The news just keeps coming!

I thought I was done writing about Boeing's current Quality problems, but the news just keeps coming and coming. Some of the stories simply confirm what we've already said about Boeing's current Quality culture; other stories talk about legal issues, and have less to do with Quality strictly understood. But one way or another, there continue to be a lot of them.

Here's a quick sampling of recent stories that I've found around the Internet:

• About sudden leadership changes at Boeing:
• Head of Boeing 737 MAX programme out amid safety concerns at planemaker | Aviation News | Al Jazeera
• About the Boeing 737 MAX a week ago that had a gear collapse after the plane landed in Houston:
• United Boeing 737 MAX Suffers Gear Collapse After Landing - One Mile at a Time
• About criminal investigations into the Alaska Airlines flight 1282 failure:
• Report: DOJ opens criminal investigation into Alaska Airlines blowout | AP News
• US opens criminal probe into Boeing 737 MAX mid-flight blowout | transport News | Al Jazeera
• About Boeing's treatment of their suppliers through a program that demanded more production for less money:
• Boeing strikes conciliatory tone with suppliers amid 737 MAX crisis | Reuters
• Boeing Rolling Back Controversial “Partnering For Success” Deal? - Mentour Pilot
• About recent interviews with Ed Pierson, formerly Boeing 737 Program Sr. Manager, who explains why he refuses to fly on a 737 MAX and what risks he still sees in Boeing manufacturing:
• ‘I’m Not Trying to Cause a Scene. I Just Want to Get Off This Plane.’ - POLITICO
• Former Boeing 737 Program Sr. Manager Says Boeing Company Is WORSE NOW Than Before Two MAX Crashes! (youtube.com)
• About the sudden death last Saturday of Boeing whistleblower John Barnett, with what the Charleston County coroner described as "a 'self-inflicted' wound." 
• Boeing whistleblower found dead in US (bbc.com)
• (If I can judge from a totally unscientific review of comments on Twitter replying to this news, the number of people who believe Barnett's wound to have been truly self-inflicted seems to be pretty small just now. Naturally I make no accusations.)

It's an exciting time.

Ziad Ojakli, Boeing EVP

But the story I want to write about is a different one. In some ways it is smaller and quieter than the ones I just listed, but it sheds a helpful light on one of the least glamorous—but most critical!—of all the Quality disciplines. Yes, I'm talking about records control, and about how Boeing's records control system seems to have failed them at the worst possible moment.

The basic story is told by the Seattle Times here, and Associated Press chimes in here for corroboration. Briefly, it all started with the investigation into Alaska Airlines flight 1282, when a door plug blew out while the plane was in the air. The investigation revealed that four bolts were missing which were supposed to hold the door plug in place.

Why were the four bolts missing?

They had been removed to facilitate earlier rework.

Why was there rework?

There was damage to five rivets which had to be repaired. The procedure to repair those rivets required that the door plug be removed temporarily. Then after the repair the door plug was replaced.

Why weren't the four bolts replaced when the door plug was replaced?

… good question. Here the trail runs cold. The logical thing would be to ask the person who did the repair, but we don't know who that was.

Wait, … what?? How can we not know who did the repair? Surely that information was captured as part of the repair documentation!

You would think so. But up till now Boeing has been unable to provide that documentation. And last Friday, Ziad Ojakli, Boeing executive vice president and the company’s chief government lobbyist, sent a letter to Sen. Maria Cantwell of the Senate Commerce Committee, saying, "We have looked extensively and have not found any such documentation." He added as a "working hypothesis: that the documents required by our processes were not created when the door plug was opened."

Let me repeat that, just to be clear:

• Boeing's procedures require complete documentation of any rework, whenever rework is done. (So far, so good.)
• But now they can't find the documentation for rework that was done two months ago.
• The company's executive management is willing to tell a Senate Committee that he thinks maybe the documentation was never generated.  

This is terrifying.

To be more exact, there are several possible explanations for this turn of events, and every single one of them is terrifying!

One possibility is that the documentation really wasn't generated for this particular rework. 

But in that case, what else are they doing that hasn't been documented? How could you ever know? (Hint: you couldn't.) And if you don't know what work has been done on an airplane, why would you ever be willing to fly on one again?

Another possibility is that the documentation was generated, but Boeing can't find it.

This raises the same fears. If you can't find your documentation, it might as well not exist. At that point you are totally unable to use the documentation: for example, to monitor trends, or to connect the dots between one failure and another. You can't do anything proactive, and you can't even do much that's reactive. All you can do is wait for the next plane to fall out of the sky.

And of course a third possibility is that Boeing is brazenly lying to a Senate Committee.

In some ways, I almost hope this last one is the answer. I would rather that a company like Boeing be competent, even while doing something villainous, than that they succumb to floundering ineptitude. At the very least, a competent villain is more likely to build planes that keep flying.

But if you make the conscious decision to lie to the Senate, it's because you are hiding something really bad. Nobody does that on a whim. And so, once again, I start to worry about "What else don't we know?"

Yes, of course there are other possibilities, but mostly I think they add filigree details to the ones I have already sketched out. Maybe the documentation was created, but then the guy who did the work snuck into the records system and destroyed it afterwards so he wouldn't get in trouble when flight 1282 lost its door plug in such a dramatic way. Or maybe his friend did it on his behalf. And naturally it's easy to understand why this guy would be afraid of being in the spotlight nationwide. What's not easy to understand—what is, in fact, flatly inexcusable—is why any company as big as Boeing would tolerate a document control system that could be subverted so easily by a single bad actor.

You keep documentation for a reason. And even when the documentation embarrasses you, it's better to provide it (and own up in public to your mistakes) than to hide it (and leave everyone wondering whether things are even worse than they really are).

When I first started writing about Boeing's troubles (back in January) I tried to put those troubles in the best possible light by pointing out how few failures there have been (as a fraction of the total number of flights in a year) and by explaining that the whole point of a Quality Management System is to help you handle failures gracefully.

But document and records control is the single most basic element of any QMS. If Boeing never generated (or cannot find) rework documentation for a recent job, then their QMS fundamentally isn't working.

There is no way to tell this particular story so that it sounds good.

Photo from the National Transportation Safety Board