A terrifying mid-air emergency on an Alaska Airlines Boeing 737 Max flight in January 2024 exposed critical safety failures, and the U.S. National Transportation Safety Board (NTSB) has now placed responsibility squarely on both plane manufacturer Boeing and the Federal Aviation Administration (FAA). The NTSB’s findings, detailed at a recent public hearing, point to a cascade of errors and inadequate oversight that allowed a catastrophic event to occur.
While the dramatic blowout of a door plug at 16,000 feet ripped passengers’ belongings from the plane, miraculously, the crew’s heroic actions ensured there were no serious injuries among the 177 people on board. However, NTSB Chair Jennifer Homendy stressed that such an accident should never have happened, stating it was the result of “multiple system failures.”
Missing Bolts at the Root of the Crisis
The NTSB’s investigation determined the immediate cause of the terrifying incident: four critical bolts designed to secure the door plug were missing when the aircraft was delivered to Alaska Airlines. Further probing revealed these bolts were removed during repair work performed at Boeing’s Renton, Washington plant in September 2023. The door plug had been opened to address five damaged rivets elsewhere on the fuselage. Crucially, this work was poorly documented, and evidence suggested the plug was reinstalled without the necessary bolts. Investigators found it unclear who exactly removed the bolts or if they were simply discarded. Compounding the risk, the door plug had been gradually shifting over the 154 flights the plane operated before the blowout.
Boeing’s “Inadequate Training, Guiding and Oversight”
The NTSB concluded that Boeing Commercial Airplanes bore significant blame due to its “failure to provide adequate training, guiding and oversight.” The investigation uncovered troubling issues within Boeing’s factory culture. Workers reported feeling pressured to complete tasks too quickly and performing duties they weren’t properly trained for. Specifically regarding the door plug repair, none of the 24 people on the door team were trained to remove such a plug before working on this particular plane, and only one had ever done so previously. No trained personnel were present when the plug was reinstalled. This pointed to a lack of clear standards for on-the-job training, particularly for newer hires brought on after the pandemic and previous 737 Max crashes. The NTSB found Boeing lacked robust safety practices to ensure proper reinstallation and documentation for critical components.
FAA Oversight Deemed “Ineffective”
The FAA, the ultimate safety regulator, was also heavily criticized. The NTSB labeled the agency’s oversight as “ineffective compliance enforcement surveillance and audit planning activities.” Chair Homendy questioned the FAA’s role, calling it the “absolute last barrier of defense” for aviation safety, implying it failed in this capacity. While the FAA conducts numerous audits annually on Boeing’s manufacturing, the NTSB found a lack of clear standards for audit coverage and noted the agency routinely discarded past inspection records, hindering its ability to base future inspections on prior findings and systemic issues. An FAA audit following the incident identified “multiple instances” where Boeing and its supplier, Spirit AeroSystems (which manufactured the fuselage), allegedly failed to comply with manufacturing quality control requirements. An external expert review panel also noted a “disconnect” within Boeing’s safety culture, where some employees doubted that reporting concerns was truly supported.
Recommendations for Systemic Change
Based on its findings, the NTSB issued 19 safety recommendations: 10 directed at the FAA and 9 at Boeing. These recommendations push for improved training, better documentation, enhanced safety management systems, and more rigorous audit processes. Many of these recommendations echoed calls for change made in previous reports, including a 2024 audit by the Office of Inspector General.
Both Boeing and the FAA have stated they are taking the NTSB’s recommendations seriously. The FAA affirmed it has “fundamentally changed” its oversight approach since the accident, implementing more aggressive monitoring and holding weekly meetings with Boeing to review progress. The agency has also maintained a cap on 737 Max production rates, vowing not to lift it until fully confident Boeing can consistently produce aircraft meeting stringent safety and quality standards. Boeing, under new leadership including a recently appointed Senior Vice President of Quality, has expressed regret and stated it is working to strengthen safety and quality across its operations.
Beyond the Door Plug
The NTSB hearing also highlighted other long-standing safety concerns. Investigators noted the lack of 25-hour cockpit voice recorders (CVRs) in many older aircraft, which has hampered multiple investigations by limiting access to critical data. Congress has since mandated longer CVR recordings in new aircraft. The NTSB also reiterated its years-long recommendation for the FAA to require restraints for infants on aircraft, noting three infants were being held on laps during the Alaska Airlines flight, and one mother feared losing her child through the gaping hole.
The findings arrive at a challenging time for Boeing, which faces ongoing scrutiny following two fatal 737 Max crashes in 2018 and 2019, unrelated issues on other aircraft models, and questions surrounding its safety culture and transparency. The NTSB’s final report on the Alaska Airlines incident is expected soon and will provide further detailed insights into the systemic issues identified.
