Alaska
Boeing work instructions were inadequate for years before blowout on Alaska flight, NTSB finds
The panel blowout aboard an Alaska Airlines Boeing 737 was the result of more than four missing bolts, the National Transportation Safety Board reiterated in its final investigation report into the incident released Thursday.
The Jan. 5, 2024 blowout — which occurred shortly after the Alaska Airlines plane took off from Portland, Oregon — happened because of long-term shortcomings at Boeing and the Federal Aviation Administration, the agency tasked with overseeing the manufacturer’s quality and safety processes, the NTSB determined.
Because Boeing’s instructions for employees lacked “clarity and conciseness,” workers missed opportunities to note that the panel had been removed during the aircraft’s assembly, the NTSB said. The panel was incorrectly reinstalled but, without a record of the work being done, it was not reinspected and left the factory with four crucial bolts missing.
Boeing knew of the deficiencies in its work instructions for a decade, the NTSB said in its report, but both Boeing and the FAA failed to fix the flawed process.
The blame for the panel blowout, then, did not hang on the shoulders of workers who failed to install the four bolts that would have held the panel in place, but instead on Boeing and the FAA, the NTSB said.
The safety board has made these declarations before, including at a June hearing when board members discussed the results of the 18-month-long investigation. NTSB Chair Jennifer Homendy said at that time that “an accident like this only happens when there are multiple system failures,” adding that the “deficiencies that led to this accident should have been evident” to Boeing and the FAA.
The final report released Thursday delves into more detail about what the NTSB found following months of interviews with Boeing and FAA employees, including where its record-keeping processes and work instructions for employees fell short.
What went wrong
On Jan. 5, 2024, on Alaska Airlines Flight 1282, the first officer completed an external preflight walkaround and found nothing abnormal with the Max 9, which had rolled out of Boeing’s Renton, Washington, factory months before.
The flight’s taxi, takeoff and initial climb was uneventful, until the plane reached about 14,830 feet, when the cabin pressure suddenly dropped.
The captain heard flight attendants talking about a hole in the plane but, unable to communicate with one another, both the flight and cabin crews were uncertain about what had happened, the NTSB found.
The flight landed safely back in Portland, with some passengers and crew members reporting minor injuries. The left side of the plane had a hole that measured roughly 29 inches wide and 59 inches high. A seat back tray table, two seat headrests and nearby cabin interior panels were missing.
Months earlier, Boeing mechanics in the company’s Renton factory had removed that panel, known as a door plug because it fills a hole in the fuselage that can be used as an emergency exit for high-density seating aircraft.
Mechanics removed the panel to fix a problem with rivets. But, the NTSB found, none of the personnel working on the door plug generated a record that the panel had been removed.
Boeing mechanics then reinstalled the door plug, without four bolts meant to hold it in place. Because there was no removal record, no one conducted a final inspection to sign off that the door plug was reinstalled correctly.
After the plane was delivered to Alaska Airlines — without the bolts in place — the door plug slowly slid upwards, until, during Flight 1282, it moved far enough up to separate from stop fittings pinning it in place. The loosened plug then flew out of the airframe, leaving a hole in the side of the aircraft.
The four bolts meant to hold the door plug in place were never found, the NTSB said.
Missed chances
The NTSB determined that Boeing workers missed two opportunities to prompt a reinspection of the door plug after it had been removed and reinstalled.
Though both were needed to properly follow Boeing’s work processes, just one of the two could have prompted a second look and caught the missing bolts, preventing the near catastrophe.
Boeing’s procedures direct workers to generate a “removal record” to document what parts of the airplane they took off and what tasks are then needed to assure the parts are re-installed correctly.
That removal record is required whenever there is a “disturbance of a previously accepted installation,” according to the NTSB’s report. In other words, whenever the removal would affect a job task that had already been inspected and approved. The removal would then require the earlier task be reinspected.
In one early discussion about the door plug, the NTSB learned that a senior manager told the door manager that “if removal (is) needed, a removal needs to (be) written first.”
Still, the NTSB determined that neither the door team manager nor any of the door team personnel on duty had any experience opening a door plug, nor any knowledge of who actually performed the work. A removal record was not generated.
Separately, Boeing also incorporates a “short stamp process,” which is meant to document work that couldn’t be completed in its initial phase of production and therefore has to “travel” through the factory. A “stamp” indicates that a portion of the work has been completed.
In this case, Boeing’s post accident review showed the short stamp process “did not clearly define the work remaining,” the NTSB said.
Though the short stamp process would not have negated the need for a removal record, it may have prompted a second look at the area and found that the bolts were missing, the NTSB said in its final report.
A systemic problem
The NTSB did not identify any individuals who worked on the removal and reinstallation of the door plug, and it’s not clear if the agency knows who performed those tasks.
But, the board made it clear in its final report that the incident was not the result of a single worker or group of workers who missed a crucial step in Boeing’s process. Instead, it was the result of a company-wide problem that had long been identified.
It found that Boeing’s instructions for removal records “lacked clarity, conciseness and ease of use.”
The specific instructions for generating a removal record were more than 50 pages long, directed workers to other instructions and “provided more exceptions about when a removal record was not needed than direction indicating when it was,” the NTSB wrote in its report.
“Boeing lacked the comprehensive training and clear guidance needed to ensure that its … 737 door team personnel and others could consistently meet quality and safety standards,” the NTSB continued.
Boeing had been aware that its work instructions were not preparing employees to follow the removal process for at least 10 years, the agency determined. Those specific work instructions were referenced in 16 compliance issue reports to the FAA from 2018 to 2023, including instances of workers failing to generate a removal when it was required, the NTSB found.
Boeing had “substantively” revised the instructions 11 times between 2013 and 2023, but its proposed changes, which had been accepted by the FAA, were “ineffective,” the NTSB said. Furthermore, the FAA lacked the processes to keep track of discrepancies and nonconformances related to Boeing’s removal process.
A call for change
Boeing has since updated its instructions and training, including adding more training on when and why removal documentation is required.
Still, the NTSB said in its report that “effective guidance and recurrent training are critical” to ensure employees know what to do when a removal arises.
The NTSB, which does not have regulatory or enforcement authority, recommended Boeing update its on-the-job training to identify tasks that are necessary for manufacturing workers to be considered “fully qualified.”
That’s in part because the NTSB found that training for “nonroutine tasks,” including opening a door plug and generating a removal record, was not part of a structured program, leaving many workers unprepared.
The NTSB also recommended Boeing implement a grading system for its training program and develop a process to identify quality issues that result from human error, in order to prevent the same error from reoccurring.
When it comes to Boeing’s oversight, the NTSB said it was “encouraged by the FAA’s initial progress” but recommended the agency revise its compliance enforcement system, audit activity and record-keeping system.
It also recommended that the FAA convene an independent panel to review Boeing’s safety culture.
In response to the NTSB’s recommendations first publicized at the June hearing, the FAA said it has “fundamentally changed how it oversees Boeing … and we will continue this aggressive oversight to ensure Boeing fixes its systemic production-quality issues.”
Boeing could not be reached for comment Thursday.
HONOLULU (KHON2) — It’s the biggest milestone yet in the Hawaiian Airlines merger with Alaska Airlines.
Starting Wednesday, April 22, Hawaiian Airlines and Alaska will operate as one, powered by a single passenger reservation system, essentially the technology behind your entire travel experience.
“The system that connects all of the programs that our guests use, things like our websites, our app, our Atmos rewards program, our Huaka’i program, all of those systems, including employee tools, will be updated as of tomorrow to a more modern single passenger service system that will allow a more stream streamlined and seamless guest experience for all those that are traveling on either Alaska or Hawaiian that will allow a more stream streamlined and seamless guest experience for all those that are traveling on either Alaska or Hawaiian,” said Alisa Onishi, Hawaiian Airlines Marketing Manager.
By midnight tonight, the Hawaiian app goes dark, replaced by a new combined Alaska-Hawaiian platform, marking a major shift in how you book and manage your flights.
“If you download our new single Alaska-Hawaiian app, you’ll be able to manage your bookings all in one place, make changes, cancellations and a lot more self-service features that our guests have been asking us for for quite some time now that you couldn’t do on the old app,” said Onishi.
Behind the scenes, this moment has been three years in the making. Alaska announced its $1.9 billion acquisition back in 2023, with approvals and integration steps unfolding through 2024 and 2025.
At the airport, much will look the same, but the process is getting an upgrade. Travelers are encouraged to check in ahead of time, using the new app, then use updated bag tag stations to print tags and drop bags faster.
“You scan your boarding pass, prints out the bag tags. You can pay or prepay online or pay at the stations and then drop your bag, so you’ll get through the airport a lot quicker,” said Onishi.
Airline officials said the goal is a more seamless, self-service experience, something customers have been asking for.
Still, not everyone is convinced.
“Even today, when I was trying to get my boarding passes, there was a Hawaiian-Alaskan app that I went to, and then it referred me back to the Hawaiian app. So I didn’t know what application I was supposed to be using, but ultimately, it worked out to a point,” said Ethan Christensen, who was standing in line at customer service to confirm his flight for tomorrow. “But yeah, we’ll see. Hopefully, it gets better. I mean, I know these things take time, especially when you’re kind of merging two big things like this, but the outlook is positive for me because I know it’s a good airline. Hopefully it stays that way.”
The call centers are not going away, and customer service desks will remain at the airports for those who need one-on-one help.
Airline leaders acknowledge the transition so far hasn’t been perfect, but said this milestone is meant to fix many of those issues.
The state agency leading some of Alaska’s most polarizing development projects has approved a new communications budget, saying it needs to do a better job telling its own story amid attacks from critics.
The state-owned Alaska Industrial Development and Export Authority is run by a former chief of staff to Gov. Mike Dunleavy and is charged with promoting economic growth and expanding natural resource extraction and exports.
It is leading work to develop state-owned oil leases in the Arctic National Wildlife Refuge and also hopes to build two controversial new roads to access mining prospects in Northwest Alaska and outside of Anchorage.
Those projects have drawn sharp opposition from conservation organizations and other critics, including lawsuits, critical op-eds and campaigns that have labeled the agency “Bad AIDEA” and caricatured its leaders.
At a meeting in Ketchikan this month, board members, with no public discussion, authorized AIDEA’s staff to spend up to $700,000 a year on a new communications budget — formalizing a plan that the agency says was previously budgeted inconsistently through spending on individual projects.
The new communications plan, the agency said in its formal resolution authorizing the spending, will “ensure proper public engagement, transparency, and stewardship of the authority’s mission.” The money could go toward trade shows and conferences, responding to media inquiries and “other communications-related needs,” according to the resolution.
The agency’s executive director, Randy Ruaro, referred questions about the plan to Dave Stieren, an AIDEA employee who ran an advertising agency and hosted a conservative talk radio show before joining the Dunleavy administration.
Stieren said he could not provide exact figures on AIDEA’s past communications spending, but he acknowledged that the new plan should allow the agency to meaningfully boost its public profile.
The $700,000 a year, he added, is a limit, and the agency will set a final budget through a request for proposals process.
“Mothership AIDEA has done, frankly, little to nothing on a consistent basis to tell our story,” Stieren said in an email — particularly when it comes to its loan programs that have helped finance tourism and hospitality businesses, like the Alaska Club fitness chain and Anchorage’s Bear Tooth pizza restaurant and theater.
“We’re far more than roads,” Stieren said. “But since we’ve really not promoted or showcased our efforts in traditional finance areas, I understand the narrative or lack thereof that folks may have.”
Stieren has also personally defended AIDEA on social media, including over the weekend — when he posted a conservative news website’s positive story about an agency-owned shipyard and said that “when commie libs attack AIDEA, they attack projects like this.”
AIDEA’s board chair, Bill Kendig, declined to answer questions about approval of the new communications budget when reached by phone.
At the Ketchikan meeting, one AIDEA critic, Melis Coady, credited the agency with formalizing communications spending as a “step toward accountability.” But she said that the plan doesn’t “deliver the transparency it describes” because it gives Ruaro, the executive director, authority to approve communications spending, and only requires that he report it to the board if asked.
“The authorization is broad, the dollar amount is undefined, and expenditures are approved solely by the executive director,” said Coady, who leads a conservation group called the Susitna River Coalition.
Ruaro, in an email, said AIDEA will issue reports on communications to board members “whether requested or not.”
Nathaniel Herz is an Anchorage-based reporter. Subscribe to his newsletter, Northern Journal, at northernjournal.com.
In exchange for living in what is perhaps the country’s most beautiful state, Alaskans sometimes have to do without: professional sports teams, Trader Joe’s and, well, sunlight for half the year. But we make up for it with the Iditarod, reindeer sausages and chasing the aurora borealis. In other words, we often have to make our own fun. And by “fun” I mean “beer.” Those words are interchangeable, right?
Beer is a big part of life for Alaskans. We hike with it, camp with it, boat with it, cook with it and pair it with foods like the stuffiest of sommeliers. We throw it monthly birthday parties like the First Tap events at Broken Tooth Brewing Co. (otherwise known as Bear Tooth Theatrepub and Moose’s Tooth Pub & Pizzeria), complete with national musical acts like Modest Mouse, Clinton Fearon, and Norah Jones. We even occasionally do yoga with it (at downtown’s Williwaw Social). In other words, we take it everywhere and we take it seriously.
Beers from the state’s biggest brewery, Alaskan Brewing Co. based in Juneau, might already be in your refrigerator if you live in one of the 25 states where it’s available. Established in 1986 by Marcy and Geoff Larson, it was the 67th independent brewery to open in the country. With a steady line of signature brews, including their most recent “Wildness” beer, it’s the most well-established of all the state’s breweries. Expect seasonal specialties that incorporate ingredients like cranberries, raspberries, locally roasted coffee, locally grown white wheat from the Matanuska-Susitna area and even Alaska spruce tips. Ubiquitous around Alaska, this is our Papa Beer, if you will (I’ll show myself out).
But Alaskan Brewing is just one out of the more-than 50 breweries, distilleries, meaderies and cideries in the state (for an excellent list visit brewersguildofalaska.org). And while almost half of them are in Anchorage or within a short drive of our state’s largest city (including the relatively populous communities of Girdwood, Eagle River, Palmer and Wasilla), some of our most remote ports of call and tiniest towns are also in on the brewing action (I’m looking at you, Cooper Landing Brewing Company in Cooper Landing, population 231).
The ever-expanding Denali Brewing Co. in Talkeetna (population 997) may be a small-town hero, but it’s anything but small. Their four signature beers — Mother Ale, Chuli Stout, Single Engine Red and the ever-popular Twister Creek IPA, as well seasonal brews like Slow Down Brown and Flag Stop Milepost #3 — are year-round mainstays of summer barbecues and winter bonfires around the state.
This brewery is also home to the more recently established Alaska Cider Works, Alaska Meadery (featuring “Razzery,” a mead made with raspberries, sour cherries and apples) and Denali Spirits (featuring vodka, gin, whiskey, and “smoke” whiskey), because when you’ve fermented one, why not ferment them all?
(Denali Spirits’ canned cocktails, especially their blueberry mojito, have been so popular in Anchorage that at one time there was a Facebook page largely dedicated to tracking them down. Luckily, supply has since caught up with demand.)
Some breweries are even more remote. Ports of call and island hopping here can be one way to get your fill of hops. Breweries can be found in Ketchikan (Bawden Street Brewing Co.), Kodiak (Kodiak Island Brewing & Still, Double Shovel Kodiak Cidery, and Olds River Inn), Homer (Homer Brewing Co. and Grace Ridge Brewing Co. for beer, and you can also check out Sweetgale Meadworks & Cider House for hard cider and locally sourced meads featuring ingredients like nagoonberry), Sitka (Harbor Mountain Brewing), Seward (Seward Brewing Co. and Stoney Creek Brewhouse), Valdez (Valdez Brewing and Growler Bay Brewing), and Skagway (Klondike Brewing Co. and Skagway Brewing Co.).
Of course, many trips to Alaska begin and end in Anchorage. And if, during your travels, you’ve foolishly left some beers untasted, you can make up for lost time in our state’s biggest city which boasts — let’s face it — a ridiculous number of exceptional craft breweries.
Downtown’s Glacier Brewhouse specializes in oak-aged English and American West Coast-style beers, 13 of them, from blondes to stouts. Beneath the floor of the Brewhouse is a “Wall of Wood” comprised of casks of special release beers that are conditioned in oak barrels once used to age wine and bourbon. The history of the oak imparts “mother tongue” flavor characteristics, like vanilla and coconut, into these limited edition brews. Opt for one of these unique beers or choose from their flagship choices like raspberry wheat, oatmeal stout, imperial blonde, Bavarian hefeweizen or a flight that includes them all.
Down the street is 49th State Brewing Co., which expanded into Anchorage from its original location in Healy, at the edge of Denali National Park and Preserve. If you are unable to visit their flagship location, where you can sip beer while playing bocce or horseshoes on the lawn, you can catch up with them here. There’s a unique selection that includes beers like Smok, a smoked lager, as well as seasonal offerings like the Tiger’s Blood Sour, an homage to shave ice described as ”ferociously fruity.” Or there’s “Apple Fritter Ale,” with hints of cinnamon, icing, caramel, and vanilla. This location also boasts some of the best views in Anchorage and an expansive outdoor rooftop patio.
Just about all of the full-service restaurants in downtown Anchorage proudly feature some variety of Alaskan beers. In the heart of downtown, Humpy’s Great Alaskan Alehouse prides itself on a huge selection of beers, both international and local. Tent City Taphouse offers a diverse and carefully curated list of 24 rotating local brews, including their house beer, Tent City Tangerine IPA brewed by Glacier Brewhouse. Tent City regularly hosts “Taste of the North” beer dinners featuring Alaskan brewers. One, in collaboration with Grace Ridge Brewing Company, featured smoked salmon canapes with Black Pepper IPA, classic beef Wellington with an Oystercatcher stout and roasted honey lamb chops with a Winter Cranberry Ale.
If you have transportation around the city, treat yourself to a brewery tasting-room tour. Found in unassuming little side streets in the more industrial areas of Anchorage, some of our best beers can be sipped and savored at the source. Finding these funky little spots can feel like being invited to a secret party. And it’s a glimpse into Anchorage’s most authentic beer culture.
In midtown, Onsite Brewing Co. has unique, small-batch brews in a funky relaxed environment. Further south, King Street Brewing Co., Turnagain Brewing, Cynosure Brewing, Magnetic North Brewing Company, Brewerks, and one of our newest, Ship Creek Brewing Company are all within a stone’s throw of one another. If you’re lucky, you might run into one of Anchorage’s popular food trucks parked outside, so you’ll have something to wash down with your flights. Depending on the day, you might find reindeer sausages, pad Thai, cheesesteaks or pupusas. On the weekends, Anchorage Brewing Company features a top-notch in-house pop-up restaurant, called Familia, with a rotating menu featuring local Alaskan ingredients.
One of the newest and furthest south breweries, while still in the Anchorage bowl, is Raven’s Ring Brewing Company, which is a brewery/winery and meadery. From a traditional IPA to a Concorde grape wine called Grape Juice to a rotating Vintner’s pour like Sweet Peach Jalapeno mead, this ambitious operation is challenging the notion that you can’t please everyone.
Other Anchorage points of interest for non-hoppy but still home-grown adult beverages include Anchorage Distillery, Zip Kombucha, Double Shovel Cidery and Hive Mind Meadery.
If your travels are over and you still haven’t had your fill, check out the Silver Gulch Brewing & Bottling Co. inside Terminal C at the Ted Stevens Anchorage International Airport on your way out of town. An offshoot of the flagship Silver Gulch brewery in Fox, Alaska (about 10 miles north of Fairbanks), this location has a bar and restaurant, and a retail shop carrying growlers of their own brews as well as those of other Alaskan brewers and distillers. Last-minute souvenir shopping never tasted so good.
Before you start your great Northern beer safari, bear in mind that tasting rooms often have limited and varying hours, so always double-check before planning a visit.
Whether your travels take you to fine-dining restaurants, low-key alehouses or even rustic cabins in the woods, make like an Alaskan and fuel your adventures with one of our beloved, home-grown brews. When in Alaska, drink as the Alaskans do.
Mara Severin is a food writer who writes about restaurants in Southcentral Alaska for the Anchorage Daily News.
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