Investigators for the National Transportation Safety Board said on Tuesday that a single bolt could have averted a terrifying incident last year when a panel blew off an Alaska Airlines Boeing 737 Max 9 airplane midair.
The agency did not determine who removed and failed to replace the four bolts that typically held the door plug — a panel that fills a gap where an emergency exit would be — in place, causing it to rip off Alaska Airlines Flight 1282 midflight. But investigators said that the door plug would not have come loose if just one of the lower bolts, called vertical movement arrestor bolts, had been installed.
The finding was part of a series of failures highlighted in a public hearing held by N.T.S.B. leaders in Washington to review the findings of their 17-month investigation. The agency determined that the door plug likely detached because Boeing had failed to ensure that workers “consistently and correctly” followed its process to remove and reinstall parts.
“Let me be clear: An accident like this does not happen because of an individual, or even a group of individuals,” said Jennifer Homendy, the N.T.S.B. chairwoman, adding, “An accident like this only happens when there are multiple system failures.”
Ms. Homendy credited the crew of Flight 1282 for averting a crash or fatalities when the panel flew off the aircraft shortly after it took off from Portland International Airport in Oregon on Jan. 5, 2024. But she criticized both Boeing and the Federal Aviation Administration for overlooking or ignoring safety deficiencies that “should have been evident.”
The N.T.S.B. issued nearly two dozen safety recommendations to improve Boeing’s safety procedures and the F.A.A.’s oversight of Boeing and other companies in order to avoid similar episodes in the future.
The recommendations included an exhortation to the F.A.A. to complete the certification process needed to bring Boeing’s fix to its door plugs online, and an instruction to Boeing to urge airline operators to train their flight crews on how it works. Boeing was also told to retain records and revise internal systems so problems could be more readily identified and tracked, while the F.A.A. was urged to mandate that all required cockpit voice recorders retain at least 25 hours of audio.
Boeing was faulted for lax documentation and subpar training protocols. N.T.S.B. investigators reported that only one of the 24 members of the company’s team responsible for maintenance and repair of the doors of the 737 had been trained how to operate the type of door plug on the Alaska Airlines flight — and he was on vacation when that part was repaired in September 2023.
Investigators also said that the door plug would not have been inspected for about two years after that had it not flown off the plane the following January. In the aftermath of the incident, all such door plugs have been subject to inspection, and Boeing has produced new designs that are awaiting federal certification to upgrade new planes and retrofit old ones with better fail safes to keep the door plugs in place.
In a statement, Boeing expressed regret for the Alaska Airlines accident, pledged to continue to work to strengthen and improve the safety and quality of its products, and promised to “review the final report and recommendations” of the N.T.S.B., though it stopped short of pledging to implement all of them.
Still, N.T.S.B. members expressed wariness about whether Boeing’s door plug fix would fully address what it cited as problems in numerous internal audits by Boeing — and what they suggested was a history of insufficient oversight by the F.A.A.
“I have lots of questions about where F.A.A. was during all of this,” Ms. Homendy said during the hearing, calling the agency “the absolute last barrier of defense when it comes to ensuring aviation safety.”
Investigators revealed that since the door plug incident, the F.A.A. had increased its team of safety inspectors dedicated to Boeing facilities from 34 to 55, and that hiring was ongoing.
In a statement, Sean Duffy, the secretary of transportation, said that “the F.A.A. has fundamentally changed how it oversees Boeing,” since the Alaska Airlines accident, charging that Boeing and the Biden administration “took their eye off the ball.” The F.A.A. is part of the Department of Transportation.
“We have strengthened our oversight to address systemic production-quality issues and ensure accountability,” he added, noting that the agency had already implemented “a number” of the N.T.S.B. recommendations, would continue to closely monitor Boeing’s operations and would not lift production caps on Boeing 737s until the administration was confident the company could meet safety and quality standards.
Niraj Chokshi contributed to this report.
Karoun Demirjian is a breaking news reporter for The Times.
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