Inadequate training and supervision at Boeing cited as root cause of 2024 mid-air door plug incident
FAA faulted for failing to correct Boeing’s known recordkeeping and quality control issues
NTSB warns similar lapses could result in future manufacturing failures if not addressed
The National Transportation Safety Board (NTSB) concluded Tuesday that Boeing’s systemic lapses in worker training, guidance, and oversight were the primary cause of the terrifying mid-flight door plug blowout on an Alaska Airlines Boeing 737 MAX 9 in January 2024.
The board’s investigation also sharply criticized the Federal Aviation Administration (FAA) for ineffective oversight, pointing to the agency’s failure to intervene in Boeing’s “repetitive and systemic” recordkeeping and quality assurance deficiencies — issues the FAA had long known about.
A preventable crisis
The incident occurred just minutes after takeoff from Portland, Oregon, as Alaska Airlines Flight 1282 climbed through 14,830 feet. A door plug — installed to fill a space for an optional emergency exit — blew off the aircraft’s fuselage, triggering a rapid decompression.
Oxygen masks deployed, passenger belongings were sucked from the cabin, and a flight attendant sustained injuries when the cockpit door swung open. Seven passengers also suffered minor injuries.
The door plug was later found in a Portland neighborhood. NTSB investigators determined that critical bolts securing the plug had never been reinstalled following maintenance at Boeing’s Renton, Washington, plant in September 2023. Because the repair work wasn’t properly documented, Boeing’s quality control teams never inspected the reinstallation.
NTSB Chairwoman Jennifer Homendy said the incident laid bare “clear and preventable safety deficiencies,” adding that the absence of basic documentation and oversight could have led to “other manufacturing quality escapes — and, perhaps, other accidents.”
Safety culture breakdown
The NTSB’s final report paints a troubling picture of Boeing’s internal practices. It found that Boeing’s voluntary Safety Management System (SMS) — intended to detect and mitigate safety risks — was inadequate and lacked formal FAA oversight. The program failed to identify the missing documentation or the unauthorized work on the door plug.
Boeing’s procedural requirements called for only trained, specialized technicians to perform tasks on mid-exit door plugs. However, no such workers were present when the plug was closed during the September 2023 repair, and no checks followed.
“These failures reflect a breakdown in safety culture that neither Boeing nor the FAA addressed,” Homendy said.
Broader safety recommendations
Beyond manufacturing issues, the NTSB also issued safety recommendations to address crew oxygen mask training and to encourage greater use of child restraint systems for young passengers. These were informed by passenger experiences during the blowout.
The board reiterated earlier recommendations to the FAA, Airlines for America, the National Air Carrier Association, and the Regional Airline Association, calling for comprehensive reforms across the aviation manufacturing and regulatory ecosystem.
The final report will be published in full on the NTSB’s website in the coming weeks. For now, investigators hope the findings spur lasting reforms at both Boeing and the FAA, aiming to prevent a repeat of an incident that could have ended in disaster.