National Transportation Safety Board (NTSB) Chair Jennifer Homendy recently commended the crew of Alaska Airlines Flight 1282 for their swift and courageous actions following a severe in-flight incident that occurred shortly after takeoff from Portland International Airport in January 2024.
Homendy emphasized that the crew’s heroic response was unnecessary and lamented that the incident should never have occurred in the first place, attributing the root causes to systemic failures stemming from Boeing and the Federal Aviation Administration (FAA).
An NTSB investigation spanning over 17 months uncovered that crucial bolts securing the door plug panel had been removed during a prior repair and were never replaced.
Homendy underscored the issues, stating, “An accident like this only happens when there are multiple system failures.”
She remarked that although Boeing’s new CEO, Kelly Ortberg, has implemented significant safety improvements since taking office in the summer of 2023, further actions are needed to enhance aviation safety standards.
In its forthcoming meeting, the NTSB is anticipated to endorse several recommendations intended to prevent the recurrence of similar incidents in the future.
On the fateful flight to Ontario International Airport in Southern California, a terrifying blow out occurred shortly after the aircraft reached 16,000 feet, creating a powerful air vacuum that not only sucked objects out of the cabin but also scattered debris on the ground below.
Although seven passengers and one flight attendant reported minor injuries, all aboard the aircraft survived, as the pilots successfully executed an emergency landing back at the airport.
During the incident, oxygen masks deployed due to the rapid decompression, and various personal items—including cell phones—were whisked out through the breach formed in the fuselage.
Passengers recalled a sudden burst of chaos as the Boeing 737 Max 9 was cruising at over 400 mph, describing a profound “boom” followed by a fierce wind that left one individual’s shirt ripped off.
“We knew something was wrong,” remarked Kelly Bartlett, a passenger on the flight. “We didn’t know what. We didn’t know how serious. We didn’t know if it meant we were going to crash.”
Preliminary findings indicate that a 2-foot-by-4-foot piece of fuselage, covering an unoperational emergency exit located behind the left wing, had detached, leaving only seven of the 171 seats on the flight unoccupied.
The door plug panel that came loose was produced and installed by a supplier, Spirit AeroSystems. Following repairs made in a Boeing factory, the essential bolts meant to secure the door plug were not replaced, leading to the catastrophic failure.
Investigators reported that although four bolts were omitted after the repair, appropriate documentation regarding the maintenance was lacking.
Further examination revealed that, over the course of 154 flights prior to this incident, the door plug had gradually shifted upward until it ultimately detached from the aircraft.
Boeing factory personnel informed NTSB investigators that they faced significant pressure to work quickly, with some being assigned tasks beyond their qualifications, including handling the door plug for this particular aircraft.
Notably, only one individual from the 24-member door team had prior experience removing such plugs, but that employee was on vacation at the time of the incident.
One Boeing door installer mentioned that while no explicit instructions to take shortcuts were given, the pressure to maintain the assembly line’s momentum was palpable.
“That’s how mistakes are made. People try to work too fast,” said the installer, who was not named in the investigation documents.
Investigators concluded that Boeing failed to provide adequate training for newer hires who lacked a solid background in manufacturing, particularly those recruited after the pandemic and following two fatal crashes involving the 737 Max.
Lack of clear training standards for on-the-job practices contributed to the oversight. NTSB staff also indicated that Boeing’s safety practices failed to ensure the proper reinstallation of the door plug, while the FAA’s inspection protocols inadequately identified systemic failures in manufacturing processes.
Despite being mandated to adopt more stringent safety methodologies following a 2015 settlement, the NTSB stated that the enhanced safety measures were only in place for two years before the Alaska Airlines plane in question was constructed, and they remained under development at that time.
The FAA routinely conducts over 50 audits each year of Boeing’s manufacturing facilities; however, there are no explicit standards outlining what is examined during these audits.
The ongoing issues with the Boeing 737 Max have sparked concern since the aircraft’s involvement in two tragic crashes in Indonesia in 2018 and Ethiopia in 2019, resulting in a total of 346 fatalities.
Investigators found that the crashes stemmed from a malfunctioning system which relied on a sensor providing erroneous data, causing the aircraft’s nose to pitch downward, leaving pilots unable to regain control.
Subsequent to the second crash, Max jets were grounded worldwide until Boeing redesigned the dysfunctional system.
Recently, the Justice Department reached an agreement allowing Boeing to evade criminal prosecution for allegedly providing misleading information to U.S. regulators concerning the Max prior to the two fatal crashes.
To further temper production concerns, FAA regulators have imposed a cap on Boeing’s 737 Max production at 38 jets per month until it is verified that the company has effectively fortified its safety practices.
Moreover, Boeing hired Ortberg last year and established a new senior vice president position specifically to oversee quality improvements in manufacturing processes.
The company recently faced additional scrutiny when an Air India-operated 787 aircraft experienced a fatal crash shortly after takeoff, resulting in 270 deaths. Investigations into the cause of that crash remain ongoing, though no anomalies with that aircraft model have yet been identified, which historically boasts a strong safety record.
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