The United States’ National Transportation Safety Board has concluded that the lack of adequate “training, guidance and oversight” from Boeing for its factory workers was the reason behind the Alaska Airlines incident in January last year, where the in-flight mid-exit door (MED) plug blew out mid-air on the airline’s Boeing 737 MAX 9 aircraft.
The safety board also said that there were insufficient efforts from the Federal Aviation Administration to regulate Boeing’s “known recordkeeping issues.”
The Alaska Airlines incident
The incident happened on January 5, 2024, where the MED plug of the Boeing 737 MAX 9 blew out while the flight, operating as Alaska Airlines flight 1282, was at around 14,830 feet above ground, six minutes after departing from Portland, Oregon. Due to the pressure release on the aircraft bound for Ontario, Canada, some passengers’ belongings were sucked out of the aircraft.
The impact also led to oxygen masks being released from the overhead passenger units. The door to the flight deck opened, injuring a crew member. Seven passengers onboard also sustained minor injuries while the remaining three flight attendants and 164 passengers remained unharmed.
NTSB Chairwoman Jennifer Homendy said:
“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable. This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”
The incident led to a major crisis at Boeing, including its new CEO, Kelly Ortberg, taking over the reins as Dave Calhoun stepped down following the accident.
NTSB investigation and conclusion
Authorities found the MED plug in a neighbourhood in Portland two days after the incident. Post examination, the investigation found that it was missing four crucial bolts meant to secure the plug.
NTSB investigators found that the unsecured plug kept moving up slowly every time the aircraft flew in previous flights before the blowout on this fateful day. It is to be noted that the aircraft itself had been delivered to Alaska Airlines just three months prior to the accident.
During repair work on the fuselage, the plug was opened and closed without properly documenting the procedure at Boeing’s Renton factory in Washington on September 18, 2023. As per procedure, certain technicians were required to close the MED plugs. However, as no specialised workers were present at the time, there was a lack of quality assurance and proper inspection.
The investigation thus concluded that the probable cause of this incident was “Boeing’s failure to provide adequate training, guidance and oversight to its factory workers.”
It also stated that the FAA had not been effective in making sure that the repetitive issues regarding noncompliance with the parts removal process were addressed by Boeing. These voluntary safety management issues had persisted for two years before this particular incident happened.
The investigation further stated:
“The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.”
The NTSB has issued 19 recommendations to the FAA and Boeing in total, including additional training for flight crew and more oversight and better systems for Boeing’s factories.
It said:
“Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and the Regional Airline Association.”
NTSB will publish the final report on its website.
What do you think of Boeing’s oversight and safety issues? Do share your views in the comments.
