PSD are scared to death of writing obvious defects up that will cost them their jobs. So that "scare of death"
is simply transferred to the passengers on our airplanes when something we have let go or intentionally haven’t seen
goes awfully wrong at high altitude. Over a thousand engines have went out with the first two problems. Probably the same
with the last problem. Please fix this problem of inspectors intentionally overlooking defects to save their jobs. How can
you fix that? Hold on for a few more reams of paper and I’ll tell you.
8-22-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The fourth example is wire bundle installations that you can play any
of your favorite banjo tunes on, even that great one from "Deliverance." I can think of a couple cases of this. The first
is the wire bundle to the interphone jack at the bottom of (engine vendor) (model number) inlets (just aft
of the inlet aft bulkhead). See drawing (drawing I.D.) sheet 3 zone A11. The wire bundle number involved is the (part
number) wire bundle, and the equipment number of the interphone jack is (I.D.). Just go ahead and strum your favorite
tune on the section of wire bundle between the interphone jack and the first clamp. Of course, this jack is only there, I
guess, because mechanics used to get sucked into the engines when they were spooled up when they were working nearby. So as (my
QA supervisor) says, "is it critical?"--I guess not, unless you’re the mechanic, or the CEO of the airline that
has to miss a schedule and buy a new engine because of the damage, along with sending a letter of condolence to the mechanic’s
family. The second case is on the wiring of a more critical system. It is the wire bundle that hooks up to receptacle (I.D.)
of the EEC (Electronic Engine Controller) (located at the 9 o’clock position of (the engine configuration) (model
number) engine fancase). See drawing (drawing I.D.) sheet 3 and sheet 7 zone D11. The wire bundle numbers involved
are the (part number) wire bundle and the (part number) wire bundle, and the equipment numbers of the
connectors that hook up to EEC receptacle (I.D.) are (I.D.) and (I.D.). Just go ahead and strum your favorite
tune on the section of wire bundle between EEC receptacle J-2 and the breakout from the main bundle. I don’t know what
will happen if the contacts pull out of the connector insert if the strain relief backshell on the connector fails to take
the strain, but maybe you, the experts, know. Anyway, these two cases have never been written up to my knowledge, so please
document them for me. I will be inspecting yaks in Siberia if I attempt to. (The Customer Coordinator Inspector) was
researching the amount of slack required in high vibration unpressurized area wiring installations just a few weeks ago. Talk
to him for what to quote on your finding. If you look at the noted drawings, they definitely don’t show the wire bundles
installed taught, like they are on all engines.
8-21-07 quote: This
quote is also from my addendum (supplement) to my first report (continued from previous day's quote):
The third example happened on the (part number) bracket installation
on the (model I.D.) (line number) EBU (Engine Build-Up) I was inspecting on (date). I noticed two extremely
short Hiloks C/T a bracket on the installation and the inlet attach flange of the fancase. I found out the drawing ((drawing
I.D.) sheet 20 and 22 prior to ADCN 3) called out Hiloks that were three grip lengths too short for the installation.
Shop was just installing them, and other inspectors were just buying them that way, visually obviously too short. The engine
I inspected was the 360th EBU produced with the obvious discrepancy (to any minimally trained mechanic or inspector). I wrote
NCR (I.D.) on the discrepancy. The inlet was already installed, and shop had to remove it to change out the Hiloks per
the tag disposition. A drawing change resulted ((drawing I.D.) sheet 20 and 22 ADCN 3 and sheet PL revision AD). I don’t
know if prior units were addressed. You might want to add this to your list of item 71 tags.
8-20-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
This just in: I looked at an engine "as received," before shop had begun
ripping it apart without authorization in the area of the transmitter. The vendor B-nut comes already safetied to the vendor (part
number) bracket upper flange bend--to the bend, not a hole. Why don’t we re-safety it as it was, so we can install
the safety cable per drawing with one safety cable per two bolts? Probably because our drawing is all hosed up and does not
show where to re-safety it.
References:
(Industry specification I.D.) (called out in the (specification I.D.) industry spec), section X.X.X., "Installation
holes: In all cases the safety cable must be installed through the holes intended for this application of the parts being
secured."--Install per drawing? Novel concept.
(Industry specification I.D.) section X.X.X., "Installation: Unless otherwise specified in the application engineering
drawing, safety cable shall be installed in two or three bolt patterns with two bolt patterns being the preferred method when
safety cable is applied to an even number of fasteners."
8-19-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
...The second example is on the (part number) fuel transmitter
installation. Drawing (I.D) sheet 5 view 1C7 zone B6 shows (part number) safety cable installed two places
per flag note 1 C/T four bolt heads C/T the installation. A B-Nut at the fwd end of the transmitter is also supposed to be
safetied per flag note 1 per zone C7 of the drawing, but if the two (part number) safety cables are installed C/T
the four bolt heads per the noted view, then there is no place to safety the B-Nut to. View 1C7 shows safety wire leading
from a corner of the B-Nut downward, but there is nothing there to attach it to. What does shop do in this situation? Contact
engineering to fix the drawing or have QA write a tag to get the drawing fixed? No. They "MRB (Material Review Board) it"
themselves to save costs and schedule and install one safety cable C/T three bolt heads and then safety the B-Nut to the remaining
bolt. Ingenious disposition, but now if the safety cable breaks, three bolts will loosen, leaking much more fuel than if only
two bolts were loose in the per drawing installation. Remember, this is the safety cable that has no crimping standards per
item 42 above, so breakage is more likely than .XXX" diameter cable that has crimping standards, assuming I, the likely only
inspector who inspects crimps on .XXX" safety cable installations, inspected all the .XXX"diameter safety cable installations,
which I didn’t. Please have us fix this unauthorized installation substitution. If the way the shop has "MRB’d
it" is O.K. with the real engineers, as I’m sure it will be due to cost, and not safety being their main driving agenda
these days (see item 42 above), please have them authorize it on the drawing. I told (a fellow inspector) about
this problem yesterday, and, as he blindly still believes somewhat in the FAA-approved Quality System, he may be trying to
get engineering to fix it. He probably won’t have any luck, however. Please light a fire under our engineer’s
asses on this, the same high intensity fire that will result if the three noted bolts come loose due to unauthorized MRBing
of installations by shop mechanics and line QA, inherent high vibration in the area, and item 42 above.
8-18-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
Do not allow a global buyoff. This is a safety of flight item, as engine
mounts with uninspected safety devices should be. Issue an AD (Airworthiness Directive) with the appropriate urgency as determined
by your unbiased FAA Engineers, removing these bolts, removing all traces of the illegal (lubricant I.D.) from the
parts, checking the bolt and bushing dimensions, doing any non-destructive testing required, reinstalling the bolts with a
new nut, doing the run-on torque the correct way (from the nut side), and final torquing them to the correct torque, XXX-XXX
in/lbs, not the wrong torque they may have been installed with at PSD [up to XXXX-XXXX in/lbs is possible (maximum XXX
in/lbs run-on torque plus XXX-XXX in/lbs, which should not have been added together, but according to shop, sometimes were)--have
PSD pull completed records to see what each bolt was torqued to], installing the cotter pin before cutting the ends
(as opposed to the way we did it at PSD), having the cotter pin inspected before the sealant is applied (as opposed
to the way we did it at PSD) to more definite criteria than is in (specification I.D.) (say in AD how approximate
is the required approximately (distance) around the bolt circumference), and then resealing the cotter pin. This AD should
be very similar to AD 99-26-09 in your files that was issued to prevent separation of the engine from the airplane because
of a (vendor I.D.) engine primary thrust link shoulder bolt defect. The noted problems (uninspected saftety devices,
incorrect run-on torque addition to final torque, and bolts/nuts lubricated that shouldn’t have been) may exist on similar (part
number and older engine configuration) mounts, and some aspects, especially unauthorized lubrication of bolts/nuts, could
exist on any engine mount fasteners installed at PSD.
References:
SB 747-71A2277, On a (engine configuration) aft engine mount bolt revision, Background section, third paragraph,
"There is also evidence that lubricants were used on the threads on some of the bolts. This allows the nut to rotate and disengage
from the bolt."
(The bolt installation spec does state that lack of tooling access can be used as a reason to torque the head side instead,
but)...unless you interpret this as "lack of the will to go to the tool room and get or order the correct tools to torque
the nut," (that doesn't apply in this situation.)
8-17-07
quote: This quote is also from my addendum (supplement) to my first report (continued from previous day's quote):
Anyway, a few days ago, I was getting the info for this item from the
intranet at work, and I was perusing the drawing I noted for the installation, for my notes. Something stuck out then, or
more accurately, didn’t stick out--no lube was called out for the (part number) shoulder bolt on the drawing!
Shop was lubing them with (lubricant I.D.) without authorization! No wonder the head side run-on torque was probably
close to what the correct way of doing the run-on torque might have been! I checked the drawing to see if the shoulder bolt
on the Boeing Portland installed shoulder bolts on the aft end of the links had lube called out. They didn’t. (By the
way, you may want to peruse the Portland plan, also, to see if they inspect their cotter pins on their shoulder bolts before
sealing, like it should be done, or after sealing, like us "Superman" PSD inspectors do, whose X-ray eyes can see through
huge globs of opaque (material specification) sealant to do the safety device inspection, and whose super minds
know the imponderable, like how approximate approximate should be.) Engineering didn’t want those bolts to be lubed
for some reason. I’m no engineer, but lubricating a bolt with natural end play like a shoulder bolt in a high vibration
area might have very undesirable effects, like increased amplitude of the end play of the bolt in service, with unknown consequences,
although that is probably not possible with the links loaded during EBU operation. Maybe the materials of the bolt and bushings
in the links and mount fitting are not compatible with the (lubricant I.D.) lubricant. Maybe the lubrication will
allow undesired/unknown wear or point loading of the bushings, causing them to degrade. Maybe shop got (lubricant I.D.) under
the sealant or nut, causing the seal to fall off in service, and allowing the cotter pin (which is of unknown installation
integrity due to the shop cutting them to an unknown length, and bending them over for retention to an unknown degree due
to the lack of these safety devices ever being inspected) to fall out, as it is not being retained on the bolt by the sealant
anymore, allowing the nut to fall off, etc., etc. Admittedly, these are worst case situations, but such things must be considered
when hundreds of lives are at stake during each cycle of use of our products, and our products are used for tens of thousands
of cycles in their lifetimes. Please fix this particular problem with the (vendor I.D.) forward engine mount installation,
as me, the lowly line inspector who was nearly fired for inspecting, and not training, (has) no power to fix it, as our
FAA-approved manual says we should have.
8-16-07 quote: This quote is also from my addendum (supplement)
to my first report (continued from previous day's quote):
The first item is somewhat related to item 62, lack of "O.K. to Seal"
inspections, but involves a little bit more than just that. On the (vendor I.D.) engine (Part Number) forward
mount installation, the final installation of the forward end of the two mount links is done on the "crate" job, due to "slave"
barrel nuts are installed in the mount fitting for engine monorail hang, then removed and replaced with "real" barrel nuts
when the engine is off the monorail and in the shipping buck (the aft barrel nuts cannot be installed without removing the
links’ shoulder bolts and swinging them outward so the barrel nuts can be slipped into the sides of the mount fitting).
Anyway, (name), EBU (Engine Build-Up) mechanic, asked me to inspect for him and (name), fitcheck mechanic, a few
weeks ago on that mount installation, as the EBUs they were working on were positioned in their bucks (transport fixtures)
in the fitcheck area. The EBUs we worked on were the (model number) (line number) POS X and X EBUs,
I believe. They had me inspect the eight "real" barrel nuts and retainers for the two EBUs for cracking of the locking element
and retainer, and then inspect the installation of them in the mount fittings. Then they lubricated the four (part number) shoulder
bolts with (lubricant type) for the two EBUs and installed them loosely. They had me witness the run-on torque of the
four (part number) nuts on the four shoulder bolts, and buy off the witness inspection on the plan, as they were
all within the required XXX-XXX in/lbs run-on torque required per sheet 5 zone B3 note. During the run-on torque I asked them
a few questions, and had them modify the way they did the run-on torque. They were going to do the run-on torque with the
nuts barely engaged on the threads of the shoulder bolts. I told them that the way I remembered the (specification I.D.) spec,
the nut had to be within "X" turns of seating to check run-on torque. (The EBU mechanic) said they always did
it the way they had started to do it, but they would do it "my" way. One of them put the dial-indicating torque wrench on
the head of the shoulder bolt, and one of them put a wrench on the nut and they tried to do the run-on torque before I interrupted.
I told them that...the run-on torque had to be taken by turning the nut with the torque wrench, not the head of the bolt.
They said there was no access on the left link for the torque wrench, so they had always checked the run-on torque of the
nut by turning the head. I asked to use the torque wrench. I put the wrench on the head of the right shoulder bolt and turned
it with the torque wrench, without holding the nut with anything, to see how much torque they were losing by turning the head.
The needle of the torque wrench barely moved. Of course, the torque wrench was about a XXX-XXX in/lb range torque wrench.
They were losing something, it just didn’t show on that range torque wrench well. It was a very small in/lb amount,
as they had lubed the bolt well with (lubricant type) lubricant. I let them do the run-on torque from the head side,
as they had always done, even though it looked to me that they could easily put the torque wrench on the nut on the right
link with a short socket, and on the left link with a crow’s foot. They were just torquing it from the head side for
convenience. I believe we got approximately XXX-XXX in/lbs on the four nuts. Then they started to do the final torque. (Name),
their supervisor, arrived and stood by, staring at us in his usual manner. (The EBU mechanic) asked me how I wanted
to do the final torque, if I wanted to add the run-on torque to the final torque requirement (which was XXX-XXX in/lbs) for
the shoulder bolts, or to just torque them per just the final torque value without the run-on torque added. I told him that
that was the first time I had done that job that I remembered, and I asked them what they usually did. He said they did it
both ways at times. I looked at the plan, then we did it just per the final torque value. Then they got the (part number) (I
guess, that was the drawing callout) cotter pins and cut the ends shorter than what they were manufactured as I stood there,
and began mixing up a kit of sealant. It looked like it was going to take them a while to install the cotter pins that were
a safety device that was installed into the shoulder bolts to keep the nuts from falling off if their locking feature failed,
so I grabbed the work copy of one of the jobs and went over to the shop computer a short distance away to look at the drawings.
They didn’t come get me when they had finished installing the cotter pins and sealing them per the drawing. I guess
that I had asked too many questions, so they bypassed me and got another inspector. I was actually glad. I didn’t want
to have to inspect those cotter pins, as they had cut them to an unknown length and sealed them over after maybe installing
them. I wouldn’t be able to see the cotter pins through the sealant to inspect them. They were just doing it per the
plan, which was sequenced to seal the cotter pin before the safety device inspection. I had also looked at the (specification
I.D.) spec, which I wasn’t familiar with for cotter pin installation requirements. It allowed them to cut the cotter
pins, but the installation requirements were pretty bogus from an inspector’s standpoint. The spec showed the cotter
pin ends bent back about (distance) around the bolt thread circumference, with a note stating something like "bend back
approximately as shown." I hate that. That gives mechanics the latitude to do pretty much anything they want with safety
devices, as how do you inspect how approximate is "approximate"--you can’t. If they had got me to inspect it, I
would have been placed in the typical position an ethical inspector was put in in these situations--do it right, and have
the shop remove the sealant so I could inspect the cotter pin installations, and if they refused to remove the sealant because
of the inevitable "it was planned that way so I did it that way so you have to buy it that way" backlash that would come from
the shop mechanics or (their supervisor), then I would have to write a planning pickup on the job for incorrect sequencing,
and another "unable to inspect safety device because" pickup that would end up simply being roller stamped without rework
by my lead (name). Then I would probably shortly thereafter have another meeting with (my QA supervisor) about me disobeying
him and inspecting, and not just training, thereby not supporting the delivery schedule. I would then probably be presented
the CAM I narrowly avoided in that promised Wednesday meeting that never came following the 1/11/02 meeting. Or, I could just
roller stamp the sealed and uninspectable safety devices, saving my ass from holding a sign up at the busiest offramp as my
new job, and resulting in the same outcome that would have resulted if I had gone the ethical route--possible discrepant safeties
on an installation, that if they failed, could result in possibly the same thing that happened in the case that I told (my
QA supervisor) I was thinking of in the 1/11/02 meeting when he asked me if I knew of any planes that had crashed because
of an EBU problem (but he hadn’t wanted to know my answer, as he himself probably didn’t know the answer and he
was scared I would trump him with mine)--the El Al cargo fight 1862 crash in Amsterdam, in which one 747 EBU departing the
airplane knocked the adjacent engine off, causing the plane to crash, killing four people on board and 47 people on the ground.
While this was caused by the strut and engine departing the plane, and not just the engine departing the strut, the results
could be the same. This was the crash I was thinking of in that meeting with (my QA supervisor), although it wasn’t
an EBU problem that caused it (I haven’t had time to search and see if there was a crash that was traced to an EBU or
not since that meeting, as I have been working on this in all of my free time).
8-15-07 quote: This quote is also from my addendum
(supplement) to my first report:
This is an item that makes inspections at PSD pretty much a joke, along
with the prior items. It is that inspectors at PSD are so afraid of what will happen to them if they document discrepancies
of any type, but especially engineering and planning, that they won’t, and just let discrepancies deliver to customers.
The ultimate consequences of the resulting ineffectiveness of our timid inspection force, which has been "trained" into that
state by our corrupt management over the years, will not be ultimately known until the untold numbers of plane crashes appear
over the years on CNN during the life of these intentionally uninspected/misinspected airplanes.
8-14-07 quote: This quote is also from my addendum (supplement)
to my first report:
This item I have no direct evidence of, as all of the "negotiating" goes on behind closed doors, but it is that Manufacturing
gets to select their own inspectors. I have described in detail how Manufacturing virtually is the QA Department, so this
item should be no surprise. I usually find out where I am being transferred to next from shop mechanics, who get that information
somehow before I do. I believe it is unethical for manufacturing to select which inspectors inspect their product. In an honest
QA System that had integrity, it would not matter which inspector shop selected, as each inspector would do their job with
the same high ethics, consistency, and integrity. The only differences between inspectors would be their unique personalities.
However, that is not the system in place at PSD, or BCAG. Since some inspectors inspect, and some just collect paychecks and
pretend to inspect, shop has a motivation to select their preferred inspector. It is not the motivation you would expect of
a world-class high technology aircraft manufacturing company, where millions of people’s lives are at stake because
of the integrity of our products. Nope, they don’t want the ethical inspector that will help them ensure the product
is built right, they all want the roller stamping inspector that will help them ensure the product gets out the door on time,
regardless of how critical that product is to the safe flight of the airplane. Ask shop mechanics how they find out where
we are transferred to before we do.
8-13-07 quote: This quote is also from my addendum (supplement)
to my first report:
I informed (name), Customer Coordinator, about the lack of "A" dimensions
while I was in the (model number) strut area and he would do the customer shakedowns of the struts after we did
the BAC shakedown, hoping to get him to write it up on the customer shakedown, and making him take the heat for it. Shop was
hell bent at getting me fired at that point for doing my job with the minimum level of integrity I did it with at that time,
but me writing that up would be, I was sure, the lead piano that crushed the entire camel to a pulp. (The Customer Coordinator) didn’t
take the bait. He didn’t seem concerned about it for some reason. He seemed more concerned about the weight of the extra
sealant, and frequently wrote up shop for excess sealant. Anyway, Wichita has revised some of their seal drawings to detail
a special "reduced fillet" for some of their fillet seals, but, unless the drawings have been revised since I left, which
is doubtful, as that costs money (its cheaper just to do it the way you want to at PSD, and not worry about the drawing changes
to authorize it), none of our seal drawings have such a "reduced fillet." Don’t let undimensioned and unlabeled poor
depictions of fillet seals on some drawings fool you---they do not cancel out specific (engineering specification) requirements.
I actually did write up lack of "A" dimensions when I was assigned to the (model number) EBU (Engine Build Up) line,
before I used up eight of my "ethical inspector’s lives," and started getting "sent to the office" when I wrote up discrepancies
shop disapproved of (and (my QA supervisor) threatened to take my final, ninth "ethical inspector’s life"
on 1/11, attempting to send me to the great hereafter for BCAG executed ethical inspectors, unemployment). When I arrived
there, none of the electrically bonded and fillet sealed brackets on the EBUs had "A" dimensions to protect the integrity
of the electrical bonds, as they should have. I wrote them up. Apparently other inspectors got the hint, and they still do
it today, as I recently noticed, having stumbled across NCR (number) on a bad "A" dimension on a (model number) EBU
bracket. It’s nice doing something right occasionally that improves the quality and perhaps safety of the product, even
though I probably got docked a "life" for that one, as shop was none too happy at having to learn to fillet seal with "A"
dimensions. Some of them still don’t have it, as the noted NCR attests. (Hopefully you got the cat analogy.)
8-12-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please check into the lack of correct fillet sealing on parts at PSD,
mainly in the strut area. All parts that are less than .XX" thick require the fillet to extend over the edge of the part for
integrity of the fillet seal, to ensure a sufficient width of fillet seal exists to bond to the part to protect the faying
surfaces from infiltration of corrosive elements and leaking fuel--called an "A" dimension (reference (engineering specification)
page 31 Figure 10). You’ll find this omitted "A" dimension, and the corresponding hazard of ineffective electrical bonds
and fuel leakage, pretty much everywhere in the strut shop, but especially on the (model number) struts. Just look
at all of the electrical receptacle fillet seals and fillet seals around wire bundle pass through covers and maybe the raceway
access covers we install. Also, take a peek at the midspar TAI (Thermal Anti Ice) boot fillet seal. It may be thicker than
.15", but there is a thin metal plate that stacks on top of it to fasten it to the spar. I talked to my seal instructor on
interpretation of the .XX" dimension in the spec, and she said that such a stackup would still require an "A" dimension because
the top part was thinner than .XX". I never tried to write this up, as that would have resulted in my earlier banishment to
"writing QOIs that are never used hell" or new job as a sign holder-upper. Also, while you are at it, please write us up for
not having the minimum .XX" cap seal thickness on pretty much all of the fasteners we fillet seal. You can probably guess
why I never touched that one either.
8-11-07 quote: This quote is also from my addendum (supplement)
to my first report:
This item is closely allied with item 46 above, "OK to Install" and "OK
to Close" inspections, and owes to our corrupted QA Planning department that is more concerned than Manufacturing about the
efficient flow of work through PSD without inspections to slow it down. It is the complete lack of "OK to Seal" inspections
at PSD. If I remember right in Everett, they had such inspections to ensure that QA had inspected the fastener installations
and part installations before the Seal Shop cap sealed and fillet sealed over everything, making such inspections impossible.
At PSD, all inspections are optional, per (my QA supervisor) and the actions of our QA Planning department, so you
will not find such inspections. If you find evidence that such an inspection ever existed at PSD in its twenty-one
year period, I’d be extremely surprised. Consequently, some part inspections and fastener installations, however critical
they are to the safety of the airplane, have never been inspected at PSD in our over twenty year history. The shop
could be saving the Company money by installing cheap substitute fasteners from (hardware store chain name), for all
us inspectors know. Many of these installations, knowing how often I find loose parts during inspections, have delivered to
customers and are flying around now with loose parts under the sealant, as shop has these parts and fasteners encased in cap
and fillet seals by the time we have our first look at them. Hopefully that sealant will hold those parts together in service.
A specific example is job (I.D. number) (model number) (line number), which does the (part number) chine
installation on the fan cowls. The thirty-six fasteners holding the chine to the fan cowl are cap or aero sealed on both sides
per operation 170 before we inspect the chine installation. There is a torque buyoff on the job prior to the covering of the
fasteners, but it is just that--a torque inspection, and no inspection of the fastener installation is done at all during
the inspection. Please make us fix this problem. If we had an ethical QA Planning department, this problem would never have
existed, but we don’t.
8-10-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please check to see if our QA Test Planning department, if we have one, audits our released F/T (Functional Test) datasets
per (document I.D.) requirements. If Prime Division does it for us, then maybe, just maybe, they are correct. Check
to see if all mandatory inspections are included on PSD F/Ts listed in (document I.D.) page 24 and on. If our QA
Test Planning is half as bad as our QA Planning, then you will find many findings.
8-9-07 quote: This quote is also from my addendum (supplement)
to my first report:
This just in: I was right (I hate it when that happens, not)! I checked
the Prime Division’s recent Stamps and Seals QOIs, and they (the manual administrators--not their QA Supervisors, whom
I believe are as corrupt as ours) had the ethics to revise theirs to state what ours should say. Make us revise our (document
number) Torque Requirements and (document number) Stamps and Seals QOIs to state we have to use (material
specification) tamper proof putty and (material specification) anti-sabotage inspection lacquer per similar
requirements to the below Everett QOI (I think Renton’s QOI has been revised to be very similar to Everett’s).
PSD Engineering would have to determine which areas of the engine, struts and APUs are high heat areas (above XXX degrees
operating temperature). Review the QACR (Quality Assurance Change Request) that revised the two noted QOIs to delete inspection
putty. See what the reason they gave you was. We had this (material specification) blue lacquer at PSD before we
had the QOI’s changed (per the above paragraph). See if whomever submitted the QOI to you lied. That should be instructive
of the ethics of our management. By having us change our QOI back, you’ll be proving that preserving the inspection
integrity of the product is paramount, and by association, that inspection integrity is paramount, something our management
does not believe. Us using inspection putty again would also ensure integrity of the critical torques we witness, due to the
fact that if inspectors putty fasteners as they are torqued, which is not done now, there is much less likelihood that
inspection and shop would make a mistake, and miss the torquing of a critical fastener or fasteners on an installation.
8-8-07 quote: This quote is also from my addendum (supplement)
to my first report:
At the same time that this whole push to get rid of inspection putty
took place, (my QA Director) was near retirement, and was trying mightily to get self-inspection implemented at
PSD, perhaps to get a hefty bonus to his retirement earnings. Inspection putty is a divider between the inspection and mechanic
ranks. An inspector applying this "anti-sabotage" putty is applying it to ensure the integrity of his inspection, from the
prying wrenches of unethical mechanics. Even the existence of "anti-sabotage" putty is anti-self-inspection in itself, as
it implies that some mechanics cannot be trusted (which, I believe, is true, by the way, from my experience, CDC’s stealing
of parts at PSD, and the simple fact that inspectors like me exist at all, means mechanics can only be trusted so far). Also,
if self-inspection came into existence at PSD, what is the mechanic who "witnesses his own critical torques" going to do after
he torques the fasteners? Putty them per the QA manual requirements so he won’t sabotage the product by loosening them
later? So, I believe, the "high heat" reason was only a lie to you to get the change done, for the real reason was to ready
PSD for implementation of self-inspection.
What’s curious about all of this self-inspection stuff, is the
separate reasons we were told when it went down in flames shortly thereafter. We were told by our management that the union
stopped it, but I also heard that you stopped it because of the roller stamping of inspections found in audits. Anyway, there
is no real reason that we should have ever stopped using inspection putty to protect the integrity of critical inspections,
as there is, I’m pretty sure, a blue (other material specification)-type putty that can be used in high heat areas.
I believe Wichita uses it, and I think (name), line inspector, was using some of it she got from some unknown source
when we still used to putty things. Also, just changing the QOI does not relieve us of the requirement to inspection putty.
The (document number) Document...(still states that QA witnessed critical torques need to be puttied and inspection stamped).
8-7-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate the torque "anti-sabotage" putty situation at PSD. During the time of QA Supervisors (name) and (name),
the requirement to apply tamper proof putty (blue (material specification) putty at PSD) to fastener torques we
witnessed was removed from our (document I.D. number) Torque Requirements and (document I.D. number) Stamps and
Seals QOIs under the guise of all our products at PSD being "high heat areas" in which the putty would burn off in moments
once the engine was started. (One of the noted QA supervisors) just came out and told us to stop applying putty
when he made the personal decision to stop the use of it, and then when (the other noted QA supervisor) came in,
he at least had the sense to have us start doing it again until the QOIs were changed (reference the Exhibit AD email. Also
see the Exhibit AE email for his direction not to apply it anymore, later). Anyway, the "high heat" reason not to apply
putty, I believe, came from Renton’s Stamps and Seals QOI. The problem is this: most of our products are not composed
of high heat areas. Any area forward of the engine cores are not, and only the underside of the struts are. 90% of the strut
areas, and most of the engine fancase areas are made of aluminum, which cannot be used in high heat areas by engineering design.
We should at least still be applying putty in those areas. But there is another problem with the current "no use of putty
by QA" policy. You’d think that, if QA could not apply (material specification) putty on the engines and struts
because it does not withstand high heat, then there would be none of it at PSD, right? Wrong. Shop mechanics use it all of
the time on the plumbing installations, even those in the definitely high heat core areas of the engines. They use the same (material
specification) putty we used to use, just pink...and yellow...colors, not "QA" blue. What, you’re asking? How could
this be? Why was QA so hot to get rid of inspection putty, when shop still uses the same stuff, just different colors, on
the hottest parts of the airplane? I’m glad you asked, as I believe I have the answer, and it even fits perfectly in
with the corruption so far documented first-hand in the QA Management ranks.
8-6-07 quote: This quote is also from my addendum (supplement)
to my first report:
Comment about a requirement that QA must ensure designs have enough
criteria in them so valid inspection and test processes can be performed:
You mean Quality is to blame for this too? (the lack of calling out the required
process specifications on the drawings that tell mechanics how to install parts and inspectors how to inspect parts
on the airplane) We already have enough crimes on our rap sheet!
8-5-07 quote: This quote is also from my addendum (supplement)
to my first report:
References:
FAA Order 8120.2B, Production Approval and Surveillance Procedures, Section 26.b.(15): "Advising FAA engineering elements
whenever technical data is found to be inadequate for producing duplicates; e.g., missing dimensional characteristics, material/process
specifications not listed, etc."
Rework NCR (number) items 2 and 5 on the (Part Number) accessory installation, where I wrote up incorrect
duct hose installation per (process specification I.D.).
Rework NCR (number) item 4, where I wrote up an incorrect duct hose installation per (process specification I.D.).
Rework NCR (number) item 8, where I wrote up two incorrect duct hose installations per (process specification I.D.).
8-4-07 quote: This quote is also from my addendum (supplement)
to my first report, showing more proof cost and efficiency trump safety at Boeing:
This just in (written later than the above): I guess you won’t
be able to have the (process specification I.D.) called out on the TAI boot installation drawings in the struts, and all pneumatic
duct boot installation drawings in the struts yet. There are no duct boot installations referenced in (process specification
I.D.), even though these duct boots are just duct hose halves with bolt attach flanges at one end. Please have the PSD engineers
give minimum standards for placement of the band clamp, minimum protrusion of the boot above the band, and minimum installation
requirements of the boot cuff onto the duct, on either the spec or the installation drawings. I communicated with the key
engineers of the (process specification I.D.) spec several months ago to get these duct boots added to the spec, among
other improvements to the spec. I don’t know if they ever will follow through, however, as even deficient safety device
specs are not now revised, no matter how urgent the need, due to cost concerns.
8-3-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please make PSD engineering add this essential BAC spec to all PSD drawings
that install duct hose, all TAI (Thermal Anti-Ice) boot installation drawings in the struts, and all pneumatic duct boot installation
drawings in the struts. Also make BCAG issue the necessary Service Bulletins to inspect all of the installations that required
this spec to be added, to ensure that these critical parts to cooling of engine accessories, in the case of the duct hoses,
and fire protection of the struts and engines, in the case of the boots, are installed in the correct position on the ducts
to ensure retention in service, have their band clamps positioned correctly to ensure they won’t slip off and loosen
and/or perform no function in service, and have the band clamps torqued to the correct value (as who knows where the mechanics
at PSD got the torque from to install them), per the spec. I think I’m pretty much the only inspector that inspects
to this spec, so you can be sure that any installations that I didn’t buy off were not inspected per the (process specification
I.D.) specification requirements, and need a Service Bulletin. I remember the sad state these accessory cooling duct hoses
were installed in when I first started inspecting on the 747/767 EBU (Engine Build Up) line. Some band clamps were installed
on top of the bead, some were loose, some were not even picking up the metal duct underneath the duct hose at all, if I remember
correctly.
(Yet more evidence that points to why I later called myself "The Last
Inspector" when starting my web site.)
8-2-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate the following which I copied from my later "CFRs violated"
section because I have not listed it yet:
CFR14.25.1041, (Cooling) General, quotation "The powerplant and auxiliary power unit cooling provisions must be
able to maintain the temperatures of powerplant components, engine fluids, and auxiliary power unit components and fluids
within the temperature limits established for these components and fluids, under ground, water, and flight operating conditions,
and after normal engine or auxiliary power unit shutdown, or both."
End of quotation.
Who knows if they will be able to maintain those temperatures, as all of these cooling systems were designed at PSD without
calling out (process specification I.D.) for duct hose installation, therefore there are no standards on our drawings
for installation of these duct hoses or the placement or torques for the clamps that hold them onto the ducts. The mechanics
can install them any way they want, and I wouldn’t be able to document a nonconformance, as I have no standards to inspect
their work to. They can install the clamp directly over the duct bead where it will slip off in service and be loose and in
essence performing no function whatsoever. They can slip the hose only an eighth of an inch over the duct end, not even over
the bead, and then install the clamp hanging halfway off the edge of the hose. Where PSD mechanics get their torques to torque
the clamps on these installations I have no idea. I always inspect these installations per (process specification I.D.)
requirements, although technically I can get in trouble for doing it, as I got in trouble once in Everett for writing something
up I shouldn’t have. But every mechanic so far has complied with my write-ups on their duct hose installations, and
hasn’t called me on it. If they did know the drafting requirements that each spec that has to be used on a particular
installation must be called out on the PL (Parts List) or picture sheet for that installation, and called me on writing things
up per it, even though the hose was half hanging off of the duct, I would then have to write a tag on the drawing stating
that the part was unable to be installed as there were no requirements for installation of it listed on the drawing. Considering
the way (my QA supervisor) is, I would shortly thereafter be holding a sign up on a freeway offramp as my new job.
8-1-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
My comment after Quality Sytsem requirement quotation:
Yikes! I, the only inspector who actually inspects composite repairs at PSD, didn’t even do the stamping of the "temperature
recording chart," even though I inspected it. You learn something new everyday. Especially in a quality system that is so
widely noncompliant that I would uncover such requirements we never performed frequently.)
7-31-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
Another 737NG T/R (Thrust Reverser) was reworked at PSD in the last few
weeks by (name), Renton EMF Composites composite repair technician. You probably recognize his name, as it is in the
table above. The lay-up repair on the NCR that did the repair, (number), was also done with the wrong material, (material
specification), and had only one thermocouple monitored on the printout during the repair, just as all of his prior repairs
to 737 T/Rs had. There was one major difference between this most recent repair and all of the prior repairs in which he used
the wrong material without the required engineering or stress approval---this one was done after NCR (number), in which I
wrote his repair up for using the wrong material and not having enough data to inspect the cure, and after which he went and
got (my QA Lead) to roller stamp his work off. When I told him he had used the wrong material on NCR (number), had
to write a revision to the tag to get it approved, that, at that point, was simply an error, I might believe. But what do
you call it when a person intentionally does something wrong to an airplane again, as was done by him on NCR (number), after
he was warned it was wrong previously, as he was on NCR (number)? Right--sabotage. (Another QA Lead) bought the (number)
tag on 1/31/02.
This just in: More sabotage: Another 737NG T/R was reworked at PSD last week by (name) (it is 3/11/02 when I am writing
this), and the wrong material was used again without required Engineering and Stress approvals. Reference NCR (number)
on the (Part Number and Serial Number) T/R.
7-30-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
All the repairs were made with (material specification) material
and should have been made with the drawing and composite repair document required (material specification) material. Please
have BCAG send the necessary documentation to the airlines for the airlines to disposition these faulty repairs. Please do
not let BCAG do some "global buyoff" by just reviewing these tags in house, that results in no notification to the airlines.
I hope that this report of mine, and your investigation and corrective action requirements will result in the pulling up of
the BCAG airplane, figuratively, that is currently in a death spiral toward the ground because of BCAG’s belief in,
and use of their unwritten Quality System (basically no Quality System at all would be as poorly effective), instead of the
FAA-approved Quality System. The only way to wake the pilots that control this Company up is to slap them, and slap them as
hard as possible, to wake them up so they will right this "airship." By the way, I have the two "missing from the NCM system" (number)
forms (at work) if you need to see them. Only the first tag listed in the table had a cure printout scanned into NCM, and
it showed insufficient thermocouples monitored for inspection and no vacuum applied, if I remember right. Please get a composite
repair expert to look into all the composite repair NCRs done at BCAG in at least the past year to look for similar noncompliances
with procedures to get approval from engineering and stress for alterations to established composite repair processes (illegal
repairs), and to view scanned in cure printouts for discrepant cures. Please write us up for, what I’m sure will be
many, noncompliances during these critical repairs, and ensure BCAG reviews all composite repair NCRs or R/Ts (rejection tags)
in the past and notifies airlines that may be flying airplanes with bad composite repairs. Also, require that all inspectors
that accept any composite repairs attend a class and be certified annually. While lack of certification of inspectors for
composite repairs is not the cause of the above problems--roller stamping and bypassing of ethical inspectors is--certification
will increase the knowledge level of all inspectors on composite repair inspection requirements and remove the incompetence
excuse from the tool bag of inspectors who roller stamp these inspections.
7-29-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
This just in:
I found a stash of official shop stamped off and QA stamped off Form (number) Composite Repair Records that supported
work done per NCRs (Non-Conformance Records). I checked the NCRs listed on them in NCM, and some of them, but not all, as
should have been the case, had been scanned into the NCRs they supported. I looked at the forms, and something curious stuck
out. They were all repairs on 737NG T/Rs (thrust reversers), and all of them showed that the composite repair technician used
the wrong material to lay up the repairs! I checked the NCRs again to see if this "substitute material" had been written up
on the NCRs on a revision and approved by our PSD engineering and project stress engineering, which is required for repairs
done with materials used that are not the same as the drawing required materials per our composite repair document, (number)
section 8.1.4.a.(2). Nada. No such approval from engineering or stress on any of them. Do you think that a T/R sleeve installed
on a 737NG airplane that is probably flying around with people on it right now, with a composite lay-up repair that was done
with the wrong material without required engineering approval of that material for the repair, and without the additional
required stress approval for use of that material, could be a safety problem? I think so. While the T/R sleeve might withstand
the rigors of flight (or may not, in time), it may blow apart during T/R deployment when stresses on it might be greater.
But I’m not an engineer. Just a lowly line inspector. I think that these listed repairs are only the tip of the iceberg,
obviously, in relation to all of the repairs that probably have been done similarly without full engineering and stress approvals,
by at least these two listed composite repair technicians, to unknown parts of unknown criticality to the integrity of the
airplane:
7-28-07 quote: This quote is also from my addendum
(supplement) to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope
their 787s are not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
I wrote bad cures up on the PSD repairs I inspected, even after consulting
with (name), the Auburn QA Lead that oversaw the inspectors that worked with (name), composite repair mechanic,
whose work I was inspecting on NCR (number), I believe. (The Auburn QA Lead) said that his inspectors had stopped writing
similar bad cures up at the Auburn Site, as the disposition of the tags always came back "structurally and functionally acceptable"
to engineering. I knew that that didn’t absolve QA from having to write up the tags, as "structurally and functionally
acceptable" meant it was still a discrepant part, and the only organization that could allow such products to be used, by
"structurally and functionally acceptable" dispositions, was Engineering. I ignored his ignorant or careless method and always
wrote bad cures up at PSD, before the composite repair technicians bypassed me, because, as I stated earlier, it was always
my ethic to get discrepant items fixed, or documented, as required, once they came to my attention.
7-27-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
I said that, "We don’t buy off a mechanic’s work just by who he is, we buy off the work by inspecting the
work itself, right?" (My QA Lead), seemingly reluctantly, agreed. (He) was always good at spouting occasionally that
things should be done per procedure, demonstrating, occasionally, quite a knowledge of those procedures, but when it came
to actually performing his own inspections per those procedures, he ignored them, revving up his "Briggs and Stratton" endowed
stamp to the redline in order to "support the delivery schedule." (Another QA Lead) didn’t even have that
many ethics, as he would tell you to ignore procedures, and then roller stamp. I had somewhat more respect, although it was
in the negative range, for (the other QA Lead), because at least, in a sick way, he was more consistent in not doing his job.
Anyway, I believe examples of the tags I wrote on these bad composite repairs was (number) and (number) Revision
1 and Revision 2 on 737X T/Rs (Thrust Reversers).
7-26-07 quote: This quote is also from my addendum (supplement)
to my first report, This corruption at Boeing bodes ill for the 787 program, I believe. Customers should hope their 787s are
not damaged at Boeing and have to be repaired and "inspected" by these Boeing personnel:
Please investigate composite repairs at Auburn, Renton, and PSD, at a
minimum, per the information I gave you earlier which I reiterate:
On composite repairs, I, the "thorough inspector", was the only inspector that would actually inspect the composite repairs
on the T/R (Thrust Reverser)sleeves when the Field mechanics would leave the slats down when they opened the T/Rs, or maybe
run the slats down into the open T/Rs, or would run something else into them, per inspection procedures, before stamping the
work off. Because I inspected the work, and prior PSD inspectors had not, the composite repair technicians were very sloppy
in their repairs at PSD, as they had always been under "self-inspection" at PSD, in effect, even though we made it look like
the work was inspected by stamping the Form (number) composite repair record, and NCR that did the work, off. Of
course, it may have been that they did their jobs sloppily everywhere they worked. I had only anecdotal information on that,
as I inspected only at PSD. Anyway, I found that often the composite repair technicians would use the wrong composite material
to lay up the repairs, or would set their equipment to heat up or cool down the repair too fast during the cure, or record
insufficient thermocouple readings than the minimum required. I wrote NCR revisions on these items, as there was no way to
fix the errors without ripping out the repairs and starting over. This threw the composite repair mechanics for a loop, as
that had never happened to them before at PSD. One technician, the one who usually did the repairs at PSD, (name), (from)
Renton EMF Composites shop (number), thereafter would go get my lead of the time, (name), to do the "inspection,"
as he didn’t like me inspecting his work, and writing his mistakes up. (My Lead) came out to speak to me about
the situation, stating that he had known that composite repair technician for, I believe, a seemingly ridiculous amount
of time, like 15 years, and that he "did good work," implying I should not be looking at his work at all, like him.
7-25-07 quote: This quote is also from my addendum (supplement)
to my first report:
Parts are being shipped out of PSD blue tagged as the wrong part number. This happens due to the (part number) chine
installation is done at PSD C/T (Common To) the vendor P/N (part number) (this is one of the fan cowl P/Ns
from my memory, there are others, also) 767 fan cowls, which go out as the same P/N they come in as, (part number). The job
that does the installation is job (number) 767 L/N (Line Number). Inspectors, namely (name), have tried to get planning
to issue a planning part number on the non-engineering part numbered configuration we ship out, to no avail. We have to blue
tag it as the part number we receive from the vendor, to which we add additional parts. The blue tag is an indication of inspection
status document at BCAG, so, in effect, the inspection status of the part is incorrectly identified on the part, as the tag
only states the vendor portion of the assembly has been accepted.
7-24-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate the use of NCRs to substitute parts, which I believe
is prohibited per my NCR/R/T writing training, but at PSD we do anything, even prohibited actions, "to support the delivery
schedule." The last NCRs I know of that did this are (number) and (number), but it may still be happening now for all
I know. Please keep an eye out for them during your suggested audit of at least the past year’s tags written at PSD.
7-23-07 quote: This quote is also from my addendum
(supplement) to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed
myself "The Last Inspector". Another item the FAA chose to ignore, at your peril.):
I saw some tubes that were "fresh off the press" and brought out for installation on the L/N (number) position
2 and 3 engines. The part number of the tubes was (part number). They had a line inspector stamp of 2/21/02. The ovality in
the bend area of the tubes sure looked bad to my "calibrated eyeballs," but as we have no tools to check that, there would
be no way for me to tell. I assumed the inspector who bought those tubes checked them for ovality some way, as they were stamped
by QA. Please ask them if they did check them for ovality.
7-22-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector". Another item the FAA chose to ignore, at your peril.):
Also perhaps audit some tubes that were built in the PSD tube shop for discrepant dimensions that may have been roller
stamped by inspectors to support the delivery schedule. Also check those tubes for the right parts used, especially the material
used for the tube component itself. I, the "Thorough" inspector, found once or twice that the tubing mockup shop had tried
to sell me the wrong wall thickness material, and I had them get the correct, higher wall thickness material before I bought
the material block on the form. Some of our roller stamping inspectors may not be, intentionally, so observant.
7-21-07
quote: This quote is also from my addendum (supplement) to my first report. (Continued from previous day's quote. These
quotes should explain more why I dubbed myself "The Last Inspector". Another item the FAA chose to ignore, at your peril.):
Getting an expert (and ethical in that he will tell you the unvarnished
truth, no matter how much that truth will hurt Boeing) tubing inspector from the "Tubes and Cables" group of BCAG, that only
inspects tube fabrication all day long, to help you audit our inspection of tubing fabrication at PSD, may be helpful. If
the inspectors cannot show you what tool they use to inspect those features, and react in much the same way I said they would
react when asked the same question in the above clearance inspection item, then please write us up. Here is a cheat sheet
of tools I found while looking for ST tools for the prior item, of tools that we should probably have to do inspections in
the tube shop. I realize that ST tools are not valid for inspectors to use unless they have been checked with certified tools.
I seem to remember an incident with Boeing "ST" Hilok gauges having to have a green dot on them to be used, I guess meaning
that they had been "certified" as OK to use to inspect Hilok pin protrusion by checking their dimensions with a certified
measuring device...This issue also has raised it’s head during our Pre-ACSEP cover-up activities. One of the issues
our management has identified as a "threat" to getting a finding is this issue of inspection using non-certified "ST" gauges
to inspect product, as we have been doing for years on the 747 strut Wiggins fittings installations with the STXXXX (from
memory) and STXXXX tools. Of course, if using ST tools to inspect product, the appropriate controls, as we have never had
at PSD, will have to be put in place to ensure that these ST tools are valid for inspection use. I believe, from chatter at
a previous crew meeting, that (our QA supervisor) has told the 747 strut people that use the Wiggins fitting tools to
measure them with calipers when using them as the "fix" to ensure no write-up by you in this area. At least that is what they
are supposed to tell you if asked about the subject. Back to the subject at hand. Ask if we have any of these:
STXXXXX-X-X Flareless fitting gage.
STXXXX Ovality gage for 21-6-9 steel tubing.
STXXXXX Ovality Calipers
STXXXXX Ovality Go/No Go Gage
Note: The above ovality tools should probably be available at PSD for inspection of tubing installations also. Ovality
of the tube can change due to allowable preload upon tube installation, and I believe our PIs or the (docuiment I.D.) spec
states that tubing must still meet ovality requirements upon installation (so the I.D. of the tube is not reduced enough to
impact liquid flow design requirements by installation).
7-20-07 quote: This quote is also from my addendum
(supplement) to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed
myself "The Last Inspector". Another item the FAA chose to ignore, at your peril.):
Also please investigate the "calibrated eyeball" inspection technique being used for tubing inspection of tubes built
in our mockup tube manufacturing shop, that builds production tubes and NCR dash "M" tubes for PSD and elsewhere. Sure, we
are very good at inspecting the tubing bends per laser tracker reports and the old adjustable jig, surface table, and plot
system, but we use the "calibrated eyeball" method for everything else, such as ovality and protrusion of the tube beyond
the swaged sleeve. Please investigate the tube mockup shop, and make sure we have the right tools to inspect the features
I said we inspected with calibrated eyes only, among any others from the (document I.D.) series specs that we should
be inspecting that I am unaware of due to my, and my coworkers, non-expert tube fabrication inspector status. The inspectors
in the strut shop usually support the inspection of the tubes made in the mockup shop, so please ask them to show you the
tools they use to inspect the ovality and protrusion of the tube beyond the swaged sleeve, among other dimensions you find
that we should inspect.
7-19-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector". Another item the FAA chose to ignore, at your peril.):
Anyway, please write us up for this. Go to multiple inspectors and have
them show you how they inspect tubing installations for clearance. I believe you’ll see panic in their eyes as they
mentally fumble with what method they could make up to do the clearance inspection that will satisfy you. Ask them to show
you what "calibrated tools" they use, such as ST tools, they use to inspect .XX" and .XX" clearances. Then write us up for
our backwoods inspection methods in the 21st Century, working on some of the most complex machines man has yet built, that
are the only reason our planes are not gliders. Make us do what we should have done (if we really cared about doing our inspection
jobs correctly) twenty-one years ago at the start of PSD--make us get our own ST tools made that have all the PSD Engineering
required clearance dimensions on them in one or two tools, including .XX" and .XX" dimensions, so that ethical inspectors
like me don’t have to improvise with bolts to do the inspections. Then require us to use them, when obviously required,
on all tubing installations we inspect. Also make our QA planning department put the mandatory clearance inspection from the (Document
I.D.) document on all tubing installation jobs (and maybe all W/B (Wire Bundle) jobs as well, if Prime Divisions do that also).
You might find that our QA department will try to hide behind their corruption when you investigate this, and say that all
the discrepant tubing installations we have shipped out, and continue to ship out, because of the "calibrated eyeball" clearance
inspection method, only happened because someone made an "error" and forgot to put the clearance inspections on the jobs for
twenty-one years. Don’t buy it. It is only due to what I, and (my QA supervisor), by my documentation of his comments
in his meeting with me, have told you about the corruption of our Quality System--our "altering our processes to support the
delivery schedule," status as instructors, not inspectors, and the fact that we are not at PSD to catch manufacturing errors,
we are only at PSD to make sure the correct parts are installed, no matter how hard they ride together, or how many lives
may be lost due to our intentional ignoring of those manufacturing errors.
7-18-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector". Another item the FAA chose to ignore, at your peril.):
There is a problem with all of the above besides the obvious great danger to the public that results from basically uninspected
clearances between critical tubing installations in the airplanes we build using our extremely fallible "calibrated eyeball"
inspection method. It is that I, the "thorough inspector," can easily find discrepant tubing installations, using my "calibrated
tooling" inspection method, virtually every place in the factory I am transferred, as I have detailed above, simply by using
this minimum, I think, inspection method. These are installations that have gone out to service for perhaps hundreds of times
in their discrepant state, as they cannot be built any other way due to the design will not allow them to be built with the
minimum required clearances, no matter how much the tubing is preloaded. This makes me a threat to delivery schedules, as
due to my integrity, if I know something is discrepant, I will write it up, most likely, less the few instances I have described
above that will result in my downgrade to freeway off-ramp panhandler status. So maybe the above examples of tags I wrote
are just another reason I was put in my "make work" job for approximately eight and a half months, and one of the reasons (my
QA supervisor) had his meeting with me accusing me of "not supporting delivery schedules."
7-17-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector". Another item the FAA chose to ignore, at your peril.):
This just in (this is being added on 4/21/02 between the above and below paragraphs): While I had been recently substituting
for (name) on 777 EBUs (Engine Build Ups) while he was on a work related trip, I wrote a shakedown NCR, (number),
on the POS (position) 1 L/N (number) (engine vendor) EBU. It was a 26 item NCR, alot of which was poorly installed
wire bundles. Two of the items were on power feeder wires riding each other (items 12 and 20). But the most worrisome item
was number 11, in which the core side of the power feeder W/B (wire bundle) was riding the metal tube portion of a vendor
hose. The POS 2 EBU had some clearance. This item should have been obvious to any inspector who used a mirror to inspect.
Unfortunately, some prefer to inspect with just a coffee cup in their hands. The EBU traveled with the noted items open. I
suspect this discrepancy exists on many of the (engine vendor) 777 EBUs we have delivered. Please check into it.
7-16-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector". This ciritcal to safety problem only I found after approximately 382 inspections of the same job by other "inspectors."
This overlooked defect, or a similar one, I believe, could have led to an accident similar to the TWA800 accident.
And, as far as I know, the FAA ignored my asking them to ensure it was fixed in the fleet.):
Another example, but dealing with critical wire bundle to fuel tube clearance on 747 (vendor) struts: When I was
assigned on the 747 strut line I wrote NCR (number) on 747 unit L/N (number) for insufficient clearance between
a wire bundle and an adjacent fuel tube, the X" diameter fuel tube that supplies all of the fuel to the engine. The clearance
should have been a minimum of X" , but was about half that minimum (yes, I know that should have been easily visible to any
inspectors eyes, regardless of calibration, but you only see what you want, or think you are allowed, to see--Do you get a
sense of deja vu just now, or is it just me? (I like copy and paste, obviously)). This was clearly a safety of flight issue
(to me) as the wire bundle was above the fuel tube, and the fuel tube was well supported from movement, but the wire bundle,
which had never obviously been inspected for minimum clearance to that fuel tube, was not. An unknown clearance, or even riding
condition, existed on all prior units, as they could never had been built with the minimum 2" clearance due to design error.
What’s worse is that the clearance between the wire bundle and the fuel tube would only get worse over time in this
high vibration area, as the wire bundle would droop more and more over time due to gravity, loosening and migration of wire
bundle ties, and possible axial movement of the wire bundle forward through the clamp just aft of the area, making the drooping
worse. A drawing change resulted from my tag (see PI drawing (number) sheet 1 zone C10 flag note AL and revision D block
of PI). I believe the installation I wrote up originally was approximately the 383rd installation inspected prior to the write
up of this design error that made attaining the minimum drawing required clearances impossible. Please check to see if BCAG
issued a service bulletin to inspect for the minimum X" clearance allowed by the drawing change so no fires result in the
fleet, although I believe an AD would be more appropriate for this problem.
7-15-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector".):
This just in (this is being added on 4/21/02 between the above and below paragraphs): While I had been recently substituting
for (name) on 777 EBUs (Engine Build Ups) while he was on a work related trip, I wrote an NCR, (number), on the
POS (position) 2 L/N (number) (part number) EBU on insufficient clearance of .XXX" between the (part number) tube
and a (part number) vendor bolt (which should have been .XX" minimum clearance) C/T the core diffuser/combustor
case. This clearance problem should have been obvious to any inspector’s "calibrated eyeballs." I actually tried my
old clearance check with a bolt to confirm the "calibrated eyeball" discrepancy, as we had no tools to check .XXX" tubing
gaps with. I found out that this method was unwise on EBUs. The first time I got the bolt into the cramped position to check
the clearance, I dropped it, and it lodged somewhere in the EBU just below the discrepancy. Thankfully it only took a few
seconds to find it and retrieve it from on top of the left gearbox attachment fitting. The second time I tried to use it I
also dropped it, but thankfully it dropped all the way to the floor. There are some areas on the core where such a bolt could
lodge that would be very difficult to find and/or retrieve. What is needed is an appropriate "Z" shaped ST tool that I could
keep a grip on as I used it in tight places. Anyway, this discrepancy, in my opinion, probably has existed on all (vendor)
777 EBUs that take the noted tube assy. I believe I noted that delivered units were suspected to be affected on the NCR. Make
sure we address them and put out a SB (service bulletin) if necessary to check the clearance. I also wrote an NCR, (number),
on insufficient clearance between a tube assy C/T the (part number) drain plumbing installation C/T the VSCF and
a vendor hose. This clearance problem should have been obvious to any inspector’s "calibrated eyeballs." This discrepancy,
in my opinion, probably has existed on most, if not all, delivered units. I spoke to (name) about it, as her side did
not have enough clearance and she had already bought the job. I suggested she open the job up and have the mechanic see if
they could get more clearance, as her side was not as bad as mine and perhaps could be made per drawing. I don’t know
if she ever did that, however.
7-14-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector".):
Another example: When I was assigned on the 747/767 EBU (Engine Build Up) line I
wrote NCR (number) on 747 unit L/N (number) for a clearance of .XX", that should have been a minimum of .XX" (yes,
I know that should have been easily visible to any inspectors eyes, regardless of calibration, but you only see what you want,
or think you are allowed, to see), between a pneumatic tube on the (part number) plumbing installation and an adjacent
vendor bracket on the top of the (part number) engine core. A drawing change resulted from my tag (see drawing (number)
sheet 1 revision A). I believe the installation I wrote up originally was the 785th installation inspected prior to the write
up of this design error that made attaining the minimum drawing required clearances impossible. The reason that this went
on for so long without being fixed, in addition to (the) intentionally overlooking of it by inspectors to save themselves
from being "God Bless" or "Furniture Store Going Out of Business for the Final Time!" sign holder-uppers, was that the inspectors,
and sadly, the engineers that designed the installation, misunderstood the design requirements as written. Our PI had a section
entitled something like "fluid tubing requirements" that gave the .XX" minimum dimension I wrote the installation up against.
Other inspectors, using their own individual "common sense," and not a perusal of the drawing and specifications I used, concluded
that "fluid tubing" did not include pneumatic tubing. Logical enough, if you never read the (document I.D.) spec,
as most inspectors probably hadn’t, called out on the PI. So they "inspected" pneumatic tubing, if they felt like inspecting
it at all and did not just roller stamp the job, to the requirements of (spec I.D.) for clearance, which are not
as strict as the clearances on the drawing, and call out a minimum of .XX" clearance, which most of these installations would
still be unable to be built to, I believe. Anyway, (spec I.D.) defines "fluid tubing" as tubing that carries a liquid
or gas at positive or negative pressure, if I remember right. If you peruse the noted NCR you’ll probably find that
engineering (I don’t know if it was Liaison or Project engineering) attempted at first to disposition the tag the same
way, saying that pneumatic tubing was not fluid tubing and that the .XX" minimum clearance applied. Are aerospace engineers,
who design aircraft that carry millions of people, and who can’t read drawings and specs scary? I think so.
7-13-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote. These quotes should explain more why I dubbed myself "The Last
Inspector".):
Another example: In 777 struts I wrote NCR (number) on L/N (number) for
clearance problems between quite a few tubes and between tubes and structure on one plumbing installation using my "calibrated
tooling" newfangled (to PSD) inspection method. Several NCRs were written on the same subsequent installations by other inspectors
by copying my original tag (NCRs (number), (number), (number), and (number)). A major drawing change resulted from my tag
(see drawing (number) sheet PL revision AK that changed the (part number) installation to the (part number)).
I believe the installation I wrote up originally was the 111th installation inspected prior to the write up of this design
error that made attaining the minimum drawing required clearances impossible. I believe the clearance problems on that tag
were between fuel and hydraulic tubing. I wrote another tag on perhaps a separate clearance problem found with my "calibrated
tooling" inspection method in 777 struts, NCR (number).
7-12-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote):
Of course, using this method, I found errors those other inspectors never found because of their roller stamping "supporting
the delivery schedule" nature, or faulty calibration of their eyeballs. It was obvious this was the case, as probably the
second tag I had to write as a result of my, I thought minimum, inspection method was (I believe) on a weekend I was working
in the 777 EBU (Engine Build Up) area. It was rare for me to be assigned to that area, and that was probably the first two
days I worked in that area ever, as I have spent only about four total days in my almost four and one half year career at
PSD inspecting in the 777 EBU area. Anyway, things were slow that weekend, and I inspected very few jobs, but one of the few
jobs I did inspect had a clearance problem I found with my "inspection tool" inspection method between a tube and some vendor
bolt heads fastening a couple fancase sections together. This clearance problem was so bad it should have been obvious to
even the majority of inspectors using the "calibrated eyeball" method of inspection only. The mechanic tried to loosen the
tubing and adjust it to obtain the required clearance, but he couldn’t without preloading the tubing. It was obvious
it was a design error, and all installations built prior to that one had been bought off that way due to the "supporting the
delivery schedule" "calibrated eyeball" error-prone and see-what-you-want-to-see-prone inspection method. I wrote NCR (number)
on L/N (number) on that design error, which led to a drawing change of the one tube that had the clearance problem (see
drawing (number) sheet PL revision BH that rolled the (part number) discrepant installation to the (part number)).
The installation I wrote up was approximately the 37th installation that was inspected before being written up. What’s
disturbing, is that, I would think, but don’t know, that there would be a QA requirement (maybe this would be a FAI
or FAV inspection) for the inspector that inspected the first, brand spanking new, installation (I think the tag I noted was
written on a 777-300 installation) to go over it with a fine toothed comb and find all possible design errors that could haunt
us in production, like the installation I noted that could never be made to meet the drawing clearance requirements, so that
they could all be fixed prior to a bunch of discrepant units going out. This would save the company a lot of money. But apparently
that is not a requirement at PSD (or is but we don’t do it, which would be normal), but this is: If an inspector writes
up a design error that was missed by multiple other inspectors, we won’t reward him for catching the possible safety-related
defect and chastise or fire the other inspectors for their incompetence, we’ll instead "shoot the messenger," and chastise,
fire, or transfer the inspector who wrote up the possible safety-related defect and made the other roller stamping inspectors,
the kind of inspectors we want, look bad, into a meaningless "make work" job to keep him from writing things like this up.
7-11-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote):
Before my banishment to the office (for the "crime" of inspecting, with
the approval of the PSD QA director of the time, now the leader of the 787 quality department), I attempted to inspect
the tubing installation jobs I stamped in on to the PI clearance requirements--not with "calibrated eyeballs," but with actual
"tools" of sufficient accuracy to perform the clearance inspections with the same high accuracy every time. Most of our tubing
clearances are minimums of .XX", .XX", and .XX" clearance to adjacent tubing and structures. We have a tool, (tool number),
available at PSD, which is a tool designed just for tubing clearances, except, I believe, that I was the only inspector to
use it for that purpose. Most, if not all inspectors, only used it to do the in-process inspection on the 747 strut fuel tube
alignment prior to Wiggins fitting installation, for which purpose it is perfect, and is what it was probably actually designed
for, not just tube to tube or tube to structure clearance checks. It has only the three dimensions you need when doing these
fuel tube alignment checks, .XXX", .XXX", and .XXX", and no extraneous dimensions to the task on it. So I used that tool for
the common .XX" minimum tube to anything clearance checks. But no tool existed at PSD for the .XX" and .XX" clearance checks
(I found out just a few days ago, in doing research for this, that a tool, (tool number), exists that would work for .XX"
clearance checks, but, to my knowledge, it is not available in the PSD tool room--but I could find no tool designed to check
.XX" tube clearances in the...ST Tool Catalog). Anyway, that did not stop me, the "thorough" inspector. I simply did the obvious,
and got long .XXXX" and .XXXX" bolts and did the clearance checks with them. That even gave shop a half a thousandth pad,
as if that would matter. I was no fool, and did not check all clearances between tubes with these "tools." I only used them
when my "calibrated eyeballs" detected the need to check the clearances with them. I thought this was the way the clearance
inspections should be done, as opposed to the way I described above that other inspectors did it (except for probably (name),
who also writes NCRs on clearance problems) using only their calibrated eyeballs, and no "tools" to check the "calibration"
of them.
7-10-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's
quote):
The "calibrated eyeball" clearance inspection method works like this: An inspector simply looks at the clearances between
the tubes and adjacent structure and tubing, and then, with his "calibrated eyeballs", makes a judgment whether or not the
PI clearance requirements, as he remembers them, as he likely works only from memory of those requirements, are satisfied
to his "calibrated eyes." This judgment depends on how much he has to alter his inspection methods to meet the delivery schedule,
how he feels that day, and how much trouble he thinks he’ll get into from our QA Management if he writes a tubing clearance
discrepancy up, and shop disapproves of it. So, almost all of the time, if a mechanic cannot adjust the tubing installation
to pass the inspection of the inspector’s "calibrated eyeballs," the installation is just bought off that way, as writing
a tag on a tubing installation that has passed inspection hundreds of times before, that could never have met the PI clearance
requirements because of a design error, will not bring you adulation from our management for finding a defect many other inspectors
missed--quite the opposite is true.
7-9-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please investigate the inspection of critical systems tubing installation clearance requirements utilizing only "calibrated
eyeball" inspection techniques. While, if we had an ethical QA Planning department, we would have actual in-process tubing
clearance inspections on every job that installs tubing, as the (document number) canned note document (which used
to be in our QOIs as the authority for inspection point control on our plans, but then was removed when some of us line inspectors
audited plans to it) requires, every inspector at PSD knows that each tubing installation has its own clearance requirements,
for those requirements stare them in the face every time they look at a PI drawing, on the rare occasions they might, as they
are pretty much always in the first frame general notes for the PI drawing, and, even if they don’t refer to the PIs,
these clearance requirements are remarkably consistent across product lines, even between strut and engine tubing installations.
Inspectors therefore have the right knowledge of clearance requirements, and therefore can inspect these tubing installations
(which are probably the most common installations we as inspectors see at PSD) for conformity to these clearance requirements
to ensure no safety related tubing riding conditions, that would cause loss of propulsion systems in service, exist? Nope.
We don’t do it. Yes we have the requirements available to us if we want to look at them, but due to our management’s
lack of direction because they really do not want us to inspect the product, only train mechanics, each inspector is allowed
to inspect, or not inspect, as they prefer, as long as it does not result in additional costs to the Company, like extra NCRs,
or drawing changes, or "not supporting the delivery schedule." So, a system of inspecting these critical clearance requirements
has evolved in this environment which relies almost exclusively on what is perceived by inspectors as the most accurate and
efficient method of inspection available in the 21st Century to meet these requirements--the "calibrated eyeball" inspection.
Of course, you might have expected that, instead, some sort of ST tool might exist for inspectors to inspect these critical
clearance requirements. Some ST tools do exist, they are just not stocked at the PSD tool room. Instead, the "calibrated eyeball"
method of inspection is used at PSD. Unfortunately, as you might expect, each inspector’s eyeballs are "calibrated"
a little bit differently, and so this method of inspection is not as accurate, by far, as an inspection with the correct (inspected
with actual calibrated tools by tooling inspectors) ST tool might be.
7-8-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote):
Nope, that one instance
was not the end of this problem. (The inspector) said this problem (holes too big for safety cable or even safety
wire per (the spec), allowing safeties to be ineffective) exists on EBUs (Engine Build-Ups) on the 747/767 line. He used to
have 747/767 EBU mechanics install safety wire in places where safety cable was optional to the safety wire on the drawing,
because the holes the safety device had to go through were too big for safety cable per the spec, but were OK for safety wire.
Now he doesn’t worry about it, as (our QA supervisor) said "it was designed that way." It seems PSD engineers,
the engineers of some of the most complex hardware anywhere, don’t know how to pick the right size of safety device
for the hole. Please review all PSD drawings with safety devices, and tell our management to immediately fix by NCR or advance
drawing change, whichever is fast enough to prevent discrepant products from getting into service, any installations with
the noted discrepancy (for both safety cable and safety wire. I don’t know, offhand, what the maximum hole sizes for
different safety wire diameters are per (the spec). I’m pretty sure the (design manual) states the same requirements).
Make them treat it as safety of flight, as they probably should have. Then make us put out the necessary SBs or ADs to fix
the discrepant safety devices in the fleet.
Some references:
See the revision B block of (drawing I.D.) sheet 60, which changed the .XXX" diameter safety cable hole in the (part
number) detail of the (part number) bracket to .XXX"-.XXX" diameter. Revision C changed it back to .XXX" to
.XXX" diameter, with a "must comply" urgency. The same thing happened with the (part number) detail of the (part
number) bracket on sheet 13.---Why didn’t the same thing happen for the (part noted above that our QA supervisor
interfered with fixing)? Corruption of our management.
7-7-07 quote: This
quote is also from my addendum (supplement) to my first report. (Continued from previous day's quote):
Anyway, (the inspector) didn’t write the tag, per management
direction, even though engineering admitted it was a screw-up that should be fixed. A change, maybe because (the inspector) told
Engineering about it or (our QA supervisor) told shop to write an ELR for it, in the (part number) detail
drawing made the hole smaller, but allowed the larger hole as an option. So discrepant parts are still flying around in the
fleet. I guess that saved us lots of money. Please check into this, write our management up for poor judgment that could ultimately
jeopardize lives, and make us address the discrepant brackets in the fleet that may allow the anchored safety devices to come
loose.
7-6-07 quote: This quote is also from my addendum (supplement)
to my first report. (Continued from previous day's quote):
(The noted inspector) was working the 737NG line one day, taking
the place of an absent inspector, when he noticed, or was told by a mechanic, that the safety cable hole in the (part
number) bracket was larger than the .XXX" maximum requirement in (the BAC spec). He checked with the engineers (I think
in MRB, but it could have been the Project Engineers that designed the bracket), and they agreed with him that it was Engineering
error and needed to be fixed. (He) started to write a tag on it. Somehow (our QA supervisor) found out about
it (probably by the Manufacturing Leads complaining to him that (the inspector) was going to write a costly tag
on the EBUs (Engine Build-Ups)). This is where the unbelievably bad judgment (that happens when QA Management allows cost
and schedule considerations to cloud, or replace, rational thought) comes in. (Our QA supervisor) told (him)
not to write the tag "as it was designed that way." Hard to believe, isn’t it? You’d expect that BCAG QA Supervisors,
who are in effect making the judgments that FAA personnel would make if we didn’t have a PC (Production Certificate),
would make the same judgment an impartial FAA ASI manager would make in this situation, which would be to have the ASI write
the tag, and getting a line check done to ensure the safety devices in the fleet wouldn’t fail. But no. Our management
is corrupted to the point where they are unable and/or unwilling to make valid judgments based even on the flight safety of
our products. They only consider cost and schedule concerns, just as their twins, unethical Manufacturing Managers do. The
recount of what happened that day on the 737NG line is from only what I heard from (the inspector). Please see him for exact
details.
7-5-07 quote: This quote is also from my addendum (supplement) to my first report.
Please investigate this sad affair: This situation shows the poor judgment
of our QA Supervisors that results when cost and schedule concerns trump quality or flight safety concerns. It also shows
the poor engineering skills of our engineers by inference only. This situation involves (name), fellow line inspector,
and I only know what he told me, so you’ll have to get with him for details. It involves safety cable installations. (The
BAC spec section) states that .XXX" diameter safety cable is to be installed only in holes that are .XXX" maximum diameter,
and that .XXX" and .XXX" diameter safety cable is to be installed only in holes that are .XXX" maximum diameter. While BAC
specs rarely tell you why a requirement exists in the spec (they only list the requirements) the reason for this one is pretty
obvious. It is so the ferrules on the safety cable do not pull through a hole that is larger in diameter than the ferrule’s
diameter, making the safety cable useless. I believe this incident involves the (part number) bracket (reference (drawing)
installation on sheet 34), and might have happened prior to 10/6/01.
7-4-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please investigate the lack of any QA or QA DCAC procedures on our online reading list. Our QA reading list is about
99% just changes to BAC specifications. It seems our QA Management does not want us to read QA Procedures and DCAC desktops
related to QA as we may then try to comply with them. QOI (number) requires that DCAC desktops be added to reading lists.
We should always have a few of our QOIs on the reading list, even if they never change with the times as ours don’t,
just to re-familiarize the line inspectors with them...We used to have desktops on our reading lists in 1998 when we implemented
NCM. Review our records of past reading lists and you’ll find we’ve missed almost all DCAC rolls in the past few
years of desktops that affect us.
7-3-07 quote: This quote is also from my addendum (supplement)
to my first report.
(Comment about a quality system requirement that inspection and testing techniques have to be equavalent
to the level of technology being produced, and accurately assess the performance of manufacturing methods and processes.)
- - Darn, the "calibrated eyeball" "see what you want to see" method saves the company a lot of money due to the huge quantity
of defects that go undocumented due to its use on these engines, which are some of the most complex machines yet built by
man. There goes my Sharevalue payout (sarcasm intended).
7-2-07 quote: This quote is also from my addendum (supplement)
to my first report.
Update: I got the opportunity to work the 737NG EBU line yesterday (2/25/02)
and I gathered some info while I was there. It turns out that inspectors are not the only ones that use "calibrated eyeballs"
to inspect the fit and fairs on I&R installations, but shop does also (I guess this fits in with item 14 above)! Proof
is documented right on the planning for (job I.D. number and line number), the exhaust plug and sleeve installation job.
In operation 110, last paragraph, the shop "visually checks" and buys off the fit and fair for the plug, and in operation
140, they do the same for the exhaust sleeve. The installation for this particular line number was the (I.D. number) installation.
On the related aerosmoothness drawing, (I.D. number) sheet 1, the exhaust plug and sleeve area of the EBU is defined
as an "extra critical" aerosmoothness area in zone C7. Per General Note GN02 in zone C5 of the drawing, states that compliance
with the aerosmoothness drawing requirements must be verified using tools or procedures with accuracy and repeatability of
equal to or better than (dimension), and where the hardware configuration prevents the application of accurate measurement
devices, use the best means available. Linear scales are not acceptable (then it goes on to say which tools are acceptable.
No, "eyes calibrated to (the drawing tolerance) are not listed). General Note GN06 in zone C5 of the drawing, states
that the measurement points used for final fit verification on any interface should be coordinated where practical with HVC
points identified on A.I.P. drawing (I.D. number) sheet 6. Also, on sheet 2 of aerosmoothness drawing (I.D. number),
view 3A7 in zone A12, which calls out fair requirements for the plug, and view 6B7 in zone B11 (I believe), which calls out
fair requirements for the sleeve, call out flag note 5, which states, if measurements are taken, that they must comply with
requirements. I suppose this also applies to measurements taken by eyeball. Also, on (job I.D. number and line number) (737NG
inlet installation job), shop checks the gap and fair on the inlet installation, without any QA buyoff, in operation 120.
7-1-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please investigate I&R inspections, or the lack thereof, at PSD. Please audit
our plans for lack of the required I&R caution notes per (procedure I.D.). I think you’ll find many I&R
parts without the required notes. Please interview (name), manager of the PSD phase I and phase II I&R committees. (Name)
chairs and administers the I&R committees. Also please check into the use of "calibrated eyeballs" by our PSD inspectors
to inspect the fit and fair of the engine inlets and exhaust sleeves and plugs, rather than calibrated tools. Please see item
54 below for a definition of what a "calibrated eyeball" inspection really is---I won’t bore you with a repeat of it
here. I believe most of our I&R inspection plans have been canceled, probably due to the fact that we never write I&R
tags any more due to the inaccuracy of our "calibrated eyeball" inspection method to detect discrepant fits and fairs. We
used to have to fill out a fitcheck document page on the gaps and fairs of the engine inlets and exhaust sleeves and plugs
when we inspected the jobs that installed those parts. Actually, we never filled them out, shop took the measurements, manipulated
them if they wanted to, and then presented the page to us for inspection of that data. We had no idea if those measurements
were correct or not, as we didn’t take them. After a time of doing this, the requirement to fill out the page was deleted
from the job, probably due to no rejections being initiated from them. I have no idea if this bogus data is what resulted
in the cancellation of some of our I&R plans, or not, but it is quite likely it was. I know some of the jobs that install
the noted I&R items currently still have fit and fair buyoffs on them (the inlet job on the engine I inspected the weekend
of 1/12/02 had one), but inspectors don’t even use the gap gages and misfair gages shop might have used when they used
to do the measurements for us, we just use the "calibrated eyeball inspection method." Please check into this. Make sure all
jobs at PSD that install I&R parts have the required I&R notes against them. Ask inspectors to show you what tools
they use to inspect these fit and fair in-process inspections. Don’t be surprised when you get that "deer in the headlights"
look in response. When you see that look, don’t "brake;" "gas your car" instead, and hit us with write-ups. Make sure
we have fit and fair buyoffs on all I&R parts jobs. Some access panel jobs in the strut area may require I&R notes
and fit and fair buyoffs also. Review our I&R inspection plans, or lack thereof, to see if they were validly canceled
with accurate data, and see if we are complying with those plans that have not been killed without cause yet. Please audit
all PSD bought off I&R installations still in BCAG inventory with accurate inspection devices to see if any discrepant
products were delivered due to some of our inspector’s eyeballs being out of calibration, even after our 2/4/02 eye
test. Please nail us if we do not comply with the as-written processes, or any discrepant engines or struts are found.
6-30-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please verify we routine tools we use as a medium of inspection, such as the fitcheck
tool in front of the 777 EBU work cells. I don’t know if we do or not, but considering our history of compliance on
everything else, it is worth investigation. I guess the same thing might be true of the duct locating tools used in the strut
area, such as (Tool I.D. number). They are used as a medium of inspection, or should be, but the "Verify ducts are located
per tool. O.K. to remove tool" inspections are probably missing from our jobs per our AWOL QA Planning department. Renton
Prime Division Tooling Inspection does our tooling inspection at PSD, though our QA Manual doesn’t document that. Please
audit them to Directive 110 of our QA manual on this. Also please make us add the applicable noted inspections to our plans
for any tool that locates parts.
6-29-07 quote: This quote is also from my addendum (supplement)
to my first report.
Our management will probably try to tell you that this audit (Area Surveillance
Audit) is the system audit in the previous QOI. That would be a sign of desperation, but we can read, so their arguments will
fall flat.
5/8/02 note: Today, in our crew meeting, we were notified of our 5/1/02 QA Manual change. After the meeting, I did the
required reading of the changes to the manual. I found that the above two QOIs have been canceled. However, I’ll leave
this item as is, for I expect you can still write us up for noncompliance with our previous QOIs as I have reported. Even
though our management has supposedly new procedures that "fully" take the place of the above two QOIs (procedure I.D.s) that
they can now start not complying to as they did our past QOIs, you’ll note that Directive 030 is still in place, which
requires a System Audit.
6-28-07 quote: This quote is also from my addendum (supplement)
to my first report.
I know that System Auditing is not a mandatory requirement for the FAA,
but it is a requirement of the QA Manual that you approved, and we said we would work to, so please write us up severely
anyway. What’s curious is that, per our (Process Instruction), Delegation of Inspection Authority to External Suppliers,
Boeing will not delegate inspection authority to any supplier if their System Audit is not on schedule. Please make us live
to the rules we supposedly make our suppliers live by. Also, since we do not do our System Audit, please do it for us. I believe
item 28 above does the compliance part of the audit, so per this item, please do the other part of the audit---audit our manual
to ensure all applicable Company procedures to QA at PSD are referenced in the manual, such as OPA (I.D. number), and that
our manual is up-to-date with your current requirements and our contractual QA requirements.
6-27-07 quote: This quote is also from my addendum (supplement)
to my first report.
Anyway, you’ll see by the Exhibit AC Audit Schedules, that our
side of the QA house, production inspection and MRSA, had only certain QOIs from the QA Manual to audit. Those were "our QOIs,"
even though some "other side of the house" (Completed Records, QA Planning, CAU) responsibilities were on them. The remainder
of the QOIs in the manual were audited by "the other side of the house’s" auditor, who still works for them, (name),
I believe (at least the last name is correct). He told me, when I started to make the System Audit book up, that the System
Audit QOI, (I.D. number), was production QA’s QOI, and that he didn’t work to it, only we, production QA, had
to. He was canceling all of the QOIs that his side of the house had to work to and he was instead going to work to the new (Process
Instruction Procedure (PI)) instead. As you investigate this, you might be told that (he) does all of the auditing
for PSD QA, both sides of the house, to make it look like we comply with the QOI. If so, have him show you his audit schedule
and verify that "our QOIs" listed on my Audit Schedules are on his schedules. If we do not comply with the System Audit QOI,
as I know we don’t because of my firsthand experience with what I’ve told you so far and the fact that no one
has ever audited me to see if I was complying with any PSD QOIs, then please write us up.
6-26-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please investigate our lack of compliance to our System Audit QOI. I
spoke of what I went through when I tried to work to that QOI in item 1 above. See if you can find the System Audit book I
made up that I turned in to (my QA Lead) to give to (my QA supervisor) for his signatures on the Audit
Schedules that were required before I could do any auditing per the schedules. I never got the book back with the required
signatures, as they did not want me to actually work to the QOI, but to only pretend I did, as the "audit schedule" that was
done by (name) and (name) attests was done prior to the time I was assigned to do it (See Exhibit AB). If they won’t
give it to you, no matter. I’ve attached pretty much everything that was in it (Exhibit AC). When I didn’t get
the book back so I could do the auditing the way it was supposed to be done per our QOI, which included auditing QA to see
if we complied with our QOIs (I think you can see now, after reading all of the above, why I didn’t get those signatures,
as it scared the holy hell out of them to have a "thorough" ethical inspector like me, with some integrity, auditing us for
compliance to our QOIs), I just continued on, and worked per the procedures of the system audit QOI dealing with auditing
our QOIs for content, less the compliance part they didn’t want me to do for obvious reasons.
6-25-07 quote: This quote is also from my addendum (supplement) to
my first report.
Please investigate the roller stamping of shakedown jobs at PSD, when other jobs, that should have been complete prior
to the completion of the shakedown job, travel to the Prime Divisions. We should always travel the shakedown job if we have
any traveler to the Prime Divisions open, with an info pickup stating that the shakedown is done less those jobs that travel.
That would allow the inspector at the Prime Division to actually complete the shakedown after all of the work was done on
the engine or strut, by doing a shakedown of the area that the traveled work was done in, and then completing the shakedown
job, as it should be done. But instead, as it is taboo to travel the shakedown job at PSD, we roller stamp it. The Prime Division
inspector has no knowledge he should do that shakedown of the area after the work is done, as we never travel the job. True,
some of these travelers are completed by PSD crews traveling to the Prime Division to do the work, but I assume some of them
are done by Prime Division inspectors. In any event, even if PSD personnel are doing the work at the Prime Division, the shakedown
job, or any job that is not yet complete, should still travel there with them. The PSD inspector doing the inspection at the
Prime Division does not have to do the shakedown of the area that is worked there after the work is complete to find any FOD
or any other problem a shakedown inspection would look for, as there is no job left to do that inspection. I fixed this problem
in my revision to our shakedown QOI (Exhibit F, section V.A.12.), which I wrote mostly while on forced "hiatus" from inspection.
6-24-07 quote: This quote is also from my addendum (supplement) to
my first report.
Please investigate the 777 strut and EBU (Engine Build-Up) programs at PSD to see if we are controlling any key characteristics
per HVC (Hardware Variability Control) plans, if we have any. This is a customer and Prime Division requirement. It may be
more...indication of us defrauding our customers in not making sure we meet requirements that we promised them, rather than
a strict violation of FAA requirements. I’m not aware of any specific key characteristics on a particular drawing, but
777 Engineering can point you in the right direction, I’m sure. A good place to look for key characteristics would be
on aerosmoothness drawings such as:
Drawing (I.D. number), aerosmoothness drawing, zone D8, flag note 3.
Update: I got the opportunity to work the 737NG EBU line yesterday (2/25/02) and I gathered some info while I was there.
I forgot that the 737 drawings got updated to 21st century requirements during the NG Program, so key characteristics are
not limited to the 777, it seems. On the aerosmoothness drawing, (I.D. number) sheet 1, General Note GN06 in zone
C5, states that the measurement points used for final fit verification on any interface should be coordinated where practical
with HVC points identified on...drawing (I.D. number) sheet 6. That drawing sheet shows key characteristics for
the 737NG powerplant.
6-23-07 quote: This quote is also from my addendum (supplement) to
my first report.
Closure Inspection:
See Exhibit P for the Closure Inspection QOI I submitted to our management by QACR, but which was never
added to our manual because it relied too much on product inspection, and not on mechanic instruction, as our unwritten QA
Manual requires.
See Exhibit AN for an email that has some very good answers to my questions on closure inspections I was
seeking for my closure inspection QOI, from (name).
6-22-07 quote: This quote is also from my addendum (supplement) to
my first report.
References for 6-15-07 reference to lack of required "OK to Install" inspections:
Job (job I.D. and Line Number) (747 strut blanket job) has no "OK to Install" inspection for the raceway blankets.
Job (job I.D. and Line Number) (747 starter job) has no "OK to Install" inspection for the starter in operation 80. the
installation of the (part number) starter adapter and the (part number) bolts that attach it to the gearbox,
and the O-Ring installation on the starter shaft are uninspected.
Job (job I.D. and Line Number) (737NG hydraulic pump job) has no "OK to Install" inspection for the pump in operation
130.
Job (job I.D. and Line Number) (737NG IDG job) has no "OK to Install" inspection for the IDG (Integrated Drive Generator)
in operation 140.
Job (job I.D. and Line Number) (737NG inlet installation job) has no "OK to Install" inspection for the inlet in operation
120.
Job (job I.D. and Line Number) (777 RR Ship Loose Parts installation job) has no "OK to Install" inspection for the
EEC (Electronic Engine Control) suitcase lid final closure. Enclosed in this suitcase are all of the critical electronic components
of the engine. There is not even a minimal shop FOD "inspection," let alone a QA FOD inspection of the interior of this critical
area prior to closure. I’ve seen inside this area during a receival inspection, and it is a perfect place for FOD of
any kind to hide, especially under the EEC components. This "suitcase" should actually have a full-blown QA "OK to Close"
inspection for it to ensure no FOD is inside, because this area is inaccessible to shakedown inspection because it is closed
prior to shakedown, and to ensure nothing was damaged, loosened, or otherwise compromised during Boeing assembly operations.
Who knows what is bouncing around inside these EEC suitcases against the critical wiring inside (I say "critical," due to
my "uneducated" opinion--even though my boss said the engine would run without the wiring) on EBUs we have shipped with the
lack of this obviously required inspection. Please have issued the necessary SBs to find out what mysterious items are in
there.
6-21-07 quote: This quote is also from my addendum (supplement) to
my first report.
References for 6-15-07 reference to lack of required "OK to Install" inspections:
Job (I.D. and (L/N) Line Number) (hydraulic pump installation job) has no "OK to Install" inspection for the hydraulic
pump installed in operation 230.
Job (I.D. and (L/N) Line Number) (767 exhaust job) has no "OK to Install" inspection for the exhaust plug and sleeve.
Job (I.D. and (L/N) Line Number) (767 strut blanket job) has no "OK to Install" inspection for the raceway blankets.
Job (I.D. and (L/N) Line Number) (777 inlet installation job) has no "OK to Install" inspection for the inlet. On
4/12/02, I inspected the receival of a Wichita built 777 inlet for a PW4090 EBU (Engine Build-Up) on this O&IR, and I
also witnessed the torque on the two shear pins C/T the inlet attach flange of the EBU. During the torque witness, I noticed
some damage to the inner edge of the inlet attach flange adjacent to the L/H shear pin. It was not major damage, but rejectable
to BCAG standards with displaced metal. It looked like the mechanic had done it when running down the shear pin before the
witness. I inspected the rest of the attach flange and documented the original damage on NCR (I.D. number). What’s bad
about this is that this was probably the first tag that ever documented such damage to the engine inlet attach flange during
inspections prior to inlet installation, as there is no "OK to Install" inspection for the inlet that would catch such damage.
Damage that would be covered up prior to final inspection of the job. So, probably hundreds of EBUs have gone out of PSD with
such damage, or much more severe damage, undocumented due to the lack of the required "OK to Install" inspection on the O&IR.
6-20-07 quote: This quote is also from my addendum (supplement) to
my first report.
References for 6-15-07 reference to lack of required "OK to Install" inspections:
This just in (it is 4/21/02 now): I have had the opportunity to do the two witness torques on this job for the (part
number) spinner installation in the past week or so when I was assigned to take the place of (name) when he was
absent. The inspector (me) stands on the 777 EBU FME (Floor Mounted Equipment) platform some eight feet away while the mechanic
does the torques on the spinner from a scissor lift. Who knows what fasteners shop uses to install the spinner. From my viewpoint
some eight feet away they appeared to be twelve point headed bolts of aircraft quality with some kind of spacer or washer
underneath. But they could have been from Home Depot for all I could see from that distance (I was doing this torque witness
the way the mechanic indicated it was always done (while the inspector stood on the FME). It was a good thing that I was just
inspecting the torque and that I was not responsible for inspecting the fastener installation for being per drawing and spec.
I could not do that at this distance. If I had my way I would be on the lift with the mechanic watching the torque, but I
didn’t want to make waves by doing something that different. I did do something different that other inspectors did
not do, judging from the reaction of the mechanic to my request, however. The mechanic was torquing the spinner per the newfangled
(the way we should always have done it) method of torquing opposite bolts all around the spinner and not torquing it the old
way of torquing all bolts consecutively in a circular pattern (the way it was done in the past until a few weeks ago). He
was marking the bolts with tape as he went, but I couldn’t see if the pretorqued bolts were moving as he torqued them
when he did the bolts on the opposite side of the spinner, so I turned the fan after each torque so I could see what he was
doing. When he finished torquing the spinner bolts, I asked if that was it. He asked me to hold on. He grabbed the (part
number) spinner fairing that he had in the lift with him and slapped it over the uninspected installation of the spinner
attachment fasteners and started to install the bolts for the fairing. I waited for several minutes while he got the fasteners
ran down enough for me to witness the torque. When I was done witnessing the torque, we both went to the job panel and did
our stamping after the process was completed, as shop has been somewhat consistently doing in preparation for the ACSEP
audit. Of course, the day after the ACSEP, us inspectors and the shop will be back pre-stamping the whole jobs again.
Anyway, this torque witness of mine illustrates more part and fastener installations that have never been inspected at
PSD due to our AWOL QA Planning department that "does not do their processes to meet the delivery schedule." Please hit us
up for each of these missing inspections. There should be an "OK to Install" inspection for the (part number) spinner
fairing so the fasteners and spinner installation are inspected prior to the fairing being installed.
Also, the (installation number) installation of the two (part number) clevis brackets C/T the inlet
attach flange that are done on this job should be inspected prior to the (job I.D.) inlet installation job being
done so QA can inspect the fastener installation C/T the two brackets before the fastener heads are covered up by the inlet
installation. There are probably other similar fasteners we install on the inlet attach flange of the fancase that have never
been inspected because of similar planning omissions. I believe shop inspects the two noted brackets before installing the
inlet on the (job I.D.) job. They also, I think, are supposed to inspect to be sure certain jobs are complete prior
to installing the inlet on the same job. Whether the listed jobs...have all the things covered by the inlet installation on
them I do not know. Probably not, knowing our planning.
6-19-07 quote: This quote is also from my addendum (supplement) to
my first report.
References for 6-15-07 reference to lack of required "OK to Install" inspections:
Job (job I.D. and A/P line number) (777 inlet job) inlet cover is installed in operation 200 before any inspection of the
covered area by QA once inlet is installed.
Job (job I.D. and A/P line number) (VSCF installation job) has no "OK to Install" inspection for the VSCF installed in
operation 400.
Job (job I.D. and A/P line number) (Rolls Royce kit installation job) has no "OK to Install" inspection for the spinner
installed on the fan hub in operation 120! Not even a FOD inspection. Shop just inspects for damage before installing the
spinner/nose cone.
6-18-07 quote: This quote is also from my addendum (supplement) to
my first report.
References for 6-15-07 reference to lack of required "OK to Install" inspections:
References:
Job (job I.D. and A/P line number) (777 strut crate job) has no "OK to Install" inspection for the access doors installed
in operation 40.
Job (job I.D. and A/P line number) (777 exhaust job) exhaust cover is installed in operation 200 before any inspection
of the covered area by QA, and the cover covers up most of the exhaust installation except the external sleeve attachment
flange area, which area I wrote tags on both L/N (Line Number (specific L/N) EBUs (from memory) for 71 of 72 of
the bolts attaching the exhaust sleeve to the engine being too long. Who knows if any of the fasteners attaching the plug
to the engine are too long, as they never are inspected.
6-17-07 quote: This quote is also from my addendum (supplement) to
my first report.
A third example is on the PREs (Protective Equipment) that shop covers the inlet
with to protect them during transport and installation of the engine. Why would you need an O.K. to install on a PRE? Because
shop puts them on even before they put the inlet installation job up for final inspection. The inlet installation jobs will
not lie about this. It is the way they are sequenced. On the last weekend I worked I told you about, I had the shop open up
the PRE so I could inspect the sealant around the probe, the inlet interior area for FOD, and that area of the inlet and fan
blades for damage from installation. Do other inspectors make shop do this so they can inspect for the noted items? No. They
just inspect the areas of the inlet not covered, or if they are a hardcore roller stamper, they don’t even make an effort
to do that.
In actuality, the installation of the PRE should not be done on the inlet installation
job at all, but that is just par for the course for our AWOL QA Planning department. It should instead be installed after
the shakedown inspection, so the shakedown inspector can inspect that area also. It also should only be installed after shakedown
due to the fact that, the way it is done now, shop performs a lot of work with small fasteners and such after the cover is
installed, and I have seen cases where this FOD is laying on the inside of the fan case, between the fan blades. Please make
us fix this problem also, if for nothing more than to allow the inner half of the inlet to be inspected on the inlet installation
job.
6-16-07 quote: This quote is also from my addendum (supplement) to
my first report.
A second example of this problem is on the 737 EBU line. The exhaust plug is installed in two parts, a forward plug section
and an aft plug section. The forward plug section is installed to the engine and the torque on the attaching fasteners is
inspected. Then the aft section of the plug is installed with no "OK to Install" inspection on the job (see O&IR (I.D.
number)). Hence, over two thousand 737 engines have went out without the closed off portion of the forward plug, and the fasteners
that attach the entire plug to the engine, inspected.
True, I believe all of the fasteners were inspected for torque on the O&IRs, but the fasteners themselves were never
inspected. Mechanics could have put incorrect low-temp nuts and washers on, resulting in cracking of the nuts in service,
and departure of the plug. They could have put too many washers on, resulting in not enough protrusion of the stud through
the nut, resulting in the same departure of the plug in service. Who knows, they could have done anything in there.
Maybe there used to be an "OK to Install" inspection for the aft plug, I don’t remember if there was one during the
time I was on that line. I believe I used to try to look in there to inspect the fastener installation, but I don’t
really remember. I would have if there was an inspection for it. (I can vouch that, many months after this was
written, there still was no "OK to install" inspection for the aft section of the plug after the forward section was installed,
as I was assigned to the 737 line as retaliation for turning Boeing in to the FAA after my job was eliminated at Flight Test
because I was actually doing the job there (another long and sad story about corrupt BCA management in itself). They also
hoped that I would not rollerstamp there as was required in the Boeing quality system and I would then get way behind, at
which time they hoped to fire me under the pretense I was not getting the job done, albeit I would really be fired for
actually trying to inspect these engines as required which are at the center of the current investigation of the Kenya Airways
flight 507 crash that killed all 114 people on board. My boss actually started down the road to doing this as I refused
to rollerstamp as they knew I would, and he started disciplinary action against me by comparing by "productivity" with the
most notorious rollerstamper on our inspection crew, which I worked with at the time. Of course, by productivity, all my corrupt
manager compared was how fast the other inspector rollerstamped the jobs off as compared to how fast I stamped them off
(after actually inspecting the work on the engine). It wasn't a comparison of how much work we actaully did and how well
we did our jobs at all. I actually worked much, much harder than the other inspector I was compared with. I did the most inspection
I thought I could get away with without losing my job before I stamped the jobs off, which entailed actually looking at in
detail with mirror and flashlight all of the work I was buying off, although there was never time to look at drawings
or to ensure the correct configuration parts were actually installed. I also ensured the defects I found were reworked
and NCRs were written on defects that needed engineering disposition before rework/repair. However, none of this work was
mandatory even though it was required per our FAA approved quality system, or in fact was done in most cases by the other
notoriously rollerstamping inspector I was compared with only on a "throughput" (get the garbage out the door, as a coworker
described it) basis in just this one of many obvious attempts by my QA management to retaliate against me for turning
their crimes into their employees at the FAA).
Our management will probably try to get inspectors together in order to have them assure you that they inspected in there,
even though they didn’t have to per the paperwork. Don’t believe them. While even having an inspection on a job
and stamped off by shop and QA does not ensure that inspection was actually done at PSD, or BCAG for that matter, that paper
is all we’ve really got to go on, regardless of its validity. Hold PSD to it. If a required closure inspection is missing,
have BCAG put out the necessary service bulletins to have the installation inspected to ensure safety. While I don’t
think, from my limited knowledge of engine operating conditions, that an exhaust plug departing from the airplane could cause
it to crash, it could hurt quite a lot if it hit you on the head, along with hurting Boeing’s cherished reputation.
The aft plug doesn’t have to be removed for inspection. A borescope put into the aft plug opening could make for
a quick and accurate inspection on a service bulletin. Once again, don’t let BCAG do an engineering analysis on this
and try to convince you a fleet inspection is not necessary. Make them do it in any event, if only for a very instructive
learning experience that will show them that deleting required inspections to "facilitate the delivery schedule" and save
costs, will only cost them more money than they would ever have saved by deleting the inspections, and the inspectors that
do the inspections, in the end.
It would also motivate us to make sure the required inspections are on the jobs for no other purpose than avoiding the
embarrassment that results to BCAG when such a service bulletin is released, that lets customers in on the true state of our
inspection system.
6-15-07 quote: This quote is also from my addendum (supplement) to
my first report.
Please investigate the lack of "OK to Install" and "OK to Close" inspections at
PSD and the lack of anti-tamper seals on closures done, between the time closure is done at PSD and when the area is opened
back up at the Prime Divisions--if they are opened back up.
Because of our lack of a Closure Inspection QOI and our lack of an ethical QA
Planning department, a lot of critical work that is done at PSD is closed off to inspection before an inspector inspects it,
and/or there is no evidence that the work was inspected if you looked at the plan.
One example, of a possible many, is in the strut shop. Normally, except for the
case of the item 43 shakedown inspection referenced above, line inspectors do the shakedown inspection of the struts before
the access panels that close off the interior of the strut are installed. These panels are temporarily installed in Wichita
or at the vendor, as the case may be, and then removed from the strut by mechanics prior to the receival inspection of the
struts. They do their work, we sometimes inspect it [pending on whether the inspector thinks they are an inspector, as our
job description (see Exhibit AA) and FAA-approved QA Manual states, or simply a mechanic trainer, as our QA Supervisors say],
and then do the shakedown inspection when the work is complete. It used to be that the shakedown inspection was done on its
own job, and the access panels were installed on their own crate job, but now, I believe, all of the shakedown inspections
are simply in-process inspections on the crate jobs, fitting in with our QA Management’s diminution of our line inspector’s
jobs into nothingness, and we do not have our own separate QA shakedown jobs anymore in struts.
This also dovetails with our QA Management’s goal of getting us to roller
stamp the shakedown inspection, as they don’t see it has any value, as their thinking is exactly the same as the Manufacturing
Supervisor’s, who bitch when an inspector takes more than a few minutes on a shakedown inspection. Having a separate
QA shakedown job implies that the job is so important and extensive that it requires its own, separate, O&IR. Having the
shakedown be just another in-process inspection on a shop O&IR implies it is no more important or time consuming than
an electrical bonding inspection most of us line inspectors roller stamp.
I guess I’m somewhat off subject on this. Anyway, after the shakedown inspection,
shop just installs the access panels, no matter if they are installed on the same job as the shakedown inspection was done,
or not. There is no "OK to Install" inspection for the panels that would invoke the controls, by line inspectors, of the closing
of the panels per our Closure Inspection (written procedure), which I believe is (a procedure) that only I am aware
of in the PSD QA ranks.
So, once the shakedown is done, shop could install the panels immediately thereafter,
maintaining the integrity of the inspection, or install them the next day, the next week, whatever they want to do. We will
never inspect inside the strut again, no matter how long the period between the time when we did the shakedown and when the
panels were installed, as there is no required "OK to Close" inspection on the jobs.
There is one exception. 747 struts have an "OK to Install" inspection on the fairing
installation job after the Customer Shakedown of the struts (reference job I.D. and line number). But, to my knowledge,
the 757, 767, and 777 struts are afflicted with the aforesaid problem.
I believe I was told at one time that all of the access doors on the struts were
opened at the Prime Divisions for functional testing inspections, so that is why we are so cavalier about the "OK to Close"
on these panels. But, even if that rumor is true, there should be a note on the plan that states that the panels will be opened
on a certain job in Everett or Renton, and that is not the final installation of those panels prior to delivery. And if only
some of the panels are removed later, then there should be, at a minimum, an "OK to Close" inspection on the panels that will
not be removed.
But there is also another problem with this whole situation. What about controls
for securing these inspected strut interior area’s inspection status from tampering between the time of the "final inspection"
of them--the shakedown inspection--and the time the panels are removed, if they are removed, at the Prime Divisions? Right.
There are no controls, although the integrity of the inspection status of parts is of paramount concern, I believe, in your
FARs, and in our, unknown to virtually all inspectors at PSD (because our management wants us to be ignorant of it, among
other things), (written procedure) on Closure Inspection.
There should be an "OK to Close" inspection for these panels, even if they are
to be removed later, so that the necessary controls will be put in place to preclude tampering with the inspection status
of the part, and/or entry of FOD and/or animals into the to-be-closed-some-unknown-time-in-the-future strut interior areas,
by application of "Do Not Break" inspection seals on the access doors, as the (written procedure) requires, to assure
the Prime Divisions that the closed areas weren’t tampered with between our shakedown inspection, and the time they
are opened at the Prime Divisions, if they are opened.
Some strut locations have double doors, with both an interior, primed door, and
an exterior, top coated door/fairing. The interior door could have a paper label, or inspection putty (as the wing tank access
doors get), and the outer doors would just get a temporary paper label that would be removed in preflight, or when that door
was opened during scheduled work in the factory.
This could actually save the Company money, by only complying with requirements
(this would be an alien concept to our management, whose philosophy only states that money can be saved by not complying
with requirements).
If a panel does not need to be opened at the Prime Divisions, there would be no
need to open it just to see if that area was not tampered with in the factory before flight, or to see if CDC had conveniently
"borrowed" a part from an accepted installation as they are rumored to do on occasion, without the bothersome paperwork, if
the seals were still intact on the panel, indicating it had not been opened since inspection. These seals could be removed
at any convenient time during preflight activities.
Anyway, please investigate this whole situation, and tell us how we should be
doing these closures and coordinate the jobs to ensure that both PSD and Prime Divisions know what each other does to these
panels, so the proper controls can be put in place to preserve the integrity of inspection status, as we have no clue.
6-14-07 quote: This quote is also from my addendum (supplement) to
my first report.
(PSD's QA Manual definition of a Close Tolerance hole) I would dare
anyone to find a division of the Boeing Company that has so tight a tolerance for C/T holes! And most of our mechanics, in
a "drill off" for the best quality holes with other Boeing divisions, with their lives in the balance, using the same equipment
and materials, would no longer exist after the competition...
(Comment on PSD Close Tolerance hole QA manual statement that inspection of non-close tolerance holes (as defined by PSD
differently from other divisions for some reason--likely to let PSD mechanics "self-inspect" their own drilling,
for efficiency over quality and safety reasons only, (although they are not required to measure them to see if they
meet requirements) of "non-close tolerance holes" on critical strut (pylon) and engine retaining structure that would
be critically tight tolerance holes at both the Everett and Renton factories and would be required to be inspected
for obvious reasons) is "optional" for QA):
...Of course, every inspection at PSD is optional, no matter how critical, per our QA Management, so this is a redundant
statement.
6-13-07 quote: This quote is also from my addendum (supplement) to
my first report.
With the roller stamping and lack of process buyoffs on NCOs (Non-Conformance Orders) that occurs at PSD, even a good C/T
(Close Tolerance) hole QOI probably wouldn’t change the level of C/T hole inspection at PSD, unless those things are
also changed. You might want to check out NCR (number), which reamed a hole that did meet our current definition of a close
tolerance hole. Ask the inspector who bought it what he used to check the hole. As I don’t think we have any intramicrometers
in our current limited stash of tools in MRSA, they probably did the usual thing--putting a bolt in the hole and wiggling
it to see how loose the hole was. I think the tag had to do with a hole that was too small for insertion of a bolt, so that
is probably what happened. Ask the inspector to show you the tools he used. If he acts like he doesn’t know where he
is going to go to show you, you’ll have your answer. I think the inspector that bought it was (name), who is a
pretty good inspector. I don’t want to get him into trouble, as he is only doing what his management expects him to
do at PSD. I’m just trying to illustrate the problem for you by this example.
References:
Business Process Issues Management issue (number) covers the lack of uniformity among sites that build BCAG products
in the definitions of close tolerance holes in their QA Manuals, and the resulting bad consequences it could have on the conformity
of the entire airplane once put together (some C/T holes would have been inspected, while others with the same tolerances
would not have been, like those drilled at PSD). This issue has been sitting on the web for almost a year with no action noted.
Who knows when it was first identified. It is being "worked" by the same group (under (name)) that is sitting on my safety
device RDR (item 42) so fixing it does not cost the Company money. The issue lists FAA findings as a possible risk in not
fixing the problem. They have not fixed the problem and are dragging their feet purposely. Their time is up. Make their prediction
of consequences for letting this slide come true--please hit us with a finding on it.
6-12-07 quote: This quote is also from my addendum (supplement) to
my first report.
Please check into the lack of close tolerance hole inspections at PSD. I’ve heard our QA department used to have,
before my arrival at PSD, a huge stockpile of inspection equipment with which to check holes and other dimensions, and then
someone revised our QOI (I.D. number) on close tolerance holes to state that the definition of a close tolerance
hole that required inspection was a hole ((X") and less diameter, which is most of the holes we deal with) with a tolerance
range of (.XXX") or less. That made pretty much all of the holes at PSD "non-close tolerance holes," even though holes with
a tolerance range of (.YYY") or less are considered close tolerance holes, I believe, at the Everett and Renton Prime Division
sites, so the equipment was not needed any more. I suspect this was done "to facilitate the delivery schedule," and not done
because our mechanics, who rarely drill holes, can drill holes any better than those mechanics that drill them all day long
at the Prime Divisions. I suppose there are jobs at PSD where the mechanic has to drill what would be considered a close tolerance
hole at the Prime Divisions, but which is "self-inspected" at PSD, but I’m not aware of any, as there are no inspections
(that would be required at the Prime Divisions, but are not required at PSD due to our QOI) to call my attention to them.
Knowing PSD’s M.E. (Manufacturing Engineering) department, the whole operation that should be there to drill the C/T
(Close Tolerance) holes could be missing, for all I know. We, as line inspectors, are generally under too much time pressure
from the Manufacturing shop and our own management to really read the jobs we are buying at all. That was one of the reasons
why I used to read the jobs between inspections when I was assigned to 747 struts, even though I could (and probably did,
with my banishment from the shop) technically get in trouble for "inspecting a job that was not put up for inspection yet"
by doing that. Anyway, please investigate this, and make PSD change our QOI to be compatible with the Prime Division’s
QOIs on definition of C/T holes, as our mechanics are no better at drilling holes than those mechanics at the Prime Divisions,
and are probably actually much worse, as a few of the freeze plug tags we have had, when figure eight holes were drilled during
some of the limited drilling that was done at PSD, attests. Please check out the revision to the (I.D. number) C/T
hole QOI (Exhibit Z attached) I did during my forced time in the office, but did not finish and turn in (as if that would
have mattered).
6-11-07 quote: This quote is also from my addendum (supplement) to
my first report.
Please investigate the lack of process inspections on the NCOs (Non-Conformance
Orders) that support each NCR (Non-Conformance Record). This is evidence of the self-inspection of rework and repairs done
per the NCRs by vendors and Boeing personnel, even when throwing out consideration of the extensive roller stamping of the
limited process inspections that do exist on the NCOs. Each NCO must reiterate exactly the disposition per the revision of
the NCR it works and then detail any process inspections required to accomplish that disposition. It is not
the engineer’s job to detail the required inspections, it is M.E. (Manufacturing Engineering) planning’s, or the
QA Approver’s job, whomever makes up the NCO. It is not being done, or is being done very sporadically. Therefore, repairs
and rework are being done without the required inspection of that work. This is work that is beyond the minor defects reworked
by rework-type NCOs. These are significant defects that, except for some vendor items, are more critical to the safety of
the product generally. Our QA Management may try to tell you that, even though the required inspections are missing, that
somehow the inspector had enough integrity to find out which inspections were needed and did them, even though there is no
evidence of them on the NCO. Nope. Doesn’t happen, except for maybe me. Even though there is sometimes no separate blending
inspection and sometimes shop puts up a damage repair NCO with all the blending already done and finished to where you can’t
see if they blended out the damage correctly or not, I’ll let them know to make sure they come and get me to OK the
blend prior to finishing, at least on the next NCO. I’ve grown pretty good at seeing a bad blending job through multiple
layers of primer because of our lack of in-process inspections on NCOs. Please audit at least the last years NCOs for lack
of required process inspections. There should be the same process inspections on the NCOs that would have been on the job
that did the original work that is being redone, and, in the case of a blend and finish NCO, an "inspect blend," "inspect
first finish" (alodine, primer, etc.), "inspect second finish" (primer, top coat), as applicable. There should also be hole
inspections, if C/T (Close Tolerance) holes are drilled on the NCOs. If a Removal Record was filled out for the NCO, then
the required inspections may be documented in the "Additional Information" block of the Removal Record, instead of on the
NCO, but don’t hold your breath while looking for a required Removal Record for an NCR, they probably don’t exist
(see item 7 above). They also could be on an "alternate authority" G/L (Greenline) or B/L (Blueline) (job), but those are
not common. If they are not on the NCO, they probably don’t exist and weren’t done. If so, please write us up
for each occurrence of uninspected repair/rework done on an NCO.
6-10-07 quote: This quote is also from my addendum (supplement) to my first report:
I guess this fits somewhat into the intentional incompetence of our QA Planning department and corruption of our QA Management,
but please investigate the sequencing of our plans. For an example: (Job, unit, and area I.D.) 777 struts. The shakedown
inspection was sequenced after the operation 30 access door and blanket installation. If the job was inspected that way, and
not revised, the question is this: What did the inspector look at during the shakedown? Just the exterior of the strut, as
all the access panels were installed? You should be able to answer that question by just looking at the plan, not by questioning
the inspector who did the shakedown. As our QA Planning department has a "hands off" policy when it comes to steering the
M.E. (Manufacturing Engineering) department in which direction they should be going in the adding of inspections to the plans
or the sequencing of inspections on the plans, and us line inspectors are chastised for "not working with shop" or "not supporting
the delivery schedule" or browbeat with comments such as "Is it critical!?" by our QA Supervision when we attempt to write
up planning problems, no one can fix this problem but you.
6-9-07 quote: This quote is also from my addendum (supplement) to
my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. Of course, the hundreds if not many thousands of defective safety devices allowed to deliver on airplanes because
of this problem and the rollerstamping quality system in place at Boeing are still flying around, uncorrected. As this is
a long section, I am quoting the section sequentially over several days:
It is my humble opinion that safety cable should not be allowed to be used on FAA certificated aircraft without
installed safety cable minimum crimp length standards in place where it is used. Please contact the makers of this product
(I think (name)) and find out what the minimums should be. If they don’t have such standards that can be distributed
throughout the aircraft industry, then ban safety cable until they find out what they should be. It might be wise to have
SBs (Service Bulletins) put out to inspect all safety cable installations once standards are agreed upon. After all, they
are safety devices that are used on some critical installations. This fatal flaw in standards for safety cable installations
needs to be fixed ASAP, in my opinion.
(The spec) Saying "Thou shalt not move the tool" obviously,
as I have witnessed, does not work. There must be valid inspection criteria when "evil" (just human) mechanics blaspheme
the spec.
6-8-07 quote: This quote is also from my addendum
(supplement) to my first report. This section documents the lack of concern by Key Engineers about safety device issues and the
fact that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. Of course, the hundreds if not many thousands of defective safety devices allowed to deliver on airplanes because
of this problem and the rollerstamping quality system in place at Boeing are still flying around, uncorrected. As this is
a long section, I am quoting the section sequentially over several days:
Thousands of these discrepant safety cable installations had been made
prior to me contacting (him), and supposedly competent inspectors inspected every one of them and were supposed to know the
spec when they inspected, but none of them had obviously written an NCR on this problem as of my call to (the Key Engineer)
a few months ago. None of them apparently wanted to be panhandlers, like I didn’t. Nobody seems to care about this safety
device requirement at Boeing except me. Please make everybody here care. Also, you may want to ask engineering about what
size safety cable the (dimension) minimum crimp length is for. I assumed for my RDR that it is for both .030" diameter and
.040" diameter safety cable ferrules. If competent engineering looked into this, then three crimp lengths may even be required,
with a longer one for .040" safety cable ferrules. My RDR did not cover .040" safety cable crimps.
This just in: I stamped in on a "job complete" inspection on the call sheet
for (name), 747/767 EBU mechanic (I believe the job number and unit was (number) on (customer I.D.) POS 4). There was a safety
device inspection that wasn’t yet bought off, so I inspected them (novel concept at PSD, I know). It was the infamous
.020" safety cables installed on bolts on the 14th stage duct flanges. When I looked at the crimps on the ferrules for just
curiosity purposes (as I couldn’t inspect them because there was no valid standards for inspection as I noted), I noticed
that some were crimped about two-thirds of the length of the ferrule, and some were about half that, one-third of the length
of the ferrule. I probably would have "written" up the one-third length crimped ferrules if I had a spec I could write them
up to. Hopefully they’ll still perform their function.
This just in (it is now 3/13/02): I found a Program Bulletin (I.D.
number) from the Space Shuttle program that identifies safety cables falling off of the Main Engines (as they will probably
fall off of our engines) due to insufficient crimping of the ferrules. See Exhibit AO. It’s interesting to note that
our planes carry orders of magnitude more people than the Space Shuttle does.
This also just in (it is now 4/8/02): I had emailed (name), who wrote the
noted SSME Program Bulletin, several weeks ago, and only recently received a return phone call. I had emailed him to ask what
their minimum crimp lengths on the ferrules were, if they had such a requirement in their (I.D. number) spec, thinking they
might have come up with such standards after all their problems with safety cable. He said that they had found in their investigation
that it was a certain brand of safety cable tool that they thought had created the problems, due to the fact it had an adjustable
depth that the ferrule could enter the tool nosepiece that had not been calibrated. He said that they had just eliminated
the adjustable tool type and allowed safety cable to be used again after some lab testing. I told him of our problem with
insufficient crimps, and that it was due to operator error during use of the tool that created the insufficient crimps. He
seemed surprised, and said that perhaps they should check into that. That was pretty much the phone call. Maybe I averted
the next Challenger accident by getting him to look into operator error and lack of crimp length standards on SSME safety
cable! Yeah, I know. Delusions of grandeur. Just like the guy who spoke up about the o-ring problems before the Challenger
disaster probably had before he realized noone would listen to his dire warnings due to their own political agendas.
6-7-07 quote: This quote is also from my addendum (supplement)
to my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. Of course, the hundreds if not many thousands of defective safety devices allowed to deliver on airplanes because
of this problem and the rollerstamping quality system in place at Boeing are still flying around, uncorrected. As this is
a long section, I am quoting the section sequentially over several days:
Anyway, I digress. I almost lost control of my bowels due to the fact that
the obviously incompetent engineer, the "key engineer" of the safety device specification, BAC5018, at Boeing, was
just going to change the spec to say the minimum required crimp length would be what I said was the average crimp length I
had guessed I had seen, while inspecting the .020" diameter safety cable installations at PSD, on my RDR. I had even
noted on my RDR that the exact minimum ferrule crimp length would have to be determined by MR&D or Engineering, inferring
that some research and testing needed to be done to determine the length, as I had no idea what it should be, only what I
seemed to remember. I couldn’t believe he was going to simply take my word for such a critical spec requirement. I called
(him) and told him that he shouldn’t do the change that way, as I was no expert, only a lowly line inspector, and he
should do some testing first before he determined the minimum acceptable length and added it to the spec. He reluctantly agreed.
I didn’t hear back from him, so I contacted him a few months ago. I asked him what the status of my RDR was. He said
it was not a priority as they didn’t have the budget for the testing required. I couldn’t believe it. I asked
for his supervisor’s name. I called her. She gave me the same answer. I called back (him) and asked what would make
it a priority, as I thought it was essential, as product with discrepant safety devices was shipping from Boeing to customers
everyday. He didn’t know. I asked him, if I wrote a tag on an installation for it, if that would make it a priority.
He said yes. I never wrote a tag, as I work in fitcheck, where we don’t install much of anything, much less safety cable.
Plus I wouldn’t have written it up anyway, as I didn’t much like the thought of standing on that highway off-ramp,
holding my unoriginal sign up for small change and braving the disparaging looks from people who think I should just get a
shower and go get a job.
6-6-07 quote: This quote is also from my addendum (supplement)
to my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. Of course, the hundreds if not many thousands of defective safety devices allowed to deliver on airplanes because
of this problem and the rollerstamping quality system in place at Boeing are still flying around, uncorrected. As this is
a long section, I am quoting the section sequentially over several days:
Anyway, I digress. I almost lost control of my bowels due to the fact that
the obviously incompetent engineer, the "key engineer" of the safety device specification, BAC5018, at Boeing, was
just going to change the spec to say the minimum required crimp length would be what I said was the average crimp length I
had guessed I had seen, while inspecting the .020" diameter safety cable installations at PSD, on my RDR. I had even
noted on my RDR that the exact minimum ferrule crimp length would have to be determined by MR&D or Engineering, inferring
that some research and testing needed to be done to determine the length, as I had no idea what it should be, only what I
seemed to remember. I couldn’t believe he was going to simply take my word for such a critical spec requirement. I called
(him) and told him that he shouldn’t do the change that way, as I was no expert, only a lowly line inspector, and he
should do some testing first before he determined the minimum acceptable length and added it to the spec. He reluctantly agreed.
I didn’t hear back from him, so I contacted him a few months ago. I asked him what the status of my RDR was. He said
it was not a priority as they didn’t have the budget for the testing required. I couldn’t believe it. I asked
for his supervisor’s name. I called her. She gave me the same answer. I called back (him) and asked what would make
it a priority, as I thought it was essential, as product with discrepant safety devices was shipping from Boeing to customers
everyday. He didn’t know. I asked him, if I wrote a tag on an installation for it, if that would make it a priority.
He said yes. I never wrote a tag, as I work in fitcheck, where we don’t install much of anything, much less safety cable.
Plus I wouldn’t have written it up anyway, as I didn’t much like the thought of standing on that highway off-ramp,
holding my unoriginal sign up for small change and braving the disparaging looks from people who think I should just get a
shower and go get a job.
Thousands of these discrepant safety cable installations had been made
prior to me contacting (him), and supposedly competent inspectors inspected every one of them and were supposed to know the
spec when they inspected, but none of them had obviously written an NCR on this problem as of my call to (the Key Engineer)
a few months ago. None of them apparently wanted to be panhandlers, like I didn’t. Nobody seems to care about this safety
device requirement at Boeing except me. Please make everybody here care. Also, you may want to ask engineering about what
size safety cable the (dimension) minimum crimp length is for. I assumed for my RDR that it is for both .030" diameter and
.040" diameter safety cable ferrules. If competent engineering looked into this, then three crimp lengths may even be required,
with a longer one for .040" safety cable ferrules. My RDR did not cover .040" safety cable crimps.
6-5-07 quote: This quote is also from my addendum (supplement)
to my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. Of course, the hundreds if not many thousands of defective safety devices allowed to deliver on airplanes because
of this problem and the rollerstamping quality system in place at Boeing are still flying around, uncorrected. As this is
a long section, I am quoting the section sequentially over several days:
Anyway, most engineers I worked with seemed to be that way (incompetent),
with the lone exceptions of the engineers I worked with when I installed the first flap supports on the 777 and the PEDs.
Most Liaison Engineers seemed to be lost if they didn’t have a similar previous tag to copy the disposition from, or
would simply ask you what disposition you wanted and wrote it on the tag. I joked once, to who I don’t remember, that
most engineers I knew couldn’t engineer their way out of a wet paper bag given a pencil, a piece of paper, a calculator,
and a Stanley knife. When I was a mechanic or inspector on the 777, I would choose my passwords based on species of dinosaurs,
silently voicing my belief that the 777, the plane that everyone was so excited about, as it was a "totally new airplane,"
was only a 767 that the engineers had put the design of in a Catia terminal, and pushed the "enlarge" key. Sure, a lot of
new technology was introduced in areas on the 777, but the design was pretty much the same. Airbus copied this same ancient
Boeing design in their A/Ps. It was nothing new and exciting like the B-2 was when I worked on it, or the Sonic Cruiser will
be. Anyway, most of the engineers I met at BCAG seemed, as I painfully made evident in my joke, unable to engineer their way
out of a wet paper bag, much less able to engineer some of the most complex machines on the planet. This led me to think up
wild laughable theories of how this could happen, back when I was a mechanic, of how Boeing airplanes managed to even get
off the ground at all with such engineers doing the engineering, much less get into service with the airlines carrying huge
loads of people and cargo without immediately disintegrating. One theory of mine to explain the situation was that Boeing
had some real brainiac-type engineers that did the "mental heavy lifting" of safety related engineering on all new A/P programs,
leaving the "minor engineering," such as bracketry engineering and liaison engineering on MRB dispositions (after all, all
MRB-type situations had come up previously on one Boeing A/P tag or another over the years, and so Liaison Engineering’s
job was just to find that previous disposition, and cut-and-paste it onto the new tag) to the engineers I knew that would
die of starvation if trapped in a wet paper bag (sorry for the repetition). The other wild theory to explain the situation
was the same, except it assumed that no such brainiac engineers existed, and they all would be challenged by wet paper bags.
That theory theorized that "space aliens" (as opposed to the illegal alien type) served the function of the non-existent brainiac
engineers, doing all of our critical A/P design, and leaving the rest for BCAG engineers. (Sorry for this insight into my
"different" sense of humor. I really did think those "joke" theories up when I was a mechanic as I said. I included them in
an attempt to lighten up what is, all in all, the very heavy subject matter of this writing, much as I tried to lighten up
my disciplinary meeting of 1/11/02 up with (my QA supervisor) by a few choice comments. Hopefully you are taking my efforts
to lighten this material up with true funny (I think) events the way I intended. If not, I apologize.)
6-4-07 quote: This quote is also from my addendum (supplement)
to my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. As this is a long section, I am quoting the section sequentially over several days:
Anyway, after about four months the new key engineer of the spec, (name),
wrote back and stated that he was going to change the spec as I requested, and it would state that a minimum of half the ferrule
on .020" diameter safety cable installations had to be crimped to pass inspection. I just about lost control of my bowels!
It had always been mostly my experience at Boeing that nearly all engineers I meet and have to work with seem to have bought
their degrees. They show no evidence of the smarts I would think they would have to have helped engineer the most complex
machines man has yet produced. Some seem no smarter than the M.E.s (Manufacturing Engineers), who I had always little real
respect for (though I always showed them respect, as that was my professional habit while on the clock at Boeing), as I could
write circles around any of them I met when it came to writing plans, as I knew the minimum requirements, and they seemed
not to, or not to give a damn if they did. If I really looked, I could find errors in meeting the minimum requirements on
probably 95% of the plans I inspected, due to their quality of being ineptly written. The five percent of jobs that were OK
probably were only one or two pages long, and the only reason there were no errors was that the M.E. that wrote one had got
unlucky, and due to the shortness of the job, had written it without the seemingly mandatory mistakes. M.E.s seemed only to
be at Boeing as sort of a corporate welfare program, and the quality of their work was unmonitored as they really weren‘t
required to do any--the same program us line inspectors were supposed to be on according to (my QA supervisor's) meeting with
me.
In fact, that brings to mind one of the inept few slogans I had thought
up even prior to my 1/11/02 meeting with (my QA supervisor). I had always been bothered that no one, not even QA Management,
whose job it supposedly was to care (except for maybe the few competent line inspectors), seemed to care if us line inspectors
did our jobs or not, or did them to any minimum standards at all. The electrical bonding inspections come to mind in this
respect, as all inspectors are allowed to do the inspection on any point on the scale, from pure roller stamping it without
any inspection, to going to get the meters themselves and checking it (my method), even though line inspectors have several
times, most recently (name) at our 1/30/02 crew meeting, pleaded with our QA Management to fix this problem and force some
minimum standards of inspection, to no avail whatsoever. I had once thought of the slogan "There is no quality in Quality"
for our quality organization to capture this careless spirit. I even said this to some mechanic or coworker once, I believe,
though who I "joked" it to I don’t remember. I thought of it because I was bothered by the fact (that I would learn
later in the 1/11/02 meeting was really a lie) that we, as QA Line Inspectors, were supposed to ensure the quality of the
mechanic’s work, but no one ensured, as they didn’t seem to care, that we as line inspectors did our work with
some minimum level of quality. That seeming paradox doesn’t bother me anymore, obviously, as (my QA supervisor's) meeting
of 1/11/02 brought crystal clarity to why that paradox used to exist for me, and why that paradox still painfully exists in
the minds of some inspectors, like (name), that still blindly and falsely think that BCAG wants them to ensure the quality
of the work done. Those inspectors who finally "get it," as I have, whether they wanted to or not, even being force-fed it
in my case by (my QA supervisor) in that 1/11/02 meeting, much like the analogy (brace yourself) of a perfectly healthy baby
being strapped to a high chair, and force-fed rancid baby food, no matter how hard the baby tries to turn its head away to
avoid it being forcefully spooned into its mouth, or how hard it tried to close its mouth or spit the poison out, those inspectors
that finally "get it," understand that no such paradox should exist, as our jobs are not to inspect, but to only pretend to
train mechanics that don’t want any training and to collect our welfare checks until Boeing forces us to get real jobs,
getting rid of our dead weight to the bottom line by making the currently surreptitiously employed System of self-inspection
official, and then casts us to the wind. (Please submit the preceding sentence to the Guinness Book of Records people for
"longest sentence ever written," I don’t have time to break it up!)
6-3-07 quote: This quote is also from my addendum (supplement) to
my first report. This section documents the lack of concern by Key Engineers about safety device issues and the fact
that budget matters trump safety at Boeing, even in the most obvious safety related areas, such as safety device integrity.
I believe this safety device specification issue was partially fixed just months before my termination, some six years after
I formally brought it to the attention of the approriate engineering department. This was well after Boeing corporate
management and the FAA had refused to fix it on the multiple occasions I notified them of it. I believe the change that partially
fixed this critical problem that allowed untold numbers of defective (insufficient strength) critical safety devices
to deliver to BCA customers with the full knowledge of Boeing and the FAA occurred when a new Key Engineer was assigned to
the spec. As this is a long section, I will break it up and quote it over the next few days:
Please investigate BCAG Engineering’s hesitancy to fix obvious errors in their specifications, even those of critical
items to the aircraft like safety devices, in order to "save costs." It seems BCAG Engineering is similarly corrupted from
doing their jobs, like Quality is. Every .020" diameter safety cable installation Boeing has ever installed has been discrepant
per the BAC5018 spec. I brought this to the attention of the "keeper of the spec", (name), on 8/16/99 by going through
the official procedures to get it fixed, submitting a RDR form to him (Exhibit Y attached). They logged it as RDR No. R99-0422,
and in their system as B-YC00-A6M-R99-0422. The RDR had to do with section 11.e. of three of the PSDs (Process Specification
Departures) (PSD 6-37, PSD 6-38, and PSD 6-41) to the spec that were out at the time, and are probably still out, that had
a caution note that the die indentation from the installation tool was to extend a minimum of (dimension) inch from the
outer end of the ferrule for all safety cable, .020" diameter, .030" diameter, and .040" diameter. The problem is that the
length of a ferrule for .020" safety cable is only .087"-.095" long before installation. This makes inspecting per the caution
note impossible, as all .020" safety cable installations will fail the requirement. Big deal, you say, the spec also requires
that a test be done everyday for each tool that is used to install that diameter safety cable, requiring a representative
installation done with that tool to pass a minimum amount of torque on a test fixture before that tool can be used to install
any .020" diameter safety cable. That will ensure that we have a good .020" diameter safety cable installation every time,
even though the spec is hosed up. Wrong. That note was put there because, even though you do the test every day and it passes,
the use of the tool to install a real safety cable installation on the aircraft requires skill due to the tight spaces on
the A/P that are not represented by the required testing with the tool that is bolted to the table surface in the unconfined
space out in the shop, and the installation tool can easily slip or be miss-positioned during the crimp, resulting in a crimp
that is way shorter, and therefore not as strong, as the one that is done right every time on the tool due to ease of access.
This results in a discrepant safety cable installation on the A/P that will not withstand the minimum test forces, and cannot
be tested on the A/P without destroying it, and will probably fail in service. A perfect, maximum length with perfect tool
use, .020" safety cable ferrule crimp is only about half the (minimum dimension) required length in the spec. Therefore
every .020" diameter safety cable installation will fail the spec requirements, which are bogus for .020" diameter safety
cable, but what is worse than that is this: I have given "verbal pickups" several times to different mechanics to change out
.030" diameter safety cable installations in which the ferrule crimp was not the minimum...length, and would have likely failed
in service (ask (name), APU mechanic for proof). How do I write up a similarly discrepant .020" diameter safety cable
crimp that will fail in service? I can’t. The requirement in the spec is bogus, and even good installations fail the
requirement. But what should the requirement be? That’s what I need in the spec in order to judge whether a particular
.020" diameter safety cable crimp is OK or not. Right now, I can’t write up even extremely short crimps that are obviously
discrepant on .020" safety cable installations, unless maybe if I touch it and the ferrule falls off of the cable, as there
are no valid inspection criteria in BAC5018.
6-2-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate this, and make Boeing Engineering fix it, as it confuses the hell out of me, (name), and (name),
inspectors who haven’t totally given themselves over to the "dark side" yet. We’ve brought this up with our only
lead that hasn’t similarly given himself over totally to the "dark side," (name), asking him to look into it, but
he won’t touch it with a ten foot pole:
Once upon a time, I seem to remember, the BAC5009 spec was written to require adjustments to both engineering drawing required
torques and BAC5009 Table VII torques when the head side of the bolt was torqued, or the bolt was installed through a fay
seal, and maybe other situations. However, apparently the spec was re-written under our inspectors’ noses, and now those
adjustments are required for only BAC Table VII non-critical torques, while not being required for drawing specified
critical torques, which we have to witness. This makes no sense to us. (One of the other named inspectors) talked
to a few engineers, and they said they just pull their drawing specified torque values directly out of BAC5009 Table VII,
unaltered, and add them to the drawing only to force QA to witness these critical torques. The torque ranges are the
same. So why would the spec only require great care in ensuring that only the maximum value of the torque range is used for
non-critical BAC5009 Table VII torques in certain situations, while ignoring critical drawing specified torques
in the same situations, pulled from the same table? Answer: Ignorance. (The noted other inspector) called the "keeper
of the spec" and asked him why only the non-critical torques were adjusted in the spec in certain situations, while critical
torques were almost specifically left out. The answer? "I’m not about to tell engineers what to do with their drawing
torques." Not the type of technical answer you would expect from a head engineer of a spec is it? Maybe he just bought his
degree. Please tell Boeing to fix this problem for the integrity of all of the critical torques on the aircraft.
6-1-07 quote: This quote is also from my addendum (supplement) to
my first report:
If you think this is just a peculiarity of (my QA supervisor’s) corrupt management style, think again. (Name),
one of my QA Supervisors in Everett, had a similar tact, proving that this is just another in the corrupt BCAG QA Supervisor’s
bag of tricks. (The QA supervisor in Everett) would say that QA is only concerned about the "fit, form, and function"
of the product when he wanted an inspector to cease worrying about non-value-added FAA-approved Procedures or even drawing
requirements, if they didn’t affect the "fit, form, and function" of the product. He said that in at least one crew
meeting, and told it to me directly at least once. The time he told it to me directly was when I noticed that shop was lifting
and installing the Ailerons on the 777 by man-handling them into position, making damaging them much more likely, but saving
time, when there was an OHME (Over Head Mechanical Equipment) tool that was specifically designed to be used to lift them
into installation position. I knew that, as I used to install the 777 Ailerons when I was a mechanic in the area. There was
a cautionary general note (general note 2 of drawing (I.D. number) sheet PL revision H and prior) on the drawing
stating (something to the effect that ) "Aileron assembly to be moved by GSE hoist points only. Improper handling of Aileron
can result in serious injury and damage to the Aileron." I assume this was to protect the delicate composite part from damage
during movement from the SME (Shipping Mechanical Equipment) to installation on the A/P. The job that installed the Aileron
also made clear to use the OHME to install the part. We all, mechanics and inspectors, had been sent to classes on the 777
Program on the correct handling of composite parts to prevent damage. I asked (name), my lead, if I should write shop
up for that, informing him that there was a general note on the drawing. (My QA supervisor) was right there listening,
and angrily interrupted, telling me not to worry about it, as we were only concerned about "fit, form, and function of the
parts we inspect," and if shop wanted to ignore the drawing note, that was their prerogative.
I later understood (my QA supervisor's) BCAG QA Supervisor philosophy in dealing with my seemingly cloned other
QA Supervisors, and was "shown the light" brightly by (my later QA supervisor) in the 1/11/02 meeting, which made everything
crystal clear: all our airplanes were designed to fly without any part, including both Ailerons, so we didn’t have to
inspect them at all, only train mechanics that never seemed to want to be trained. Only Airbus’ plane’s designs,
which were much inferior to ours, required inspection, as they haven’t yet mastered the advanced design of the airplanes
that Boeing builds, that allows the airplane to fly without any part, even engine wire bundles, Ailerons, or Vertical Stabilizers.
Airbus’ designs obviously are bad, as all of their planes (which their inspection department has actually made sure
are built 100% per design, because they know they must 100% inspect them because they are aware their designs are barely within
the safety envelope when built perfectly) disintegrate in flight in only seconds when only the Vertical Stabilizer is missing.
Boeing can, however, skimp on required inspections, ignoring the FAA requirements for us to inspect all installations due
to our fool-mechanic-proof designs, thereby enhancing shareholder value by forgoing the costly FAA-required documenting and
reworking of defects that could never cause the airplane to crash anyway. Some of our non-naive customers may know all about
this, and say nothing, because they know Boeing will split the costs saved by roller stamping the required inspections with
them. Half will go to more profits for Boeing, and half will go to the customers by cheaper airplane prices. It’s a
win-win situation, unless you’re an ethical BCAG Line Inspector who gets disciplined for doing his job, an airline passenger
on a Boeing plane, or a naive airline that thinks their 180 million dollar airplane was inspected before they got it. Please
investigate this corrupt practice of QA Supervisors telling line inspectors that Policies and Procedures, such as the FAA-approved
BCAG Quality Manual, are only guidelines. Talk to (one of my fellow line inspectors). If the 777 Aileron incident bothers
you as it bothered me, please check into it also. They finally changed the drawing, making their unwise method of installing
the Aileron by manhandling it at least not illegal, by releasing ADCN 7 of the noted PL that stated that use of the tool was
only required when removing the Aileron, some two years after my scolding from (my QA supervisor in Everett).
I found out, by reading your Order 8120.2b section 141, that our QA Supervisors are lying to us about this subject. Of
course that doesn’t surprise me in the least. The noted section states: "(Quality Control or inspection system) data
may include a quality manual, procedures, policies, standards, instructions, and/or processes." So much for truth in QA Supervising
at BCAG.
5-31-07 quote: This quote is also from my addendum (supplement) to
my first report:
QA Supervisors tell line inspectors that Policies and Procedures, such as the FAA-approved BCAG Quality Manual are only
guidelines, and that working to them is unnecessary. (My QA supervisor), in effect, told me this in our 1/11/02 meeting, but
he said it directly to (name), line inspector. He told (name) that statement, explaining it by saying that "all
we do as QA is make sure that the product, when it goes out, conforms to the drawing." Except that, after my 1/11/02 meeting,
I knew that (my QA supervisor) was only lying by saying that, to keep (name) from writing planning pickups
or to document some other nonconformance he didn’t want him to write. How can you inspect the product for conformity,
our only job, if (my QA supervisor)doesn’t want us to inspect, only train, and states that looking at the drawing
while inspecting is unnecessary? (My QA supervisor) told me the unvarnished truth about the way the unwritten BCAG
Quality System is supposed to work in that meeting. He tried to turn (name) over to working to this illicit System, in
effect, by his lie, which he told only because (name) and him were out on the production floor when he said it, and people
could overhear him if he gave (name) the real System like he gave me. Same effect though. He tried to get (name)
not to follow the FAA-approved procedures, by telling him only to be concerned about the conformity of the product, not the
plan. He hoped (name) would not have time to inspect to the drawing, as that part was a lie to divert (name’s)
efforts away from non-value-added things, like documenting nonconformities. (My QA supervisor) also used this method
occasionally in our crew meetings, usually when someone brought up the sad state of our planning. He would then say, "All
we do as QA is make sure that the product, when it goes out, conforms to the drawing," and that would stop any thought of
the non-value-added writing up of planning by us line inspectors.
5-30-07 quote: This quote is also from my addendum (supplement) to
my first report:
Our QA Department let’s shop work tags that have not been approved yet. That makes that rework illegal rework. Case
in point, which I reiterate:
On 1/13/02, a Sunday overtime day. I told (my QA Lead) that an NCR, (number) had not been approved yet,
and was in fact still enqueued in the next task after initiation, QA approval, as (name), the designated QA MRB person
that weekend, had never been called from home yet to do his function. The NCR didn’t even have a disposition at that
point. I told (my QA Lead) that the mechanics wouldn’t be able to legally work it until it was approved or
had a disposition, even though the disposition would probably be the same as the prior unit on the NCR, which would hold up
installation of the inlet on the (747) pos 4 engine. He said to tell the mechanics that they could work it, and to tell
them it was him that said it was OK. He then said "I’ve been in jail before, I guess I can go to jail again" if someone
called him on it.
Another example: NCR (number) on a 767 EBU (Engine Build-Up) mislocated vendor nutplate on a W/B (Wire Bundle)
bracket. I overheard (a fellow inspector) complain to (the Manufacturing Lead) that the shop working
the tag before it was approved, like they had done on the noted NCR, would bite us during ACSEP time. (The Manufacturing
Lead) said that (his supervisor) had authorized them to work it before the disposition was approved.
Another example: On NCR (number), shop made up their own unauthorized disposition, and instead of removing and replacing
the link of the engine mount like the NCR stated, they replaced the whole engine mount without the required revision to the
tag to authorize it.
The above first example emphasizes our QA Management’s inability to perform their QA function with any integrity
at all, as Manufacturing’s God-like status and requirements at BCAG, such as delivering the product on time, under cost,
and with no travelers, trumps any of our QA requirements, even those of you, the FAA. Please investigate this incident and
interview others to find more. Please document your findings.
5-29-07 quote: This quote is also from my addendum (supplement) to
my first report:
Check in the engineering office areas for parts that are not identified as test/sample parts that could find their way
out into production. I’ve heard there is a stash of them on a window-sill on the third floor. Don’t stop there,
look in all of the desk drawers and locked cabinets also. You actually may save the Company money by doing this, even considering
the costs to the Company your finding will entail, as some of these parts, even though it may be near impossible to tell their
inspection status by looking at them, may end up being perfectly good production-quality parts that we can install on the
engines, APUs, or struts (sarcasm intended).
5-28-07 quote: This quote is also from my addendum (supplement) to
my first report:
The rework NCRs I wrote prior to abandoning writing pickups for such missing inspections (per the QOI requirements) at
management direction in order to perform the process per (my QA supervisor's) undocumented method of writing IRCRs
(Inspection Record Change Requests) for such planning errors, which "support the delivery schedule" by not holding up the
delivery of uninspected critical torques on jet engines...(NCR and IRCR list)...This is being written on 4/16/02, two days
after the above. Well, it really hit the fan yesterday (monday). (My QA Lead) brought me the IRCRs I had written
and told me that I needed to mark up a copy of the jobs to tell QA Planning where to add the buyoffs and attach them to the
IRCRs and return them. This is even more "non-value added" to the requirements of our IRCR QOI, 060-002. There is no such
requirement in the QOI. QA Planners are supposed to decide where and if a buyoff gets put on a job, and should be theoretically
capable of doing that most basic part of their jobs. And I had put on at least one of the IRCRs exactly where on the job the
buyoffs were needed. (My QA Lead) still told me to attach...marked up copies of the jobs to even that IRCR. Naturally,
I agreed to do as directed, after I had finished an NCR I was working on. (My QA Lead) was O.K. with that. (My
QA Lead) also told both me and (name), the other line inspector working in the area, not to write pickups as I had
done to hold the jobs open while the IRCRs were being processed. He said that, on the ones I had written, we were supposed
to witness the torques, document that we witnessed the torques on info pickups, then buy all the pickups off so they wouldn’t
hold the jobs up. This was all per (my QA supervisor's) direction, I believe. (My QA Lead) also said that (my
QA supervisor) was livid that I had "held the jobs hostage" by writing the info pickups on them to keep them open. That
was not anything (my QA supervisor) told us to do. He had just wanted us to write the IRCRs and forget about them, and
forget about the jobs having to be changed. (My QA supervisor) may sign them and pass them on to QA Planning, or he might
not. QA Planning, if they get them, may process them this year, or not ever. The IRCRs I had written Friday had never been
signed by (my QA supervisor) and submitted to QA Planning in an expedited fashion so that the jobs would be revised in
time to be finished before second shift Monday, when the EBUs were supposed to ship. He had just held them until half of Monday
was over and then had (my QA Lead) kick them back to me under some bogus pretense of marking up jobs. (My QA
Supervisor) was evidently getting some pressure from shop to get the situation resolved. I believe shop was just going to
travel the pickups, making me out to be the bad guy for holding those jobs up with the pickups. I heard later that (my QA
supervisor), (name), our Director, (another QA supervisor) , and maybe (even another QA supervisor) were
having heated discussions on the subject of holding the jobs up for processing of the IRCRs. The gist I heard of these discussions
from (the other 777 EBU line inspector) and (my QA Lead) was that these meetings focused on me being an
"asshole" by doing what I did, and the lament of "how could he do such a thing," and what they were going to do about it. (One
of the other QA supervisors) was asking why we were writing up planning at all. As I went about continuing to inspect
in the area, a steady parade of people came up to peruse the jobs on the engine I was working that I had hung pickups on holding
them open until the IRCRs were processed. (Name), QA Lead, was one, and he was not even lead of the 777 EBU area, (name)
was. (One of the other QA supervisors), whose function right now I am not sure about, as he said (another QA supervisor) was
now the QA Planning Supervisor, also came up. I told him what (my QA Lead) had said that us line inspectors were
supposed to do--witness the torques, document it on pickups, and buy the pickups off so the jobs would not be held up. He
agreed that that was the plan. I talked to him about the subject of what we were supposed to do if we found witness torques
on the drawing in the future that were not on the plans. He said we should do nothing, as the BCAG torque witness plan was
still not complete. I told him that I had heard that BCAG was supposed to have all the plans in compliance to have QA witness
all drawing designated torques at the end of last year. He said that was not true, and that there was no compliance date.
I told him that I was just doing what (my QA supervisor) had said in our crew meeting that we were supposed to do
(less the writing the pickup to hold the job open part). He said that management owed me an answer to the IRCRs and that the
issue would probably be raised at the Quality Council.
Anyway, later that day, (my QA supervisor) came up and got the IRCRs from me. He asked me if I had witnessed
any of the torques that I had written up the lack of inspections for on the IRCRs. I said no. Shop had not grabbed either
me or (the other 777 EBU inspector) to do that at that point. Shop didn’t have to either, ever, as no inspections
were yet added to the jobs, as the IRCRs were not yet processed at that point to add the inspections to the jobs.
Today, I found out through (my QA Lead) that (my QA supervisor) had bought the above noted rework NCRs off
stating that the IRCRs had been turned in and were being worked. (My QA Lead) also said that the IRCRs were still
sitting on (another QA supervisor's) desk and that she was refusing to work them. The EBUs had shipped last night. (My
QA Lead) told (the other 777 EBU inspector) and I, that for any jobs on the new unit we were starting today
that were missing torque inspections, to write an info pickup documenting we witnessed the torques, then to write an IRCR
to get the inspections added to the job and hold all of these IRCRs until the EBU build was complete, and then turn them in
all at once. It seems QA lacks the guts any more to hold any jobs up from being bought, even for lack of critical torque inspections.
5-27-07 quote: This quote is also from my addendum (supplement) to
my first report:
Ask QA planning how they audit M.E. (Manufacturing Engineering--the ones who write the job paperwork plans that QA Planners
are supposed to insert inspection points in at the appropriate locations) to ensure that the as-planned = the as designed.
I’m sure you’ll find they don’t. M.E. has no checks and balances on the quality of their essential work
due to our QA Planning department’s incompetence and/or corruption. There are no checks out on the floor either with
the line inspectors, because we are discouraged from writing planning pickups constantly, as (my QA supervisor) did
in our 1/16/02 crew meeting, as QA Planning does by not processing IRCRs (Inspection Record Change Requests--the form that
must be filled out to get inspection points on jobs added, deleted, or modified) in a timely manner or at all as they did
for the 1/7/02 engines, and as M.E. does because they resent a lowly line inspector making them do their job, as our QA planning
department never makes them do them.
This is reiterated from item 85 below due to its relevance to this item: This just in: I have been working 777 EBUs (Turbofan
Engine Build-Ups) lately, and lo and behold, the 777 plans are missing many witness torque inspections, some four and one
half months after your rumored "drop dead" date to have such inspections implemented at BCAG. I started to write just rework
NCRs on these missing inspections, as our QOI 130-020 states we are supposed to do, and then I routed them to M.E. Planning.
I talked to them and they said they were O.K. with that procedure, and that they would route them to QA Planning if required.
However, after I had written three of them, (Name), my lead, brought me printouts of a few of them and told me to write
IRCRs per (my QAsupervisor's) direction for those NCRs and give them to him so he could get (my QA supervisor) to
sign them and take them to QA Planning. This process is totally extra and "non-value added" per our QOI. I suppose my rework
NCRs will now be roller stamped so they do not hold up the jobs and the EBUs will therefore ship without the required torque
inspections. After that episode I have been just writing IRCRs for the missing torque inspections as directed, however I have
been doing an additional process I was not told to do--I am writing info paper pickups to hold the jobs open until the IRCRs
are processed. I suppose those will end up being roller stamped also.
5-26-07 quote: This quote is also from my addendum (supplement) to
my first report:
I read your order 8120-2B section 26.b.(1) which requires that you let the PC holder know within 30 days of receipt if
changes to QC data submitted will be acceptable or not. Too bad it doesn’t work that way internally within BCAG!
This just in: In our All Hands meeting with (my QA Director) around the 25th of February, (the office
QA supervisor) said that PSD was going to implement the QACR Tracker system Auburn uses to address peoples concerns about
the black hole process of submitting QACRs. I’m sure that my question to (BCA's V.P. of Quality) about our
QA Manual and its lack of being updated per submitted QACRs was the impetus for this. This may fix the process in the
future, if our QA Supervisors decide to enter them in the system and not round-file them prior to entering them. This does
not absolve them from past "crimes," however. Please still investigate. My submitted QACRs’ lack of being processed
is evidence of the fact of my removal from the production floor to save the Company the costs of fixing the valid defects
I, the inspector who worked to the FAA-approved QA Manual, would find. It is also evidence of our QA Management’s corruption
and their efforts to sabotage the Quality System, and not improve and strengthen it, as my QOIs would have done. My submitted
unprocessed QACRs are also Prima Facia evidence that I was removed from the production floor because I attempted to
inspect the product, and did not simply roller stamp the paperwork to state I did, as my management wanted me to do. If I
was really "sent to the office" to review and update QOIs, then my QACRs would have been processed, or at least rejected
and returned to me.
Update: Since I have included alot of Exhibits in this report, I figured "what the hell"--see Exhibit AS for copies of
the QACRs listed in the first section of this item that I said I had copies of.
5-25-07 quote: This quote is also from my addendum (supplement)
to my first report:
Please investigate our QACR (Quality Assurance Change Request) processes at
PSD. See if you can find my QACRs...(QACR number list)...I have the green copies of these QACRs at work, please come get them
from me if (my QA supervisor) says they don’t exist, along with the disk copies of my proposed QOIs. I also
submitted the following QACRs, which I didn’t save the green copies of and so just have partial numbers of what I think
the QACRs were...(QACR number list)...See Exhibit AR for a copy of the letter I turned into (my QA supervisor) on
(or) about 5/22/00 with this QACR and the four above QACRs. A printout of the Process Monitoring QOI I submitted follows the
letter in the exhibit. I completed this big project in only about three weeks without help. That is much shorter than it seemed.
It must seem such when you are in the real Purgatory.
There might be more besides the above QACRs, that I submitted. I have disk copies of all of the work I did on revising
our QOIs, some of which I never completed and submitted. I know it was not only me that was stifled in trying to get our QOIs
up to snuff, even though my QACRs were not really wanted by my management, but only were "make-work" to keep an ethical inspector
that consistently documented defects per our written QA Manual off the production floor. I know that (name), QA Validater,
and (name), line inspector, also submitted QACRs that are still sitting on someone’s desk or round-filed. I have
a copy of the one (the QA Validater) submitted, which was to make suppliers take responsibility to determine if
a retest was required on their products reworked at PSD. Please investigate the QACR process and find out why it is so screwed
up and our management treats them like the plague. I think you’ll find the reason is this: our management is a clone
of Mfg Management, and they don’t want a working Quality System. That would only slow the production line down from
it’s present speed, which was never designed to allow line inspectors to do their work per the FAA-approved BCAG Quality
Manual. Please write us up for not maintaining our manual, deliberately, to be up-to-date with current BCAG and FAA Procedures.
5-24-07 quote: This quote is also from my addendum (supplement)
to my first report. This section documents one of the reasons even some of Boeing's critical production processes (such as
the torquing of the bolts that hold the airplane together at the points that require the greatest strength connections) really
are so ill defined that I had to ask the FAA to step in and define these critical processes for the safety of passengers,
as noone else there did, for whatever reason (reading this site I think you can infer some reasons yourself that would
be accurate). However, the FAA did not care about this item, as passenger safety (as I've seen) comes after protecting Boeing's
and their own image, so they never investigated it and had Boeing fix this problem:
See how this is worded, or not worded, now in section 8.1.6. of BAC5009,
Torque Wrench Adapters and Extensions. The spec has been constantly been revised to remove any reference to critical drawing
torque requirements. Please make sure that, when they remove/removed these requirements for drawing torque application requirements
from the spec, that they add/added them to each drawing critical torque callout. I know of no cases where they have. Thus,
they have been diluting the accuracy of the application of critical torques, while making non-drawing specified torque application
more technical. Make sense? Right, it doesn’t.
5-23-07 quote: This quote is also from my addendum (supplement) to
my first report. This section documents one of the reasons even some of Boeing's critical production processes (such as the
torquing of the bolts that hold the airplane together at the points that require the greatest strength connections) really
are so ill defined that I had to ask the FAA to step in and define these critical processes for the safety of passengers,
as noone else there did, for whatever reason (reading this site I think you can infer some reasons yourself that would
be accurate). However, the FAA did not care about this item, as passenger safety (as I've seen) comes after protecting Boeing's
and their own image, so they never investigated it and had Boeing fix this problem:
Is this (setting the torque wrench setting back to the lowest calibrated value
when the wrench is not in use for a time) why they have us set the torque wrenches to 20% of the torque range between uses,
because that is the lowest calibrated value of the wrench? What gives? Why don’t they just come out and
say in the spec, "Do not use the bottom 20% of adjustable torque wrench setting ranges--that portion of the range is
not calibrated and cannot be used on torques that require calibrated torque wrenches?" Or why doesn’t Cal Cert Vibro-Engrave
off the lower 20% of the torque wrench range, obliterating it, as that part of the range cannot be calibrated? Your guess
is as good as mine. Process Specification Engineers and Cal Cert must (similarly to QA Management) not care much if we put
out nonconforming product, as long as we make EPS (Earnings Per Share) targets. They should at least train us about this,
and if it is O.K., give us the reason why we can use the uncalibrated part of the torque wrench to build (safety critical)
product.
5-22-07 quote: This
quote is also from my addendum (supplement) to my first report. This part of my report starts detailing some of the many massive
violations of Boeing's quality system I didn't have time to report in my original report. My report, of course, did not
detail every violation going on at Boeing in violation of FAA requirements that was possible for me to document,
as I documented many times in my report that these noncompliances, though vast and systemic accross BCA, were only a
symptom of the real root cause of those noncompliances, and that I wanted them fixed, but what I really wanted fixed
was the root cause of those innumerable noncompliances--the corrupt BCA QA management that purposely let them happen
to pad their own merit bonuses and Boeing's bottom line. To do this, I told them, it would be necessary to file charges
against individual managers and convict them to long terms in prison. Fining them personally would not work as a motivator
for the remaining corrupt QA management that was not prosecuted to begin to really do their critical jobs. Boeing would
just pay those fines for them, just as Boeing paid a Boeing pilot's fine imposed on the pilot by the FAA (the
fine was about $30,000 I believe). This was common talk at Boeing Flight Test where I was banished for the crime
of trying to actually inspect critical airplane components--namely the engines that prevent them from being very heavy
gliders, and the struts and strut systems that interfaced them to the wings. Additional common talk at that time was what
really went on in the crash of a restored Boeing aircraft (destined for the Smithsonian) in Elliott Bay next to Salty's on
Alki, a local restaurant normally not accessible by such aircraft, and how the Boeing manager Flight Test personnel
thought was responsible for the crash got away scott free, even keeping the job he had had before the crash. Anyway,
back to the subject--I told the FAA (not in so flowery language) that, after a few of these corrupt Boeing managers were
thusly imprisoned, the prospect of being someone else's "bitch" in prison would make the remaining managers think twice
before they followed their manager's wishes and told their inspectors to rollerstamp inspections as done when they were
not done, and otherwise ignore FAA approved quality procedures in the hopes of getting a big bonus at the end of the year
and/or to set themselves up for a promotion. The other essential step I told the FAA would be required to restore the Boeing
quality system would be to pull BCA's PC, shutting down production until the quality system was restored and rollerstamping
inspectors were trained to actually inspect instead of rollerstamp. However, as the FAA and Boeing are not independent
as required, but instead in effect share the same bed as so many others have also observed, in the end the FAA chose to let
the corruption I reported to them continue ad infinitum, at all costs, because ending that corruption would interfere
with their job opportunities at Boeing after their retirement from the FAA, as well as expose their own complicity in
that corruption:
New items to investigate that I didn’t have time to document in my prior letter:
34. Please investigate the certification
of adjustable torque wrenches at BCAG. We are told to reset the wrenches at the engraved stop line or at 20% of the wrench
capacity to relax the spring between uses so it does not take on a set and affect the accuracy of the wrench. I believe that
we were told not to use the bottom 20% of the torque wrench range when I worked in the Military Airplanes Division, and I
have a Tip Sheet (I.D. #), Exhibit U attached, from Boeing Philadelphia Military Aircraft and Missile Systems Goup, that states
in item 1 to not use the bottom 20% of the torque wrench range because that part of the range is impossible to calibrate.
If it is impossible for them to calibrate, then how would it be possible for BCAG to calibrate? Also see the Exhibit V "Torque
Wrench Checklist" Form (I.D. #) item 4, which states to not use the lower 20% of impulse feel torque wrenches and
the lower 25% of screwdriver type torque wrenches. This is from the Boeing Guidance Repair Center. That requirement is apparently
from USAF spec (spec number). I was told by someone by email from the BCAG Torque Team that the whole torque range is calibrated
and can be used, but cannot find this documented anywhere (see the Exhibit W email). We’re not supposed to operate by
word of mouth in the FAA-approved BCAG Quality Manual. Please investigate, and follow the documentation to arrive at a conclusion,
do not believe simply what they tell you. Have the Cal-Cert lab prove to you that they certify every adjustable torque wrench/screwdriver
to within the (percentage) maximum error allowed by (spec I.D.), for any setting that wrench/screwdriver
can be set at, including the minimum and maximum settings indicated on the tool. Some of the line inspectors at PSD, including
me, have caught mechanics trying to set torque wrenches at ranges outside of the indicated ranges on the torque wrenches (by
setting them to the minimum or maximum setting and then backing off, or ratcheting up the graduated handle, respectively,
until they have rotated the handle the right amount of graduations to either subtract from or add to the indicated range and
arrive at the torque value they want) during torque witness inspections because they didn’t have a wrench with the correct
range immediately available, but that is another story (some of our "less competent" inspectors probably just let them do
it. I’ve only heard about the cases when inspectors made them stop it, not the other way around, because the type of
inspectors who wouldn’t question it won’t talk for obvious reasons). That last aside emphasizes the requirement
to be very specific and unambiguous in specifications, because if you leave something out because you think that nobody would
ever be stupid enough to do that prohibited action, you will be proven the stupid one. The maxim that if you can think of
something, however outrageous it is, means that it has probably been actually done before, applies with mechanics as well.
Some inspectors and QA Management occasionally speak of not documenting processes, as we’ll just do it with "common
sense." The only problem with that is that one person’s version of "common sense" rarely matches another person’s.
It should be common sense not to set a torque wrench at a setting outside the minimum and maximum indicated settings, right?
Wrong. It happens with BCAG mechanics at PSD, where they work on some of the most complex machines mankind has yet built!
Anyway, If BCAG’s use of the bottom 20% of the torque range is wrong,
then write us up. Hundreds of thousands of improperly torqued bolts will be the result of this if BCAG cannot prove they certify
the entire torque range, as other Divisions are unable to do. Why did I not press this with my management? I think all my
prior writings give you the answer. If I did, I would now be holding up a sign saying "God Bless" on a freeway off-ramp, trying
to support my family. If my suspicions are proven right on this, I hate to say it, but please revoke our PC, as it proves
that not only Quality at BCAG is corrupt in overlooking this, but that our engineering specifications (like spec I.D.) were
written by incompetents. Everything may be fine with this, but inquiring minds would like to get a real answer on paper, not
just a "yes, the entire range is certified" verbal answer from afar without any documentation references to prove it.
This just in: I found a Flight Test Cal-Cert specification that seems to
prove my suspicions right. See Exhibit X. In the "Performance Specification"
section of the (I.D.) spec for the Snap-On torque wrench, it states that it only applies from 20% of full scale, to full
scale, on the wrench. I couldn’t find the other BCAG Cal-Cert specs on the web. Please get them, then write us up for
building products (doing critical and BAC torques) with uncertified equipment.
5-21-07 quote: This quote is also from my addendum (supplement)
to my first report.
Placards: See Exhibits K and L for our management’s direction not to worry about UI/UT parts that require placards
and rubber stamps. Also see Exhibit T for an email that shows even the shop lead at the time, (name), requested all jobs
be revised to have an inspection to verify the part was assigned to the correct unit and to have the unit tag (placard) removed
and attached to the O&IR (job paper) for retention in Completed Records. I guess QA Management’s desire to streamline
the production flow and remove all required inspections and requirements (like rubber stamping unitized parts with the unit
I.D.) supercedes even shop’s desires to do it right, not just what gets you the greatest merit bonus.
5-20-07 quote: This quote is also from my addendum
(supplement) to my first report.
Of course, the QOI still states that we are supposed to verify they (fitted parts tags) are filled out correctly, even
if we don’t have to stamp them, and any inspector worth his salt should know that they should be attached to the job
that reinstalls the items they were attached to, even if our QOI doesn’t specifically state to do that. It also doesn’t
say not to do that, so it doesn’t conflict with the various (documents), and QOIs of Divisions that are not as
hosed as ours, that state to attach them to the jobs. I should have changed the QOI to have us stamp all Fitted Parts Tags,
considering the fact my revision never was approved. Per the QACR (Quality Assurance Change Request)process, (my QA supervisor) is
supposed to either sign and submit the QACR to you, tell me what he thinks needs to be changed and return it to me for revision,
or reject it altogether, in a reasonable amount of time, which over a year and a half isn’t. Also note, on fitted parts,
that our plans are as nonconforming as our Quality System. There should be a notation in the parts list of the plan that removes
the fitted part with the "F" coded part number, bracketed as a non-issued part, along with an inspection operation for QA
to verify the fitted part tag is filled out correctly, the part is marked with the fitted part "F" suffix code after the part
number, and the part is rubber stamped with the unit I.D. (The inspection operation will not say all of that, but that is
what the inspector should look at when such an inspection exists. This inspection operation exists in the...canned note document.)
Then the job that reinstalls the part will have the same notation in the parts list of the "F" coded part number, bracketed
as a non-issued part, along with an inspection operation for QA to verify the fitted part tag is for the correct unit and
part number, and to remove it and staple it to the job. There should also be a "OK to Close" buyoff for the parts if the reinstallation
of the parts will close an area off to inspection. When I was in the 747 strut area, the plans all were correct, with my help,
if I remember right, except for the fitted part reinstallation inspection. The same plans have probably regressed to their
former sad non-compliant state to "facilitate the delivery schedule" in my forced banishment to my "make work" job. Anyway,
check out job (I.D.) on 777 struts for an indication of how out of compliance with planning requirements our fitted
parts jobs are. I don’t believe any of the fitted parts that are removed are listed on the parts list with their "F"
codes for shop to fill out the Fitted Parts Tags correctly with, as they rarely, if ever, fill them out. Also, the fitted
parts inspection is missing for the parts that are removed in operations 20, 30, and 40. Of course, this plan is not alone
by far. All of our plans are probably noncompliant with planning and QA planning requirements for fitted parts. Check them
out. I think most of these plans are the strut uncrate and crate jobs, but there are others too in the strut shop and probably
a few on the engine lines. All of these plans that are missing the required inspections, of course, don’t bother our
QA Management. Quite the opposite. The fewer inspections, the more money the Company saves, and the higher their merit bonuses
and chances for promotion will be.
This just in: I was right! "The same plans have probably regressed to their former sad non-compliant state to ‘facilitate
the delivery schedule’ in my forced banishment to my ‘make work’ job." Yep. True, it was done, just as expected.
They deleted the fitted parts requirements from job (I.D.) (747 strut receival job, I believe).
5-19-07 quote: This quote is also from my addendum (supplement)
to my first report.
Fitted parts. Also verify that the fitted parts are rubber stamped, if practical (if the part is big enough, not if the
shop says they don‘t have the time), with the fitted part suffix as shown on the plan, and the A/P number. See our fitted
parts QOI, which is the lamest in the Boeing Company because of our QA Department‘s attitude of "if we don’t put
details in, we won’t have to do all that non-value-added work of pretending to comply with them for a few weeks around
ACSEP time." I believe we are the only Division that has the inspectors inspect the Fitted Parts Tags without having to stamp
the tag. That was most likely added to allow the QA Department cover when the FAA finds shop doesn’t make them out.
Check completed records for the jobs that re-install the fitted strut raceway, access panels, blankets, and fairings to see
if the Fitted Parts Tags were stapled to the jobs. You won’t find any. Our fitted parts QOI 060-014 does not say what
to do with them upon removal, as that omission allows us not to make them out at all, even though we should. They should be
stapled to the jobs, as my revision to the QOI states. Ask (my QA supervisor) where my "make work" QACR 153965 is.
Read my QOI revision (Exhibit S, attached). It is the way our QOI should be, except I left the section that allowed us not
to stamp the Fitted Parts Tags virtually unchanged, as I knew it would never be approved if I changed it to have us stamp
them.
5-18-07 quote: This quote is also from my addendum (supplement)
to my first report.
Supplier Line Checks. The same vendor rep, (name), that asked me if he could
rework the discrepancy on the last of the three noted NCRs, (NCR number), to avoid an NCR, asked me today, 1/29/02, if he
could do the same thing on the loose fastener I was going to document on one of his T/Rs I was receiving. I told him I had
to write the tag per our procedures, and wrote NCR (number) on the loose screw.
See Exhibit R for an email that proves suppliers do line checks at PSD! You now
have evidence in hand. Please write us up.
5-17-07 quote: This quote is also from my addendum
(supplement) to my first report.
Audit of our D6-1979-3 QA Manual: Many of our IDGs, generators, and hydraulic
pumps installed on the APUs and engines are attached with a QAD ring, and the fasteners attaching the QAD to the gearbox are
not visible after the installation of the IDG, generator, or hydraulic pump. Some of these items have "OK to Install" inspections
and some do not. They should all have them, as inspection cannot view these areas after the IDG, generator, or hydraulic pump
is installed. You may want to go farther, and require an "OK to Install" on all IDGs, generators, and hydraulic pumps, even
those without QADs, to inspect the splines, o-ring installation, and areas of the IDG, generator, hydraulic pump and/or gearbox
that will be covered when the item is installed, as that part of the gearbox is covered when the engine is received. I don’t
know how specific your "items must be inspected at stages of assembly where valid conformity decisions can be made" FAR is
intended to be. Please educate us, and make sure FAA requirements are included in our, now missing, Closure Inspection QOI.
See the attached Exhibit P Closure Inspection QOI that I turned into (my QA supervisor) to correct this problem,
which he has apparently round-filed because it does not fit in with his BCAG QA Supervisor’s "we’re here to train
mechanics, not inspect" philosophy.
5-16-07 quote: This quote is also from my addendum (supplement)
to my first report.
Please check the last years tags for line checks that weren’t done. I believe you’ll find lots of cases where
we allowed defects to escape to improve our bottom line. I know I would always ask for a line check if I thought the discrepancy
would exist on other units. I believe that very few of those requested line checks ever occurred, like on NCR (number)
on 737 classic EBUs, referenced in the Exhibit O email.
5-15-07 quote: This quote is also from my addendum (supplement)
to my first report.
And I’ve been told constantly you can’t request a line check for a delivered (delivered to Prime Division)
unit! Here it is in black and write in the manual you approved. Of course, what you want does not matter to us at BCAG, unless
you write it down in a finding, and then we only fix it minimally enough to get you off our backs, then we go back to our
old "damn the FAA-approved manual, let’s do what ‘creates the most value’ for the benefit of our, so far
elusive (and probably forever so) Sharevalue payout." Of course, the non-union workers in the office got about an extra ten
days pay each of the last two years for similarly throwing all their ethics out the window in favor of doing (or not doing,
as the case may be) what saved the Company the most money, however regulatory required or safety related the requirement they
"altered or didn’t do to support the bottom line target" was.
5-14-07 quote: This quote is also from my addendum (supplement)
to my first report.
(Our procedure on Line Check initiation), states NCOs (Non-Conformance Orders) are initiated to do line checks. See Exhibit
O for an email from one of the QA MRB people, (name), stating it can’t be done. Also see the Exhibit R email for
further quandary inducing banter on the subject. If you ask any two CAU or MRB Coordinator people at PSD what the line check
process is, they’ll probably give you different answers.
5-13-07 quote: This quote is also from my addendum (supplement)
to my first report.
Line checks on NCRs: You might want to check if the escapement (wrong strength/size safety devices on the RM052 POS 3 engine)
I notified CAU of on the Exhibit Q email got fixed by notification of the airline. I tried to get it fixed by going through
the appropriate channels before it delivered, but our CAU department allowed it to deliver with the noted discrepancy.
5-12-07 quote: This quote is also from my addendum (supplement)
to my first report.
You may want to peruse this PRO (Procedure) further in your deliberations on this
subject. Since no installations at PSD have been made "fully operational" yet, and other limitations noted in this
PRO, I doubt we should be using the AMM at PSD to rework/repair items. But you’re the judge on these matters, so please
judge and decide what we should be doing, as opposed to what we are doing.
Back to the list of things to clarify for us:
C. Are Boeing mechanics allowed to rework vendor items? We do. I believe our repair station certificate doesn’t allow
us to repair vendor parts, so why can we do it on the production line?
D. Whether we have to do the work per AMM, CMM, or vendor repair station, what in-process inspections do we need on the
NCOs? There seem to be no required inspection roles in the AMM, like torque witness inspections we have to do in the factory
on Boeing built items. The same with the CMMs. Maybe that is because the mechanics and inspectors who work to the AMMs and
CMMs are A&P certificated--the vast majority of PSD mechanics and inspectors are not. I don’t have any idea what
we would need if the vendor repair station covered the work.
E. If we work to the AMM or CMM, then do the mechanics and inspectors have to be A&P certified like at the airlines?
What certs do we need if it is vendor repair station work. I assume, if it was vendor repair station work, that the vendor
repair station manager would have to buy off the work, not us. If that is the case, then many of the vendors at PSD should
have their repair station licenses revoked, as I’ve seen the quality of their work. I guess they get what they pay for,
as the vendor mechanics only are paid about half of what BCAG mechanics are paid, I understand, with few, if any, benefits.
I guess it beats frying burgers for a living, though. I would expect the public would like higher paid workers, like we are
at Boeing, working on the airplanes they fly on, if they thought all else was equal, and didn’t know the things those
high paid workers do, or more accurately, don’t do, that I’ve recounted to you...
5-11-07 quote: This quote is also from my addendum (supplement)
to my first report.
Another problem with vendor rework is the cannibalization of engines and possibly...struts for parts to use
on other engines and struts, making "Hangar Queen" engines in effect. I really doubt all of this cannibalization is on the
up and up and done with the required paperwork (including removals) and retests. Please investigate, find out which engines
were cannibalized, and make sure all the paperwork shows the correct process was followed. I seem to remember a 737 engine
a few years ago that had a spinner and/or fan blade(s) stolen, I mean cannibalized, for use on another engine. When new parts
were put back on the cannibalized engine and/or the cannibalized parts were put on the engine that needed the parts, one,
or both of the engines ran out of balance because some required balancing was not done prior to engine run/flight. I don’t
know how they fixed the problem. I don’t know if they told you of this episode, or not. If not, please consider this
your notification.
During your investigation of this item, please clear up a problem that we have no intention of clearing up,
as we don’t have a clue about it. When a part, engine, generator, T/R, APU, etc. is rejected at PSD, what do we or the
vendor rework it to? It is the undocumented "RTS (Return to Supplier) in Place" system at PSD. Please make us document
it, and document it correctly (See exhibit N for an email I got from (name), our resident expert on this undocumented
process). Please answer the following questions for us we were too embarrassed to ask you, as they would prove just how out
of bed we are about what we do:
A. (Our QA supervisor) said once in one of our crew meetings, that even if we remove and replace
a bracket on a functionally tested item like an engine, then even that limited rework would invalidate the vendor test and
require a retest. Is that true? If its so, then please write us up for the many retests we have missed, as (our QA supervisor) doesn’t
"walk his talk" on this subject. And if it isn’t so, please give us the FAA-approved guidelines on what kind of rework/repair
of vendor items would require a retest.
B. Many of our tags say to "rework per AMM (Airplane Maintenance Manual)." Is this correct? I was under the
impression that the AMM was only used after the airplane was in service. When does a vendor item require rework per the AMM?
After delivery to the airline? Or after delivery to Boeing? I believe we take the position that it is on delivery to Boeing,
but to say PSD does anything at all with consistency is sacrilege to our beloved all "over the map" ways. If we are supposed
to rework these items per the AMM, a Boeing document, then doesn’t that conflict with the name of this undocumented
process, "RTS in place?" We are allowing the vendor to do the rework at PSD, or doing the rework for them at PSD, to simply
avoid the tax implications and production disruption that sending the part back to the vendor would entail. So shouldn’t
the work be performed at PSD to the same vendor drawings, specs, and functional tests that are used at the vendor, to which
they would have to work if we had sent it back in "as received" condition, without ever being installed on the airplane? I’m
thinking we should not be doing this work to our AMM, but to vendor drawings, specs, and tests, or maybe to the vendor CMM,
as the part is uninstalled. Or should the vendor be repairing these parts per their repair station certificate, if they have
one? On NCR (number) on a 767 T/R (Thrust Reverser) blocker door replacement (see item 8 of my original letter), I requested
a vendor Removal Record for the rework the vendor had done per our AMM. The unstamped copy had the (vendor) repair station
certificate number on the form. Please set us straight on this, permanently.
5-10-07 quote: This quote is also from my addendum (supplement)
to my first report.
This is being reiterated from a later section due to applicability: Sometimes our Liaison Engineers are so clueless that
writing a revision to get a disposition fixed is a useless endeavor. Check out (NCR number) revision 2, I believe.
The discrepancy was on two vendor clamps C/T a vendor tube that had damaged cushions. The revision 0 disposition stated to
remove and replace the clamps per AMM (Airplane Maintenance Manual). This tag epitomizes the danger of accepting vendor rework
per the undocumented "tribal knowledge" PSD way, of just making sure the vendor signature is attached to the tag, without
any inspection of the rework itself. I did my usual inspection of the rework. I got the AIPC (Airplane Illustrated Parts Catalog)
pages from the Boeing Maintenance Document website that showed the vendor clamp installations. I noticed on the AIPC figure
part number listing that under the vendor tube P/N and/or the vendor/clamp P/Ns, that only a (engine vendor) MM (Maintenance
Manual) section was listed. No AMM reference was listed. That was why I could not find the removal and replacement instructions
for the clamps and tube in the AMM--they were not there--they were only in the vendor MM. I looked at the lower replaced clamp
and it was fine--per AIPC, at least. Then I looked at the upper clamp that was replaced. The horrific scene that met my eyes
justified in spades why I inspected vendor rework when other Boeing inspectors did not. Even though the airplane was not in
all likelihood going to crash because of this one poorly installed clamp, it made you wonder what other more critical components
of the engine the vendor mechanic had worked on. The mechanic had had to remove a bolt to get the damaged clamp off of the
tube. In that process they managed to drop the washer that had been under the bolt’s head. They then slapped the new
clamp on, probably in an extreme hurry, as instead of the new clamp being butterflied under or over the adjacent clamp as
the original clamp had been, they butterflied it’s lugs with the other clamp’s lugs in an interwoven fashion,
so that neither clamp would be completely closed when torqued down. Then they reinstalled the bolt, without the washer they
had dropped, and then torqued it down, probably with their calibrated arms. Of course, the washer had been required for a
purpose, and when the bolt was torqued the uppermost clamp lug twisted with the bolt head due to friction, twisting the clamp
into permanent deformity. Of course, the vendor mechanic was in such a hurry they did not see this, or did not give a damn
if they did, and the vendor rep that signed off the work also missed it. I now had to write up the three new discrepancies
on the NCR, whereas if I had not inspected the work like my comrades my job would be much easier--like a roller stamping inspector’s
life was. I wrote the revision, and also noted on the revision that there were no instructions in the AMM to replace the clamps,
so I had inspected the work to the AIPC instead. I also stated that the rework instructions were in the (engine vendor) MM,
I believe. To make a much too long story finally end, the disposition for my revision came back to state to remove and replace
the newly discrepant clamp per the AMM! Yep, same disposition as revision 0 that was incorrect, except the engineer had actually
called out a section of the AMM in his new disposition, whereas the whole AMM document number was listed in the original disposition
and us line inspectors were supposed to fish for the right section of the AMM to do the inspection to. I looked at the AMM
section the engineer had called out. It only applied to Boeing tubes and clamps, not the vendors. Oh well. I had tried to
get the message across in my revision that the vendor MM applied, not Boeing’s--to no avail. I decided not to try again
as that would likely be similarly fruitless, and just result in me inspecting yaks at Boeing Siberia.
5-9-07 quote: This quote is also from my addendum (supplement)
to my first report. This section really illustrates how screwed up the whole quality system at Boeing really is, how desperately
Boeing's Production Certificate needs to be pulled ASAP, and how a surprisingly large percentage of workers at Boeing don't
give a damn whether the work they do is done correctly or not--they only care about "getting the garbage out the door" as
one of my former coworkers said. and playing petty, grade schoolish games with the lives of the people who fly on Boeing
airplanes, even though it may never enter their uncaring minds they are risking those many lives by their actions. It also
documents what was told to me (part of which I had witnessed) by my fellow workers about the drunk Boeing mechanics and
vendor mechanics/inspectors that Boeing allows to work on the jet engines that propel Boeing aircraft:
This just in: While I had been recently substituting for (line inspector's name) on 777 EBUs (Engine
Build-Ups) while he was on a work related trip, an NCR, (number) was written on a galled MS21902-6R union C/T the PS3
air valve supply cover C/T the engine core diffuser and combustion case of the (vendor I.D.) engine I was assigned
to inspect. (Name), the 777 EBU Manufacturing Lead for the shift, put the tag up for inspection on the call sheet. I
stamped into it and did my usual perusal of the work, even if it had been signed off by the (vendor) representative on
the NCR attachment as acceptable to him. I talked to the Boeing mechanic who had done the replacement. She gave me the bag
that the replacement part came in when I asked if she still had it. She began to get angry with me when she realized that
I was going to inspect the work. She said that the representative had signed off on the work, so my inspection of the work
was not necessary. I looked at the bag and it was marked for a MS21902J6 union. I looked at the coding stamped on the side
of the union that was installed. It was a MS21902J6 union, not the MS21902-6R union that was required per the NCR. I looked
in (the online specification library), and the MS21902-6R union was made of 321 CRES (Corrosion Resistant Steel), which had
higher heat resistance and higher strength properties (than) 304 CRES, which the substituted MS21902J6 union was made
of. Also, I knew that substitutions couldn’t be made on NCRs without engineering concurrence. I told (the Manufacturing
Lead) about the discrepancy. He said that the rep had signed for the work so I had to buy it. I then routed the NCO for
the tag back to him stating in the comments on the NCO and on the call sheet that the wrong part had been installed. (The
Manufacturing Lead) then immediately put the tag back on the call sheet as complete with the same wrong part installed,
telling me that he could "play this game all day if he needed to." I stamped into the tag and I asked him if he had the phone
number for the rep so I could call him and ask him a few questions. He said he thought that he did, but that he wasn’t
going to give them to me because I only should just buy the work off, as the vendor had signed for the work. A little while
later I saw (name), MRB Coordinator, in the area and I asked if he had the phone number of the (vendor) rep. He
said he did. I asked him if he would email me the phone number when he got back to his office. He said he would. I got the
email a short while later and called the rep who had signed off the work, (name), who was actually the (vendor)
inspector, I later found out. I told him about the wrong union being installed on the engine. He said that he had authorized
that substitution, and he had authorized that same substitution before. I believe he asked what our AMM (Airplane Maintenance Manual)
said. I told him that the part was not shown on our AMM. I asked him for the (vendor) IPC (Illustrated Parts Catalog)
and Engine Manual document numbers so I could see if PSD had a copy of them so I could look at them. He gave the numbers to
me. After the call, I went back onto the jig and told (name), the other inspector on 777 EBUs, that I was going up to
Engineering to see if I could find the (vendor) Engine Manual as the wrong union had been installed per the NCR I was
inspecting and I wanted to see if the substitution was authorized in the manual. She then told me that she had already bought
the tag I was stamped in on! I was amazed. Apparently (the Manufacturing Lead) had gone to her, bypassing me, to
get the tag bought off as I was not quick enough to roller stamp it for his liking. I asked her why she bought it. (Name)
said that she had bought it because the vendor had signed for the work, and that that was all that we were ensuring when we
bought the tag. I told her I always looked at the work because I had found many instances when the work was screwed up in
the process. I told her I was going up to look for the (vendor) Engine Manuals anyway. It was about ten after one O’clock
at that point, so the day was pretty much over as most of the mechanics went home at 1:30. After walking around the entire
three story Engineering office and asking a few people, I found the (vendor) manuals in the microfilm station on the
second floor. I looked at the (document number and vendor name) IPC index. Only one MS21902-6R union was used on the
entire engine. I forwarded to the referenced section 72-41-00 figure 3. In the figure, item 380 was the union in question.
I looked at the figure table for the item number. The item’s part number was MS21902-6R. No surprise. Looking below
that P/N in the table, I was also not surprised, from what I knew of vendor reps. No substitute unions at all were authorized
in the IPC for that union. It was past my quitting time at that point, on that Friday day. I resolved to fix the problem on
Monday.
On Monday, I wrote a revision to NCR (number) stating the new discrepancy, that the wrong part was installed.
I couldn’t simply have the tag opened up, as (the Manufacturing Lead) would just get it bought off without
rework as he had done before. I attached the IPC pages I had printed out from my Friday microfilm research to the NCR so noone
could question that I was right or not again about the subject. I found out later that the revision was dispositioned to remove
the MS21902J6 union and to replace it with the correct MS21902-6R union. Problem solved. Of course, I don’t know if
that disposition was ever carried out, as I did not inspect that rework, as it was done on second shift that night--maybe.
Later that day, (the vendor inspector) and his ((physical description)--that’s all the I.D. I have on
him, as I didn’t catch his name) mechanic showed up and asked what was going on with the tag with many expletives interspersed.
I calmy told (the vendfor inspector) what had happened, and about the revision I had written. They left. (Another Boeing
line inspector), who had taken (name of Boeing inspector who had originally rollerstamped the NCR)'s place on 777
EBUs, was there listening to the conversation. (Name), our lead, arrived on the FME (a huge jig on which the engines
were mounted and worked upon), and (the line inspector) and (the QA Lead) began to discuss the legendary
"on the job inebriated status" of the (vendor) reps who had just left. They said it would be unwise to put them in a
room with our PSD personnel that are similarly affected, (name) and (name) and have one of them light a match. Anyway,
the above incident should be somewhat illuminating on the seemingly "who cares what parts we install" attitudes of allegedly
drunk vendor representatives who rework the "two strikes you’re a glider" engines at PSD.
5-8-07 quote: This quote is also from my addendum (supplement)
to my first report:
Vendor rework: To illustrate how broken the vendor rework inspection process at PSD is: I wrote NCR (number) on a
damaged fitting on the (part number, serial number, vendor name) T/R (Thrust Reverser). I believe (a QA Lead)
bought the rework on second shift. The T/R was sent back to (the vendor) for additional rework. When it came back
to PSD, I had to write (NCR number) item 10 on the same damaged fitting, except the damage was deeper due to some
rough file marks on the inner edge of the fitting were made twice as deep as the original damage in a crude attempt to blend
part of the damage out. Most of the original damage was untouched. I inspected the rework on the fitting on the second NCR.
I had to re-inspect the blending out of the damage multiple times because the (vendor) mechanics didn’t understand
what "blending out the damage" meant. They were only removing high metal from the damaged areas. Finally they got it right. (A
first shift QA Lead) bought the NCO (plan) for the work, as I was lent to 747 struts for the day and (the noted
QA Lead) finished that NCR. Also, to illustrate the roller stamping of vendor rework at PSD, try to find a NCO in which
a PSD inspector has routed the NCO back to the shop queue with comments stating the vendor rework was unacceptable. This would
be evidence that the vendor rework is not being roller stamped and was actually looked at. In my experience, as I try to inspect
all vendor rework, even though much of it may be buried by the time it is put up for sale for me to look at, a significant
percentage (I would guess 40% or more) of the vendor rework does not comply with the disposition. See if you find evidence
of vendor rework NCOs that were routed back for unacceptable rework. I believe you will find few besides mine. True, sometimes,
if the vendor mechanic is right there I’ll have them make the rework comply with the disposition without routing the
NCO back, but if the mechanic is not available I will route it back. One I did just today was (NCR number), I believe.
5-7-07 quote: This quote is also from my addendum (supplement)
to my first report:
Engine reallocations. I’ve checked into this some more and it, like a dead fish in a trash can on a
100 degree day, stinks more and more the closer I get to it.
(Our QA supervisor) told inspectors that inquired on this taboo subject that the engines are only assigned
to a customer A/P at the point when the forklift driver brings them into the building and sets them down at the start of the
EBU monorail for receival inspection. Of course, he has no documentation to back this up, it is just "tribal knowledge" apparently.
This doesn’t satisfy those inspectors like (name) and I, who want to do our jobs correctly and per procedures,
as there are no procedures that state what (our QA supervisor) said. The vendor paper placards that are received
on some of the engine shipping covers that indicate a specific customer for that engine would seem to indicate that (our
QA supervisor) is lying to us on this subject (see Exhibit AX for a copy of a placard I removed from the fancase of a
Rolls Royce 777 engine when I did the receival of it, which indicates (Boeing customer three letter I.D.) as the customer
that engine was built for). Of course lying to a lowly line inspector is just a walk in the park for QA Supervisors with the
ethics of (ours). His ethics, though, are not his fault. They are a requirement of his job at BCAG. This is typical. QA Management
says anything, right or wrong (they don’t seem to care which, if it serves their purposes), to get inspectors off of
a certain subject they don’t want explored for obvious reasons, even if they know little or nothing about whether their
reasoning is true. This used to bother me. Now it doesn’t. The meeting with (our QA supervisor) on 1/11 filled
me in perfectly on why they don’t seem to care, as I’m sure I have repeated too many times before.
Anyway, what we as line inspectors are supposed to do if an engine is received that is not the correct configuration
required by that customer per the drawing, is to initiate an "information only" paper pickup or rework "info only" NCR stating
the fact that it is the wrong configuration. Then either M.E. Planning or QA Planning will initiate a B/L (blueline job) to
rework the engine per a SCCR (Supplier Configuration Change Request) to the correct configuration. Sounds OK, right? Wrong.
This is illegal, even if our QA Management managed to get our engine receival QOI approved to state it. The (document
I.D.) document, section 3.1.1.2., states that SCCRs are only ("only" is underlined in the document also) to be
used to incorporate engine manufacturer requested changes into the engines. This prohibits using them the way we do at PSD--to
reallocate engines. Section 6.45 of the document, which defines a SCCR, states that a SCCR requires the support of a SMB/SSB
or special installation approval by the CAA/DGAC/FAA/JAA, and commitment by the Boeing Change Board, not just a paper "info
only" pickup initiated by a lowly PSD line inspector. Section 3.2.1. of the document states that the engine manufacturers
must supply configuration changes, S/Ns, and shortages to Boeing before installation of the engine on a Boeing A/P. That information
probably is required much earlier by Boeing than when the forklift driver brings the engine in the plant.
This just in: I saw a stray email sitting on a table in my area for several days and looked at it (see Exhibit
AP). It shows how casually we "reallocate" engines at PSD, for just convenience of production issues. While this was just
a "reallocation" of engines from one position to another on a 747, which I don’t know is kosher or not to do without
a reallocation letter, the same casual, uncaring for the configuration of the product, attitude exists when swapping engines
of different configurations among different customers. I believe there used to be, but I don’t know if the situation
still exists or not, configuration differences between inboard and outboard engines on some 747s (optional ADP on inboard
engines?).
5-6-07 quote: This quote is also from my addendum (supplement)
to my first report:
UI/UT parts unit identified: I remember that we had a crew meeting once when name) was the QA Supervisor at
PSD, in which this subject came up. This was a meeting after we had heard that PSD was going to remove the requirement from
the vendor OPSPs for the vendors to rubber stamp the unit I.D. on the inlets. He said in the meeting that "he didn’t
know why the rubber stamps were on the parts," but that they were being deleted. This fits perfectly in with PSD’s QA
philosophy that, if we forgot why we do something, or if we haven’t done something that is a requirement for a long
time, that we delete the requirement, no matter how important the reason for the requirement was, in order to make the documentation
match what we are doing or to cover our asses. Rarely will we ever do the right thing, and just comply with the requirement.
You will run into this unethical philosophy constantly in your investigation. You’ll be told "I see the requirement
now that you‘ve put the document right under my nose, but we’ve have been doing it the wrong way for so long now,
and nothing has literally blown up so far, so please let us change the documentation to match the way we are doing it, because
it is saving us a hell of a lot of money and it fits so perfectly well into our Lean Manufacturing philosophy" (well, they
won’t say it in exactly those words, but you get the idea). Don’t let us do it. Make us comply with the requirement
instead. Only let us change the requirement if it is proven the requirement is totally unworkable, or in error.
Don’t fall into the trap that has gotten the BCAG Quality System so corrupted. Don’t let us delete the requirement
simply because doing so will improve manufacturing flow or cost. BCAG, as an entity, has demonstrated it can only learn lessons,
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