On Wednesday in Washington, D.C., NTSB Chair Jennifer Homendy noted the investigation into the door plug blowout in January near Portland, Oregon, has revealed that the message to Boeing workers is “you mess up, you get moved.”

The 737 flying as Alaska Airlines Flight 1282 had been in service less than four months when it lost a door plug on January 5 shortly after takeoff from Portland International Airport (KPDX). The airline grounded its fleet of 737 Max 9s and the FAA followed suit, keeping the airplanes on the ground out of an abundance of caution.

• READ MORE: NTSB Grills Boeing Over Max 9 Door Plug Loss

Within two weeks, the NTSB determined the door plug had been reinstalled without four retaining bolts. Two crews who flew the aircraft prior to the blowout reported issues with the pressurization system. The aircraft was slated to go into maintenance.

On the first day of testimony on Tuesday, Boeing officials stated that during the build process the door plug was removed from the fuselage at the Renton, Washington, factory in order to replace substandard rivets. The required paperwork authorizing and tracking the removal and subsequent reinstallation has still not been found.

Homendy stressed that no evidence has been discovered to suggest the improper installation of the door plug was anything more than a mistake. Boeing has stated there is a no-retaliation policy, and it should not implement disciplinary action for unintentional mistakes.

However, Homendy questioned that assertion, citing a decision by Boeing to move two members of the door installation crew from the plant at Renton to the factory in Everett, Washington, describing it as “a form of retaliation.” There were references to Boeing employees calling the Everett facility a “cage,” “jail,” or “prison” for workers who speak up about safety issues or report mistakes.

• READ MORE: Boeing Names New CEO to Lead Through ‘Consequential Period’

During the proceedings there were several mentions of how lucky the people aboard Alaska Airlines Flight 1282 had been, as there were injuries but no loss of life. Several officials noted that had the aircraft been much higher, the damage and outcome likely would have been much different.

A representative from the flight attendants union described his emotions when he learned of the blowout on the jet that had only been in service since October, realizing he had been assigned to the aircraft on a previous trip.

Much of the testimony over the past two days carried the theme of an “accident waiting to happen” because of a lack of oversight, rush jobs, and hastily trained and overworked technicians. Those who testified spoke of a factory culture where employee training is rushed or sometimes incomplete. In addition, employee turnover is frequent, resulting in employees with limited experience who don’t recognize a mistake or hazard on the floor during the build process.

Boeing officials touted the “speak up” process that encourages employees to call attention to airplane safety issues by reporting them to a manager or anonymously. However, many employees when questioned stated that they were not familiar with the “speak up” process, or they feared retaliation, saying “nothing within the Boeing system is confidential.”

• READ MORE: Boeing to Plead Guilty in DOJ 737 Max Crash Cases

It was noted that Boeing has faced accusations of retaliation against whistleblowers in the past, most notably in 2018 and 2019 after the two 737 Max crashes that killed 346 people. Both crashes were attributed to the MCAS, an automated system that put the aircraft into unrecoverable dives shortly after takeoff. The subsequent investigation revealed the pilots had not been told of or trained on the use of the system.

FAA representatives stated that the agency hotline has received an increase in reports of safety concerns from Boeing employees and those from Spirit AeroSystems, a Boeing contractor that builds the components of the 737 fuselage, such as the door plugs, since the accident.

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Wednesday is Day 2 of the NTSB hearing about the loss of a door plug from a Boeing 737 Max 9 in January after takeoff in Portland, Oregon.

According to Tuesday’s proceedings, sometimes the shoddy work was discovered and rectified before the aircraft was delivered. Sometimes it was not, as in the case of the 737 that was delivered to Alaska Airlines.

• READ MORE: NTSB Sanctions Boeing for Sharing Door Plug Blow Out Investigative Details

Boeing relies on contractor SpiritAeroSystems to build the fuselages. A representative from Spirit told the NTSB that the door plug for fuselage No. 8789, which was delivered to Alaska Airlines in fall 2023 and became ill-rated Flight 1282, was built at SpiritAeroSystems Malaysia and shipped to Wichita, Kansas, where it was installed in the fuselage, which was then shipped to the Boeing factory in Renton, Washington.

When it arrived at the factory, it was determined that the rivets in the assembly if the fuselage were substandard, and in order to replace them, the door plug had to be removed.

According to Elizabeth Lund, senior vice president/quality of Boeing Commercial Airplanes, when there is a need to replace a component such as a door plug, there is supposed to be a paperwork trail to indicate what needs to be done and who will do it, and then who has done it.

“We have still found no paperwork documenting the removal of 8789 left-hand door plug,” Lund testified to the NTSB on Tuesday.

Lund said the door plug was removed to replace a line of rivets that were not up to standard, and then it was put back into position so that the aircraft could be moved outside and its interior protected from the weather. The door plug was missing four crucial bolts.

• READ MORE: Boeing to Acquire Spirit AeroSystems in $8.3 Billion Deal

According to Boeing, under normal circumstances, the paperwork trail would let employees know the door plug had been reinstalled but the bolts had not been replaced. The paperwork would indicate the bolts had to be reinstalled before the aircraft could be delivered.

That was not the case here, according to testimony. The aircraft was delivered to Alaska Airlines in October 2023 and flew for approximately 100 flight cycles (takeoffs and landings) with the door plug kept in place by a series of small pins. There were two reports of crew noticing pressurization warning lights in the cockpit. The aircraft was supposed to go in for maintenance at the end of the duty day on January 5.

There were Spirit employees at the Boeing Renton plant, but according to testimony, communication between the Boeing and Spirit workers on the floor of the factory wasn’t good, and there was a lot of turnover at the facility because of low morale and early retirement of more experienced technicians due to COVID-19.

There were no serious physical injuries when the door plug blew out as the aircraft reached 16,000 feet, although seven passengers and a flight attendant were treated for injuries upon landing. The flight crew was praised for its skill, and aviation experts noted that had the aircraft been higher, the outcome would have been much worse.

NTSB Chair Jennifer Homendy offered an apology to the passengers and flight crew on behalf of the agency.

The decision to conduct the two-day hearing into the event is unprecedented. Within hours of the blowout, Alaska Airlines grounded its 737 Max 9s, and the FAA followed suit grounding the world fleet for 19 days while inspections were done to door plugs.

The post NTSB Grills Boeing Over Max 9 Door Plug Loss appeared first on FLYING Magazine.

The aircraft, operating as Alaska Airlines Flight 1282, had just taken off from Portland International Airport (KPDX) in Oregon, and as it passed through 16,000 feet, the door plug blew off, resulting in rapid decompression. All 177 people on board the aircraft survived, although eight were injured by the loss of pressure that resulted in loose objects and parts of the cabin interior being turned into projectiles.

Last week the NTSB displayed the door plug that departed the aircraft. The door has been the subject of scrutiny in the agency’s materials lab.

• READ MORE: Boeing to Plead Guilty in DOJ 737 Max Crash Cases

The NTSB’s preliminary investigation revealed that four restraining bolts designed to hold the door plug in place were missing during the last flight. On two previous occasions the flight crews had reported a pressurization warning light had activated in the cockpit. Both times the crew notified maintenance about the issue. The aircraft was removed from over-water flights and scheduled for maintenance at the end of the day on January 5.

Boeing did not respond to FLYING’s inquiries by press time, although the aerospace manufacturer has been subpoenaed to appear at the hearing.

In response to the accident, the company initiated changes in the workplace to enhance safety culture that included the removal of several highly placed company officials. In March Boeing CEO Dave Calhoun announced he would step down at the end of the year. At the end of July Boeing announced Robert “Kelly” Ortberg will be the new CEO.

As previously reported by FLYING, the NTSB sanctioned Boeing, suggesting it had released nonpublic information into the investigation.

Alaska Airlines is a party to the investigation and offered a statement to FLYING.

• READ MORE: Boeing to Acquire Spirit AeroSystems in $8.3 Billion Deal

“We appreciate the importance of the investigative hearing being conducted by the National Transportation Safety Board (NTSB) into Alaska Airlines Flight 1282 and the ‘in-flight mid-exit door plug Separation,” Alaska Airlines said in the statement.  “This hearing is part of the NTSB’s established investigation to obtain additional information necessary to determine the facts, circumstances, and probable cause of the accident. Our participating safety and technical representatives remain committed to cooperating with the NTSB.”

The Alaska Airlines statement concludes that because this is an ongoing investigation, the company is limited in the details it can release.

“Safety is always our top priority at Alaska Airlines,” the company said. “We have full confidence in the safety of our operation and aircraft.”

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