In a remarkable display of skill and composure, the crew of Alaska Airlines flight 1282 managed to avert disaster last year when a door plug panel was forcibly detached from the aircraft shortly after its departure. This incident resulted in a gaping hole that led to various objects being sucked out of the cabin, according to National Transportation Safety Board (NTSB) Chair Jennifer Homendy. Despite the crew’s impressive handling of the situation, Homendy pointed out, “the crew shouldn’t have had to be heroes, because this accident never should have happened.”
The investigation by NTSB has unearthed significant flaws in Boeing’s manufacturing and safety oversight, compounded by ineffective inspections and audits by the Federal Aviation Administration (FAA). This combination of factors ultimately led to the dangerous malfunction. During the investigation, which spanned 17 months, it was revealed that four bolts holding what is termed the door plug panel were removed and not replaced during a repair while the Boeing 737 Max 9 aircraft was being assembled. The detachment caused by these lapses took place shortly after the plane took off from Portland, Oregon, creating a powerful air vacuum.
This terrifying event left seven passengers and one flight attendant with minor injuries, but miraculously, no one among the 177 onboard succumbed to severe harm. The pilots managed to skillfully land the aircraft safely back at the departure airport. In response to the incident, Boeing and Spirit AeroSystems are working on redesigning the door plugs with an additional backup system to prevent such failures, even if bolts are missing. However, certification by the FAA for these improvements is not expected until at least 2026. The NTSB has strongly recommended that all 737 Max airplanes be retrofitted with these improved panels.
Since the incident, both Boeing and the FAA have reportedly improved their training and operational processes. However, according to the NTSB, further refinement is necessary to identify and mitigate manufacturing risks, ensuring that such oversight failures do not occur again. Homendy acknowledged the efforts of Boeing’s new CEO, Kelly Ortberg, in enhancing safety measures post his appointment last summer but emphasized the necessity for continued progress. The NTSB has put forth recommendations for Boeing to further improve its training and safety protocols, underscoring the importance of thoroughly documenting necessary actions and familiarizing all employees with the company’s safety strategies.
Furthermore, the FAA has been urged to enhance its inspections and audits, prioritizing areas afflicted by historical and systemic problems. There is also a recommendation for the FAA to evaluate Boeing’s safety culture, with an added call to reassess the longstanding policy regarding seating arrangements for children under the age of two. Many of these recommendations align with a report from the Transportation Department’s Inspector General issued the previous year, which the FAA is currently striving to implement. The FAA has since issued a statement affirming that it has “fundamentally changed how it oversees Boeing since the Alaska Airlines door-plug accident and we will continue this aggressive oversight to ensure Boeing fixes its systemic production-quality issues.” They maintain close monitoring of Boeing’s performance with regular meetings to discuss progress and challenges.
Upon reviewing the NTSB’s report, Boeing expressed regret over the incident and has vowed to continue enhancing safety and quality standards within its operations. The harrowing details of the incident reveal that it occurred as the plane reached an altitude of 14,830 feet (4,520 meters). As the cabin experienced rapid decompression, oxygen masks were deployed, and cellphones along with other objects were jettisoned through the hole amid the chaotic turbulence. The initial minutes of the flight to Ontario International Airport in Southern California were uneventful until a loud “boom” was heard, followed by powerful winds that even tore the clothing off one passenger.
A piece of fuselage measuring 2 feet by 4 feet (61 centimeters by 122 centimeters), covering an unused emergency exit behind the left wing, was the section that blew out. Only seven seats on the flight were unoccupied, and fortunately, this included two closest to the opening. NTSB member J. Todd Inman remarked that the situation could have been far graver had the incident occurred above the ocean—a place distant from any immediate landing opportunity. However, Alaska Airlines had already confined flight 1282 to overland routes due to an unresolved issue with a fuel pump, a precaution taken beyond the requirements of the FAA.
The misplaced focus on Boeing’s manufacturing practices stems from the fact that the panel that detached was removed at a Boeing facility for repairs on damaged rivets. The bolts meant to secure the door plug, however, were not reinstalled. Mystery surrounds the identity of the person responsible for removing the panel. A preliminary NTSB report highlighted that none of the bolts were replaced following the repair, which itself was not documented. Investigators noted that the door plug had been incrementally shifting upwards over 154 flights leading up to the eventual blowout.
Interviews with Boeing workers revealed a culture of rushed work and misplaced assignments involving unqualified personnel. Among the 24 individuals associated with the door team, not a single one had received training on removing a door plug. Only one individual had executed such a task prior to this incident, and coincidentally, that individual was unavailable at the time. Furthermore, the team responsible for the door’s reinstallation was not present for the initial removal. The investigation also criticized Boeing for not adequately training newer workers, many of whom joined the company post-pandemic and lacked manufacturing experience. Additionally, the company lacked clear standards for on-the-job training.
The NTSB found deficiencies in Boeing’s safety measures to ensure the correct reinstallation of the door plug. It also pointed out that the FAA’s inspection system failed to identify systemic manufacturing flaws. Boeing was mandated to adopt stringent safety standards after a 2015 settlement, but the NTSB noted that the implementation of this new safety strategy coincided with the production of the ill-fated Alaska Airlines plane and was still in development at the time. Annually, the FAA conducts over 50 audits on Boeing’s manufacturing operations, but it was discovered that these audits lack definitive standards and historical records are routinely discarded after five years, with no substantial reliance on past findings to shape current audit strategies.
The challenges with Boeing’s 737 Max are part of an ongoing saga for the company. The model has been under scrutiny since two catastrophic crashes in 2018 and 2019—one in Indonesia and the other in Ethiopia—resulting in the loss of 346 lives. Introduced issues with the aircraft’s design, specifically a malfunctioning system pushing the nose down due to erroneous sensor data, were pivotal elements in these tragedies. Following the second crash, the 737 Max was grounded globally pending a redesign of the offending system. More recently, the Justice Department reached a deal to avoid prosecuting Boeing for misleading U.S. regulators about the aircraft before these disasters.
Current production of the 737 Max is restricted to 38 units monthly as investigators ensure improved safety procedures from Boeing, a cap the FAA will maintain “until we are confident the company can maintain safety and quality while making more aircraft.” Since last year, Boeing has taken decisive steps, including hiring Ortberg and appointing a senior vice president of quality, to enhance its manufacturing standards. The company also made headlines earlier this month following a crash involving a 787 operated by Air India, which took the lives of at least 270 individuals. While the investigation is ongoing, no inherent flaw in the aircraft’s model—known for its commendable safety record—has been identified thus far.