NTSB blames Boeing, FAA for cause of Alaska Airlines door plug blowout
The National Transportation Safety Board determined that "multiple system failures," including poor practices at Boeing and poor oversight by the Federal Aviation Association, caused the Alaska Airlines flight door plug blowout , the agency announced during a hearing on Tuesday, marking nearly a year-and-a-half into its investigation of the incident.
The mid-exit door plug separated from the Boeing 737 Max 9 passenger plane on Jan. 5, 2024, minutes after Flight 1282 took off from Portland International Airport. Passengers captured footage showing a hole where the door plug came loose. The plane safely made an emergency landing and no one was seriously injured in the incident.
The NTSB held a public board meeting on Tuesday, during which its board members discussed "the investigation and vote on the probable cause and safety recommendations designed to prevent similar accidents," the agency said.
During the hearing, the NTSB announced that the probable cause of the accident was "due to Boeing Commercial Airplanes' failure to provide adequate training, guidance and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process."
NTSB Chair Jennifer Homendy said the accident was a result of "multiple system failures" that led to this accident and commended the Alaska Airlines crew for their actions.
“This was incredible communication between the captain and the first officer that, as they are required to do,” Homendy said. "Pre-planned where they were going to land and go back to an event in an emergency. So even when they had those communications issues in the cockpit, they both knew where they were going back to. They were prepared.”
While there were no injuries in the accident, the NTSB emphasized the dangers of children sitting on a lap on airplanes, with three children and four unaccompanied minors present on this Alaska Airlines flight. The agency said if these children -- who were lap-sitting -- had been seated closer to where the plug blew out, this incident would have been more tragic.
A final report containing the safety recommendations that were voted on by the NTSB board will be available in several weeks, the agency said.
A preliminary report released by the NTSB in February 2024 found that four bolts designed to prevent the door plug from falling off the Boeing 737 Max 9 plane were missing before the plug blew off during the flight.
During the hearing on Tuesday, the NTSB said they still have not been able to identify the people who forgot to put the bolts back in the door plug.
Even if one of the bolts had been installed properly on the door plug, it could have prevented the plug separation midair, the NTSB said on Tuesday.
"We asked them to do an engineering evaluation of the design of the plug, and that evaluation determined that one of the vertical movement arrestor bolts on the lower part of the plug, one of them would hold it in position, or both of the upper guide track bold would hold it in position," the agency said.
The agency also revealed that Boeing had 24 people on its door team at its factory where the plane was made, but only one had training and previous experience removing a door plug panel.
Boeing records reviewed by the NTSB showed damaged rivets on the edge frame forward of the plug were replaced by Spirit AeroSystems employees at Boeing's factory in Renton, Washington, on Sept. 19, 2023, according to the agency's preliminary report.
Boeing had to open the plug by removing the two vertical movement arrestor bolts and two upper guide track bolts for the rivets to be replaced, but photo documentation obtained from Boeing showed evidence the plug was closed with no bolts in three visible locations, according to the preliminary report. One bolt area is obscured by insulation in the photo, though the NTSB said it was able to determine in its laboratory that the bolt was also not put back on.
Boeing has said it is cooperating "fully and transparently with the NTSB's investigation."
On Tuesday, Transportation Secretary Sean Duffy said he is "closely monitoring Boeing's performance" and that a "number of the NTSB's recommendations have already been implemented."
"While Boeing is making progress, the FAA will not lift the 737 production cap until we are fully confident the company can consistently produce aircraft that meet our rigorous safety and quality standards," Duffy said in a statement.
During an NTSB hearing on the door plug blowout in August 2024, Boeing Commercial Airplanes senior executive Elizabeth Lund said the company is working on a design change of the door plug to make it even more secure. Planes currently in service will be retrofitted, hopefully within a year, she said at the time.
ABC News' Ayesha Ali contributed to this report.
