The National Transportation Safety Board has released its final report on the terrifying midair incident aboard Alaska Airlines Flight 1282, which occurred on Jan. 5, 2024 near Portland, Ore. Boeing Company shareholders can’t be pleased with it.

The investigation concludes that a critical manufacturing failure by Boeing, compounded by ineffective oversight from the Federal Aviation Administration, led to the in-flight separation of a fuselage door plug, rapid cabin depressurization, and injuries to several passengers. No one died in the incident.

The Boeing 737-9 MAX aircraft had just departed Portland International Airport when, at an altitude of 14,830 feet, the left mid-exit door (MED) plug blew off the plane, leaving a gaping hole in the fuselage. The explosive decompression resulted in minor injuries to one flight attendant and seven passengers. The remaining 164 passengers and five crew members escaped physical harm, and the crew safely returned the aircraft to Portland.

The NTSB determined that the door plug failed due to Boeing’s inadequate training, guidance, and oversight during the aircraft’s manufacturing process. Specifically, four key bolts that were supposed to secure the door plug were never reinstalled after being removed for rework at Boeing’s Renton factory. Those bolts were missing from the recovered wreckage and never found.

Boeing’s process for documenting part removals and reinstallations — intended to ensure safety-critical fasteners are tracked — was inconsistently followed, the board found. As a result, the MED plug was installed without the bolts that would have kept it from lifting upward and detaching mid-flight.

The FAA also came under sharp criticism. The NTSB found that the agency’s compliance and surveillance systems failed to identify Boeing’s recurring process failures, calling its enforcement “ineffective” and “inadequate.”

Aircraft Damage and Aftermath

The detached door plug and various interior cabin parts, including tray tables and headrests, were later recovered along the flight path. The fuselage surrounding the plug was heavily damaged, along with parts of the aircraft’s interior cabin near the opening.

Despite the chaos, the flight crew executed emergency procedures flawlessly. The aircraft returned safely to Portland and all passengers deplaned without further incident.

The NTSB issued 24 safety recommendations — 13 to the FAA and 11 to Boeing — to address systemic failures in manufacturing oversight, training, and emergency preparedness. These include:

• To the FAA:
  • Require retrofit of all in-service Boeing 737s with a design fix to prevent future door plug failures.
  • Overhaul compliance surveillance systems to better track recurring safety issues.
  • Improve record retention and provide FAA inspectors with access to historical manufacturing compliance data.
  • Convene an independent review panel of Boeing’s safety culture.
  • Mandate enhancements in CVR (cockpit voice recorder) preservation, portable oxygen mask usability, and child safety seat promotion.
• To Boeing:
  • Complete the certification and retrofitting of a redesigned MED plug.
  • Develop stronger on-the-job training and documentation for part removals.
  • Enhance integration between Boeing’s quality and safety management systems.
  • Implement new procedures for analyzing and mitigating human error in manufacturing.

The NTSB also reiterated earlier safety recommendations, such as requiring all aircraft cockpit voice recorders to retain 25 hours of audio and improving child restraint system (CRS) use among airlines.

This incident is a serious blow to Boeing’s reputation as it continues to grapple with quality control concerns and regulatory scrutiny. The report intensifies pressure on both Boeing and the FAA to address what the NTSB describes as “systemic and recurring” failures.

The NTSB’s final report leaves no ambiguity: A lack of accountability and rigor at both Boeing and the FAA nearly led to catastrophe. Thanks to a trained and prepared crew, disaster was averted. But unless the recommendations are fully implemented, aviation safety experts warn that the next incident could have a far graver outcome.