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Amy Wilder

Boeing’s failure to ensure adequate training, guidance, and oversight of its factory personnel led to the in-flight mid-exit door plug blowout on <a href="https://www.ainonline.com/aviation-news/air-transport/2024-01-08/boeing-max-9-depressurization-emergency-prompts-grounding">Alaska Airlines Flight 1282</a>, the NTSB found in a June 24 board meeting. The Board also cited the FAA’s ineffective oversight of Boeing’s quality and safety systems as a contributing factor in the Jan. 5, 2024 incident involving the 737 Max 9.&nbsp;
Climbing through 14,830 feet about six minutes after departing Portland, Oregon, the airliner experienced rapid decompression after the left mid-exit door plug blew out. Investigators determined that the door plug had not been secured with the four bolts required to hold it in place, and the plug had incrementally shifted during earlier flights before detaching entirely.
The NTSB found that the plug had been opened on Sept. 18, 2023, during a rivet repair at Boeing’s Renton, Washington factory. It was closed the following day, without the involvement of technicians qualified under Boeing’s procedures to perform plug installations. Investigators also found that the work was undocumented, which meant no quality assurance inspection occurred. This lapse,&nbsp;the agency concluded, occurred because Boeing failed to provide adequate training, guidance, or oversight to workers performing the task.
In addition, the Board cited “repetitive and systemic” problems in Boeing’s manufacturing quality processes, especially the parts removal and replacement workflow, and found that the FAA had failed to ensure that the company corrected these issues. The FAA’s role was further scrutinized for its ineffective oversight of Boeing’s voluntary safety management system (SMS), which the board described as “inadequate” and “not capable of proactively identifying and mitigating risks.” In February 2024, the FAA had <a href="https://www.ainonline.com/aviation-news/air-transport/2024-02-26/boeing-missing-key-elements-safety-culture-faa-report">called out Boeing</a> in a 50-page report for not properly implementing its SMS plan.&nbsp;
“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA—should have been preventable,” NTSB chair Jennifer Homendy said during the meeting. “This time, it was missing bolts…but the same safety deficiencies could just as easily have led to other manufacturing quality escapes.”
Minor injuries to one flight crewmember and seven passengers occurred as a result of the event. Personal belongings were ejected from the cabin, oxygen masks deployed, and the cockpit door swung open during the decompression. The aircraft had been in service for just three months and was delivered with the door plug in its altered state.
NTSB investigators emphasized the importance of better training on the use of flight crew oxygen systems and communication equipment during emergencies. The Board issued safety recommendations calling for enhanced inspection requirements after maintenance near plug installations, updated crew procedures for rapid decompression, and stronger policies encouraging the use of child restraint systems for passengers under age two.
The <a href="http://link.mediaoutreach.meltwater.com/ls/click?upn=u001.c1CHKOpYzTqygfA6cKCLCSOb68Tsz6-2Bd-2FgXKPrLnPSocA-2B66Vzd61BralqYEQOtMGhcndV-2BqnSxPgnzwrc4pJ0ysex3yyiTC0IFrBLhYBz2PTyk-2BCFh6xXOV0Q2pi8bW-2Bl5cDMLImiERPs-2FYUK3frg-3D-3D4_pk_ucghgO6pjDBaqQJ1bIxrGgk1IZPGStWnmZaJ0ZBwsWCQ3dJBQjoaSST7QlZYJfFd-2BsQ7yPqpiHIOGdefGv0fUHMccJq6magqLJqbLIN27Tu4ZLz1FTEOk361-2BDIV4JGwri3vC7gZduY6DL4bxV3HG6JAK71AJIbwUuLhCj-2BNwDn2OhSILxiMnvxDANc6-2FVWMVu2MhT2XsgskLaqQTMIfuiUwDrwWeIY9vAh9chBgRvjukLAgwELxopYoLthltS-2F67sddao7pwfQMr5tkCDeGaW4CJ1jbW5IAH3FO7qH9Xbd-2B1eXzhOrjg3hjobfAnVe6L-2FiEJcAiGi8Ck6-2BEKKeRbB63y2OgHFof0F6mqM5w9amz2w8TsCFfcb5T-2FJKKzXtw">executive summary</a> of the Board meeting includes probable cause findings and recommendations and is available on the <a href="https://www.ntsb.gov/investigations/Pages/DCA24MA063.aspx">NTSB’s website</a>. A final report has not yet been issued.

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