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Boeing work instructions were inadequate for years before blowout on Alaska flight, NTSB finds

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Boeing work instructions were inadequate for years before blowout on Alaska flight, NTSB finds


FILE – This photo released by the National Transportation Safety Board shows a gaping hole where the paneled-over door had been at the fuselage plug area of Alaska Airlines Flight 1282, Jan. 7, 2024, in Portland, Ore. The DOJ has launched a criminal investigation into the Boeing jetliner blowout that left a gaping hole on the Alaska Airlines plane this January, the Wall Street Journal reported Saturday, March 9. (National Transportation Safety Board via AP, File)

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.

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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.

A plastic sheet covers an area of the fuselage of the Alaska Airlines N704AL Boeing 737 Max 9 aircraft outside a hangar at Portland International Airport on Jan. 8, 2024, in Portland, Oregon. (Mathieu Lewis-Rolland/Getty Images/TNS)

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.

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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.

This photo released by the National Transportation Safety Board shows the door plug that fell from Alaska Airlines Flight 1282 on Jan. 8, 2024, in Portland, Ore. (National Transportation Safety Board via AP, file)

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.

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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.

The top section of the door plug from the Alaska Airlines Flight 1282’s Boeing 737-9 MAX airplane is shown at the National Transportation Safety Board laboratory, in Washington, Tuesday, July 30, 2024. The door plug is showing damaged bolts on the top right corner. (AP Photo/Manuel Balce Ceneta)

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.

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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.

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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.

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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.

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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.





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Backcountry avalanche warning issued for much of Southcentral Alaska

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Backcountry avalanche warning issued for much of Southcentral Alaska


High avalanche danger in the mountains around much of Southcentral Alaska prompted officials to issue a backcountry avalanche warning Saturday for areas from Anchorage to Seward.

The Chugach National Forest Avalanche Information Center said that a combination of heavy snowfall, strong winds and low-elevation rain Saturday “will overload a weak snowpack, creating widespread areas of unstable snow.”

The warning is in effect from 6 a.m. Saturday to 6 a.m. Sunday.

Human-triggered and natural slides are likely, and avalanche debris may run long distances into the bottoms of valleys and other lower-angle terrain, the center said.

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In Saturday’s avalanche forecast, which noted high avalanche danger at all elevations in the Turnagain Pass and Girdwood areas, the center said avalanches were likely to fail on weak layers about 1.5 to 3 feet deep.

Forecasters recommended that people avoid traveling in avalanche terrain, staying clear of slopes steeper than 30 degrees.

“Avalanche conditions will remain very dangerous immediately after the snow finishes,” the avalanche center said in its warning.

The center also said conditions may cause roofs to shed snow, and urged that people watch for overhead hazards, use care in choosing where to park vehicles and watch out for children and pets.

Areas covered under the backcountry avalanche warning include the mountains around Anchorage, Girdwood, Portage, Turnagain Pass, Lost Lake and Seward.

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Farther north, the Hatcher Pass Avalanche Center in its forecast Saturday said danger was considerable at upper elevations and moderate at middle elevations.

Snowfall in Anchorage and Mat-Su

A winter weather advisory remained in effect until 9 a.m. Sunday from Anchorage up to the lower Matanuska Valley, including the cities of Eagle River, Palmer and Wasilla.

The National Weather Service said total accumulations of 4 to 8 inches of snow were possible, with localized areas potentially receiving up to a foot of snow.

The snowfall was expected to peak Saturday evening before tapering off Sunday morning, the weather service said.





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In US Supreme Court case over which absentee ballots count, Alaska doesn’t pick a side

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In US Supreme Court case over which absentee ballots count, Alaska doesn’t pick a side


Ballot envelopes from the special primary election for Alaska’s lone U.S. House seat are prepared to be opened at the State Division of Elections Region II office in Anchorage on June 13, 2022. (Bill Roth / ADN)

Alaska’s appointed attorney general on Friday filed a friends of the court brief in a case before the U.S. Supreme Court involving whether absentee ballots that arrive after Election Day can be counted.

The filing does not side with either party in the case, which arose in Mississippi.

Instead, it informs the court of the logistical hurdles in Alaska — far-flung villages, lack of roads and severe weather — that make it difficult to receive absentee ballots by Election Day.

Alaska, like roughly half the other states in the U.S., allows some ballots cast by Election Day to be received later, the brief says.

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The case, Watson v. Republican National Committee, challenges a law in Mississippi that allows absentee ballots received shortly after Election Day to count if they are postmarked by Election Day.

The Republican National Committee, the Mississippi Republican Party, the Libertarian Party of Mississippi and a Mississippi voter challenged the law in 2024. They argue that under federal law, ballots must received by state officials by Election Day to be counted.

The case could have national implications by influencing midterm elections, and comes amid baseless assertions from President Donald Trump that mail-in voting results in “MASSIVE VOTER FRAUD.”

The Alaska brief was filed by Jenna Lorence, the first Alaska solicitor general after Attorney General Stephen Cox created the role and appointed the Indiana attorney in October to fill it.

The 14-page brief says it does not support either party in the case.

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The state’s impartiality drew criticism from an elections attorney, Scott Kendall, one of the main architects of the state’s ranked choice voting and open primary system.

“If you’re going to file something, take a position in favor of Alaska’s laws because they’re there for a very good reason,” Kendall said.

If the U.S. Supreme Court strikes down the law in Mississippi, that could lead to the disenfranchisement of many Alaska voters whose ballots arrive after Election Day, he said.

“Thousands upon thousands of Alaskans, through no fault of their own, wouldn’t be able to vote, and that’s not the democracy I signed up for,” Kendall said.

Under Alaska law, absentee ballots sent in state are counted if they are received “by the close of business on the 10th day after the election,” the filing says. Ballots from overseas must be received by the 15th day after the election.

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Asked why the solicitor general did not take a position defending Alaska’s law or siding with either party, the Department of Law said in a statement emailed by spokesperson Sam Curtis:

“The State is committed to providing fair elections for Alaskans and will do so whatever rule the Court adopts. Alaska has previously filed these factual briefs to ensure courts understand the State’s unique perspective. Here, we wanted to ensure the Supreme Court knew how circumstances in Alaska make rules that might be simple in Mississippi more complicated in our State. We’re asking for clarity, so the Division of Elections and Alaska voters have straightforward rules to apply in the 2026 election.”

The filing notes that most Alaska communities are hard to reach.

“With over 80 percent of Alaskan communities off the road system, and extreme weather making access by boat or plane unreliable during certain months, including November, Alaska’s Division of Elections will continue to establish processes unlike any other State to ensure that its geography does not limit its citizens’ ability to vote,” the filing says. “Alaska asks that as this Court crafts a rule in this case, it provide clear parameters for Alaska to apply.”

The filing provides examples of how determining when a ballot was “received” by the Division of Elections is not always clearly defined, the Department of Law said.

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In some cases, even in-person votes can struggle to reach the state elections division due to weather and geographical challenges, the filing says.

In 2024, poll workers in Atqasuk in northern Alaska tallied the votes cast on Election Day, but could not reach the elections division by phone that night.

So they “placed the ballots and tally sheets into a secure package and mailed them to the Division, who did not receive them until nine days later,” the filing says. “This exemplifies the hurdles that the Division regularly faces to receive and count votes from rural areas.”

The 5th Circuit Court of Appeals held that ballots must “be both cast by voters and received by state officials” by Election Day, the filing says.

“While that rule may invalidate laws like Mississippi’s delayed receipt deadline, what does it do in a situation like Atqasuk, where votes were cast and received by some poll workers on election day, but state officials did not receive the physical ballots or vote tallies until days later?” the filing says.

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“Even more standardized voting situations in Alaska raise these questions,” the filing says.

“For example, when a voter casts an in-person absentee ballot in a remote area shortly before election day, the absentee voting official must send the ballot (in its unopened absentee ballot envelope) to the regional office, which may take some time,” the filing says. “Is the ballot ‘received’ the day it is turned over to the voting official? Or is it ‘received’ only once it reaches the regional office, where, for the first time, the Division evaluates eligibility before opening the envelope and counting the ballot within?”

“While it is clear when a ballot is ‘cast’ in Alaska (meaning that the vote cannot be changed), when certain ballots are actually ‘received’ is open to different interpretations, especially given the connectivity challenges for Alaska’s far-flung boroughs,” the filing says.

Alaska Lt. Gov. Nancy Dahlstrom, who oversees elections, said in a prepared statement that Alaska wants the Supreme Court “to provide clear guidance that protects election integrity while recognizing Alaska’s logistical challenges, so every eligible voter can make their voice heard.”

Cox said in the statement that Alaska wants the court to “consider how a rule that seems straightforward in some states might raise more questions in others. All we want is clarity in the rules.”

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The filing also points out that for absentee ballots, many voters rely on the United States Postal Service.

“But unlike in other states, where mail delivery can be accomplished by simply driving to someone’s house via a continuous road system, USPS must use creative solutions to reach 82 percent of Alaskan communities,” the filing says.

In a separate matter, new guidelines from the U.S. Postal Service could also lead to votes not being counted across the U.S.

The postal service said on Dec. 24 it cannot guarantee that it will postmark ballots the same day they are put into a mailbox.





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Multiple small avalanches release in Juneau after city issues evacuation advisory

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Multiple small avalanches release in Juneau after city issues evacuation advisory


Ezra Strong in front of the Behrends slide path on Friday, Jan. 9, 2025. (Photo by Alix Soliman/KTOO)

Two small avalanches released on a slide path of Mount Juneau, above the Behrends neighborhood, as Ezra Strong was on a walk this morning in the pouring rain. 

The city issued an evacuation advisory about an hour earlier for Juneau residents in all known slide paths downtown and along Thane Road. Strong and his wife live on Gruening Avenue with their dog. He said he’s not heeding the advisory.

“I think in part because we’re a little bit protected by a rock wall and some other things behind us, in part because we have seen slides come down before on the main slide path that didn’t even get close to us,” he said.

During an online press conference Friday morning, the City & Borough of Juneau’s new Avalanche Advisor John Bressette said that many small slides reduce the hazard by decreasing the amount of snow that could be released in a larger slide. 

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“So it’s actually a good thing that we’re seeing smaller slides reducing the total snow load that is capable of producing an avalanche,” Bressette said. 

Some avalanches released above the Flume Trail today. The Alaska Department of Transportation and Public Facilities confirmed numerous small avalanches along Thane Road this morning. The agency expects more avalanches this evening since the forecast shows continued heavy rainfall, strong winds and warming temperatures. The closure of Thane Road could be extended multiple days. 

A slide coming off Mt. Juneau down Chop Gully above the flume in the Basin Road area on Friday, Jan. 9, 2026. (Photo by Mikko Wilson/KTOO)

Some residents of the Behrends neighborhood have evacuated to friends’ houses or Centennial Hall, the official shelter set up by the city and the American Red Cross.

Carlos Cadiente lives kitty-corner from Juneau-Douglas High School: Yadaa.at Kalé in the Behrends slide path. He evacuated at around 11:30 a.m. in one vehicle while his wife drove behind in another. At a stop sign, he told KTOO they were headed to a friend’s house just down the street. 

“We already had a go bag going and we already had the cars loaded up and ready to roll, and so we’re rolling,” Cadiente said. 

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He said this is the first time they’ve heeded an avalanche evacuation advisory in the decades they’ve lived here. 

“It’s kind of an extreme measure, you know, extreme weather that we’ve had,” he said. “So we’re just kind of trying to be proactive and not be a problem,” he said. 

Britt Tonnessen is the community disaster program manager for the Red Cross of Alaska in Southeast. In coordination with the city, the Red Cross set up an emergency shelter at Centennial Hall downtown for residents on Friday. 

At the shelter on Friday morning, she said the Red Cross has been preparing for the last week in case of an evacuation. 

“We’ve seen multiple fatal landslides and avalanches in the past decade,” she said. “Evacuating to a congregate shelter is not people’s dream idea. It’s a safe place to go. We do the best to meet the needs and we have incredible, loving, warm volunteers to meet people.”

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Tonnessen said that anyone from avalanche zones, as well as those who feel the load on their roof is becoming too heavy, are welcome at the shelter. 

She said they are prepared to take 150 people, and around 30 people signed in by the early afternoon

Avalanche, weather and road conditions are expected to worsen this evening.

KTOO reporter Clarise Larson contributed to this report. 



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