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.
Two US soldiers were wounded by a brown bear during a training exercise in Alaska on Thursday, the US Army stated.
Anchorage Daily News reported that the soldiers were from the 11th Airborne Division, and that the exercise had been a “land navigation training event” near Joint Base Elmendorf-Richardson.
State wildlife officials said that the bear attack seemed to be a defensive one, from a bear which had recently emerged from its den. Staff members from the Alaska Department of Fish and Game collected evidence at the scene in an attempt to learn more about the bear, such as its species and gender.
“The incident is currently under investigation, and we are working closely with installation authorities and local wildlife officials to gather all relevant information and ensure the safety of all personnel in the area,” the 11th Airborne Division said in a statement, reported ABC News.
ABC News also cited an 11th Airborne Division spokesperson, Lt.-Col. Jo Nederhoed, who said that the two soldiers had been seriously wounded, but were receiving care at a hospital in Anchorage, and had shown improvement by Saturday morning.
“We hope both individuals have a full and quick recovery, and our thoughts are with them during this time,” Fish and Game Regional Supervisor Cyndi Wardlow said in a statement reported by Anchorage Daily News. “In this case, having bear spray with them in the field may have saved their lives.”
Both of the soldiers reportedly had and used bear spray during the attack.
The bear’s condition and whereabouts are currently unknown.
Up, up and away … that’s where most travel prices are going.
It’s true. Not only are our nation’s geopolitical thrusts in the Mideast affecting the cost of your fill-ups, every component of your trip from airfares to car rentals and hotel stays are subject to price hikes.
Imagine filling up a jetliner with jet fuel that’s doubled in price. It’s enough to melt your credit card, regardless of the number of points you get for every dollar spent!
Because the price of oil affects everything, higher prices are eating away at your travel budget in many ways.
Bag fees
There’s lots of press on this. All airlines are increasing their checked-bag fees because of the jump in fuel prices.
Back in 2009, Alaska Airlines instituted a $15 fee for the first checked bag and $25 for the second bag. At the time, there was no charge for the first bag and a second bag was $25.
Last week, Alaska Airlines, along with other major airlines, increased its fees to $45 for the first checked bag and $55 for the second bag. Delta Air Lines charges the same.
Even if the cost of oil comes down, I don’t expect bag fees will ever be reduced.
Travelers who live in Alaska are somewhat insulated from the new hikes because both Delta and Alaska Airlines offer two free checked bags, with conditions:
1. Alaska offers two free checked bags for travelers flying to or from Alaska who are enrolled in Club 49. This does not affect other flights on Alaska. Separately, ATMOS credit card holders can get a free checked bag. Also, elite members of the ATMOS scheme get one or two free checked bags systemwide.
2. Delta offers two free checked bags for travelers flying to or from Alaska who are SkyMiles members who live in Alaska. Again, this does not apply to other Delta flights. Separately, Delta American Express cardholders can get a free checked bag.
3. Elite-level travelers with the oneworld airline cartel, including Alaska Airlines, can get one or two checked bags on American, British Airways, Japan Airlines, Qantas or other oneworld carriers.
[Anchorage’s international airport rolls out self-driving wheelchairs]
Main Cabin vs. Basic Economy
The spread between the lowest available price, Basic Economy, and a more flexible ticket, Main Cabin, has increased. While the difference used to be $20-$30 each way when the Basic Economy scheme was introduced in 2018, the round-trip upcharge now can exceed $100.
For example, the lowest Basic fare to Portland is $337 round-trip on Alaska Airlines. The upcharge to Main Cabin, with full loyalty points, pre-assigned seats and more flexibility on changes and cancellations, is $447, a 33% upcharge.
This trend is not specifically attributable to the new Iran War. It’s just a cost that continues to rise.
New fees
I’m impressed at the creativity of airline people who dream up new fees. Here are some of my favorites from Alaska Airlines:
1. Phone reservations: $15
2. Partner award booking fee: $12.50
3. Pet travel fee: $100 in the cabin, $200 in the baggage compartment with a kennel
4. Left on board item return fee: $20
On Condor Airlines, operating the only nonstop service from Anchorage to Europe, travelers can choose from four different bundles in economy class. The least-expensive, Economy Zero, from $840 round-trip, features fees for travelers:
1. Carry-on bag fee, up to 8kg: $35; a small bag like a purse always is included for free
2. Checked bag: $75
3. Airport check-in: $30
All three of these fees are included in the next-highest fare bucket, Economy Classic, from $900 round-trip. It’s cheaper to buy the bundle than it is to buy the components a la carte. Seat assignments are additional, from $25 for economy.
Airfares on the rise
There are a few good deals available for travel to select West Coast/Intermountain destinations in May, including:
1. Anchorage-San Francisco on Alaska Airlines, from $307 round-trip. Fly May 15-28 only. Add $90 round-trip for Main cabin.
2. Anchorage-Los Angeles on Alaska Airlines, from $317 round-trip. May 15-25 only. Add $90 round-trip for Main.
3. Anchorage-Phoenix on United, Delta or Alaska, from $267-$287 round-trip. Fly May 8-June 9 only. Add $90-$100 for Main.
4. Anchorage-Denver $357 round-trip on Delta. Fly May 8-June 9 only. Add $90 round-trip for Main.
For travel to other destinations, or later in the summer, be prepared to pay more.
Flying to Hawaii? Alaska Air’s nonstop prices out at $706 round-trip between May 30 and June 6. Add $110 round-trip for Main.
Nonstop flights from Anchorage to Salt Lake City start at $669 round-trip with Delta on May 17. That’s $100 more than the cost for the same flights last month. Add $90 more for Main.
Hotel costs continue to rise, accompanied by pesky resort fees.
The Outrigger on the Beach in Waikiki is a very nice beachfront hotel. It’s not plush, or the nicest property. But it’s solid. The cost is $334 per night.
But there’s more: a $50 per night resort fee, plus a variety of taxes and charges, totaling $112.55 per night.
Down in Seattle, the Sound Hotel in the Belltown neighborhood is marketed by Hilton. The discounted rate for “Honors” members — it’s free to join — is $313.34 per night for a king room in late May. Taxes and fees add an extra $56.40 per night.
There’s no appreciable bump yet for hotel rates as a result of the oil price surge. Yet. But if these hotel rates seem high, they’re in line with hotel rates in Anchorage this summer. At the Sheraton in Anchorage in June, it’s $450 per night, plus $54 in taxes and fees, when booked at Expedia.
Car rentals are not cheap
My go-to site for car rentals is the Costco site, which compares major brands and automatically includes Costco discounts.
In Las Vegas, for a one-day rental in May, Budget charges $67 per day, which includes taxes and fees of $22.77. In Anchorage, the same kind of car, medium SUV, costs $92.97 with Alamo.
The biggest differences so far in car rental rates seems to be the bill you’ll pay when you fill up the tank before returning. There’s no appreciable jump in prices because of the new war.
When it comes to making travel arrangements for the spring and summer, it’s more risky making completely non-refundable arrangements.
I made the decision to purchase most of my summer travel plans in advance, but only after determining I would not need to change the dates. Particularly with airline tickets, it’s expensive to change your dates.
There’s lots of uncertainty regarding travel arrangements, particularly international travel. As fuel prices go up due to oil shortages, travel companies will look for ways to recoup the increased costs. In most cases, those higher costs will be borne by travelers.
ANCHORAGE, Alaska (KTUU) – The reopening of the Strait of Hormuz has led to a decrease in oil prices nationally, but Alaska’s senior senator said the state faces a different situation that could threaten rural communities.
“If you can’t produce power because you don’t have the diesel or you just can’t pay the prices, your little communities can collapse,” Sen. Lisa Murkowski, R-Alaska, said at a Friday press conference at the Arctic Encounter Summit in Anchorage.
The price of oil has been a double-edged sword for Alaska. On one hand, the increased price of North Slope oil brings more revenue to the state, but consumer prices can also rise.
North Slope oil prices were $106.36 a barrel on Thursday.
“This is a very precarious time,” Murkowski said. “Our state has enjoyed a bounty because we have benefited from the higher prices of oil that goes into our treasury, but it’s the Alaskans in … the off-road communities that are threatened to be hit most hard.”
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