The Plug Door

Riddle:             What does it mean to remove a door?

Hint:                It hinges on hinges.

Henry Ford was antisemitic and a bigot, but he did some things right. He was a good mechanic – a natural in the trade. In 1911 he patented an ingenious transmission for automobiles. It used planetary gears. He is credited with inventing the assembly line. His Model T was designed to be affordable, but he offered skilled mechanics twice the going rate. He knew their skills were valuable.

It is January 2026. The NTSB Report on the depressurization incident is out. Here is what it says, based on the usual records – DFDR, ADS-B-out, and ATC communications – but also on records from the Airplane X Final Assembly Line:

  • The door blew off because the four pin bolts that keep the door from sliding up in the guides – were not there
  • The pilots and flight attendants did a great job in getting the aircraft safely back on the ground.
  • Assembly line procedures are being looked at, blah blah blah.

There are also some things the NTSB Report does not say:

  • This rapid depressurization was like no other in aviation history because the cockpit door blew open. By design. Said design is not mentioned in the Flight Manual and is news to all concerned.
  • The Airplane X assembly line differs from Henry Ford’s Model T assembly line in important ways.

Re the cockpit door:

Instead of reaching up and pulling on the oxygen mask over his and her headsets (as outlined in the drill) the pilots pulled on their oxygen masks but could hear nothing but a roar. Their headsets, their checklists, and anything else not nailed down had blown out the cockpit door in the first few seconds. They turned up their speakers, but communications were difficult and sometimes impossible. That can be heard on the ATC tapes. The blowout panels in the cockpit door were fakes. In view of all this, the pilots did a very good job.

Re the Final Assembly Line:

If you were a mechanic on the Model T assembly line you performed one task. Perhaps you installed the steering wheel. You were a good mechanic, so you did a good job. As the day went by you got even better at the task. But that repetition, after a certain point, is not good for you. For your concentration, for example. So you transfer – tomorrow, or next week – to the engine line and install the four ignition coils on the almost-ready motors.

Not so the Airplane X workers. The line moves fast. If they don’t finish the task today, the airplane moves on to the next bay. Different people work there. There will have to be communication.

But – to use management-speak – there is a process in place. Actually, two different processes. The first process is real. That process recorded that the door was opened and that there is no record of the pin bolts being re-installed. But process one failed because the lowest level of management decided that the door had been opened, but not removed. That in turn meant that – according to process one – that there need be no further inspection after the door was “closed”. Process two is lower management speaking to upper management and providing metrics for discussions at the highest levels. These high-level managers want a high rate of production and a low rate of glitches.

Complicating all this is that a spin-off supplier makes the Aircraft X fuselage. The supplier has its own process two, known as process three. Process two documents the back-and-forth blame game if something slips through process three and is discovered by process one. Meanwhile, supplier executives are paid very handsomely to sign non-disclosure agreements, assuring that process three failures are buried.

There is no Harry Truman. The buck does not stop.

The cockpit door blew open, pivoting on its hinges. The door plug blew out. It had no hinges.

Zen Riddle:      If a door is no longer there, is it open?


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