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WASHINGTON — Investigators at the National Transportation Safety Board say there were multiple systemic failures that led to a midair blowout during the flight of a Boeing 737 Max jet last year, finding fault with safety procedures both at Boeing and the Federal Aviation Administration.
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No one was killed or seriously injured when the door plug panel blew out of an Alaska Airlines flight shortly after takeoff. NTSB chair Jennifer Homendy praised the crew for getting all 177 people on board back to the gate at Portland International Airport safely.
"This accident never should have happened," said Homendy. "The safety deficiencies that led to this accident should have been evident to Boeing," as well as to regulators at the FAA.
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.
The board concluded that the probable cause of the accident was "Boeing's failure to provide adequate training, guidance, and oversight" to its factory workers, according to a meeting summary released by the NTSB.
Investigators say they still don't know who reinstalled the door plug panel at Boeing's factory 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 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."
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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.
"We at Boeing regret this accident and continue to work on strengthening safety and quality across our operations," the company said in a statement.
"We will review the final report and recommendations as we continue to implement improvements."
The NTSB concluded that regulators at the FAA also contributed to the accident by failing to "adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues" in its factories.
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The door plug incident prompted regulators at the FAA to increase their oversight of the factory where Boeing builds the 737 Max jets in Renton, Wash, and to temporarily cap production there at 38 planes per month.
"The FAA 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," the agency said in a statement. "While Boeing is making progress, we will not lift the 737 monthly production cap until we are confident the company can maintain safety and quality while making more aircraft."
Both Boeing and the FAA have improved their 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 the Alaska Airlines flight. The door plug panel blew out about six minutes after takeoff, and the plane was able to return to make an emergency landing in Portland. 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.
Transcript
ARI SHAPIRO, HOST:
The nation's top safety investigators say multiple failures are to blame for the midair blowout during the flight of an Alaska Airlines Boeing 737 Max jet last year. Members of the National Transportation Safety Board met in Washington today to review the results of a lengthy investigation into the accident. NTSB Board Chair Jennifer Homendy praised the crew of the flight for getting all 177 people on board safely back to Portland International Airport. But Homendy faulted Boeing and regulators at the Federal Aviation Administration.
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JENNIFER HOMENDY: The crew shouldn't have had to be heroes because this accident never should have happened. The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA.
SHAPIRO: NPR's transportation correspondent Joel Rose has been following this, and he's here in the studio. Hey, Joel.
JOEL ROSE, BYLINE: Hey, Ari.
SHAPIRO: It's been nearly a year and a half since the accident. Remind us how it went down.
ROSE: Yeah. Alaska Airlines flight 1282 took off from Portland on its way to California. About six minutes later, a large piece of the fuselage known as a door plug panel blew out of the aircraft. The cabin was instantly depressurized. Loose items like phones and bags were sucked out of the plane, which was now flying with a large hole in the fuselage. We found out today that there were three lap-held infants on board at the time and four unaccompanied minor children, including one 6-year-old who had never flown before.
But remarkably, no one was killed or even seriously injured. The crew was able to turn the plane around and make an emergency landing back in Portland. Luckily, the plane was only at about 15,000 feet when all of this happened. If it had been at its regular cruising altitude of 35,000 feet, it could have turned out very differently.
SHAPIRO: That sounds absolutely terrifying. Have federal investigators been able to figure out exactly what went wrong?
ROSE: There is still some mystery here. Investigators had said that four key bolts were missing when the jet left Boeing's factory in Renton, Washington. We heard today that if even one of those bolts had been in place, it could have possibly prevented the blowout. Investigators say Boeing has no record of exactly who was responsible for removing and reinstalling the door plug, and investigators say they have not been able to pinpoint exactly who performed those tasks. But NTSB Chair Jennifer Homendy said this points to bigger problems with Boeing's safety protocols.
SHAPIRO: Like what? What are the bigger problems?
ROSE: Well, Homendy criticized Boeing for relying on a single point of failure instead of having a more robust safety system that would have flagged the problem before it left the factory. Homendy also criticized regulators at the FAA for not being more proactive in their oversight before this incident.
And one other interesting takeaway from the meeting today, it just underscored the lack of experience among the factory workers who are building these planes. We knew that Boeing had lost a lot of experienced people during the COVID-19 pandemic and struggled to replace that institutional knowledge. Investigators say there were two dozen workers on the door team at this factory, but only one of them had previous experience removing and replacing a door plug panel, and he was out on vacation when this work was done.
SHAPIRO: Well, have Boeing and federal regulators taken any steps in response to the door plug problem?
ROSE: Yes, the FAA says it has fundamentally changed how it oversees Boeing. In a statement, the agency said it has capped production of the 737 Max at 38 jets per month and that it will keep that cap in place until regulators are satisfied that Boeing has improved its quality control. The door plug blowout also sparked a crisis at Boeing. The former CEO stepped down. The company announced a host of changes, including more robust training for new employees. Boeing now has a new CEO, Kelly Ortberg, who took over last summer. And NTSB Chair Homendy praised Ortberg today for renewing the company's focus on safety, though she says there is still more to do.
SHAPIRO: NPR's Joel Rose, thank you.
ROSE: You're welcome.
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