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In this National Transportation Safety Board handout photo, plastic covers the exterior of the fuselage plug area of Alaska Airlines Flight 1282, a Boeing 737 Max, on January 7, 2024 in Portland, Ore. A door-sized section near the rear of the plane blew off 10 minutes after takeoff on January 5 on its way to Ontario, Calif.
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WASHINGTON — Investigators at the National Transportation Safety Board say they still don’t know who reinstalled the door plug panel that blew out of a Boeing 737 Max jet in midair last January without replacing four key bolts that were supposed to hold it in place.
Even one of those four bolts could have prevented the door plug blowout during Alaska Airlines Flight 1282, NTSB investigators said on Tuesday. Those bolts were never found, and investigators believe they were likely discarded.
The incident on January 5, 2024 raised major questions about safety and quality control at the aerospace giant. Seventeen months later, the members of the NTSB met in Washington to hear the results of the board’s investigation and to vote on the probable cause of the accident.
The board members found there were multiple systemic failures that led to the door plug blowout — including a lack of safety processes at Boeing, coupled with an inexperienced workforce at the factory that builds the 737 Max.
“This accident never should have happened,” said NTSB chair Jennifer Homendy. “The safety deficiencies that led to this accident should have been evident to Boeing,” as well as to regulators at the Federal Aviation Administration.
Boeing 737 MAX airplanes are pictured outside a Boeing factory on March 25, 2024 in Renton, Wash. A midair door plug blowout on an Alaska Airlines flight and subsequent grounding of flights precipitated a management shakeup at Boeing.
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Stephen Brashear/Getty Images
The NTSB had previously said that four bolts which were supposed to hold the door plug in place were missing when the Boeing 737 Max jet was delivered to Alaska Airlines in October 2023.
Boeing has no record of exactly who was responsible for removing and reinstalling the door plug, investigators said, making it impossible to pinpoint exactly who performed those tasks. Board chair Homendy said that points to bigger problems with Boeing’s safety protocols.
“Boeing relied on a single point of failure, which was a human not filing or documenting a record,” Homendy said. “That was a flaw in the system.”
In addition, investigators found that Boeing relied on workers who had little formal training to carry out the tasks they were performing. They noted that the factory in Renton, Wash. where Boeing builds the 737 had lost many experienced workers during the COVID-19 pandemic.
There were two dozen workers on the door team at the Boeing factory near Seattle that builds the 737 Max, according to investigators. But only one of them had previous experience removing a door plug panel — and he was on vacation in September 2023 when the door plug panel was removed and reinstalled.
The door plug blowout sparked a crisis at Boeing. Former CEO Dave Calhoun announced he would step down by the end of that year. The company replaced the top managers at its factory in Renton, and announced a host of other changes including more robust training for new employees. Current CEO Kelly Ortberg says Boeing has only recently returned to the production rate of 38 jets per month that it had been planning before the incident.
The door plug incident also prompted the FAA to increase its oversight of the factory where Boeing builds the 737 Max jets.
Both Boeing and the FAA have improved training and safety processes since the incident, according to the NTSB. Homendy praised Ortberg in particular for renewing the focus on safety at the company since he took over as CEO last summer, although she said there is still more work to do.
The incident was a major setback for Boeing, which was still working to rebuild trust with regulators and the flying public after the deadly crashes of two 737 Max jets in 2018 and 2019 that killed 346 people.
The Department of Justice told a federal judge last month that it has reached an agreement in principle with Boeing to drop a criminal case over those crashes, despite objections from family members of some crash victims. It’s the latest turn in a long-running legal saga over how to hold the company accountable for those crashes.
No one was seriously injured during Alaska Airlines Flight 1282. The door plug panel blew out about six minutes after takeoff, and the plane was able to return to make an emergency landing at Portland International Airport in Oregon. The incident occurred as the plane was climbing to about 15,000 feet; had it happened at the plane’s cruising altitude of 35,000 feet, the outcome could have been very different.
“Frankly, it’s nothing short of a miracle that no one died,” Homendy said.
Neither Boeing nor the FAA had immediately released a statement following the NTSB hearing.
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