Alaska

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

Published

8 months ago

July 10, 2025

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.

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.

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.

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.

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.

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Alaska

Alaska House advances bill to boost free legal aid for vulnerable Alaskans

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6 hours ago

March 2, 2026

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Alaska House advances bill to boost free legal aid for vulnerable Alaskans

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Alaska

Marten visits are a glimpse into mystery

Published

18 hours ago

March 1, 2026

Press Room

Marten visits are a glimpse into mystery

A trapper fresh out of the Cosna River country in Interior Alaska said he can’t believe how many martens he had caught in a small area so far this winter.

Friends are talking about the house-cat size creatures visiting their wood piles and porches. Could this be a boom in the number of these handsome woodland creatures?

Since the late 1970s, the University of Alaska Fairbanks’ Geophysical Institute has provided this column free in cooperation with the UAF research community. Ned Rozell is a science writer for the Geophysical Institute. Portions of this story appeared in 2000.

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Alaska

Alaska Sports Scoreboard: Feb. 28, 2026

Published

1 day ago

March 1, 2026

Press Room

High school

Basketball

Girls

Monday

Kenai Central 63, Nikiski 33

Colony 68, Grace Christian 46

Tuesday

South 33, East 22

Service 62, Dimond 47

Redington 47, Houston 17

Wasilla 60, Mountain City Christian Academy 44

Kenai Central 54, Homer 27

Bartlett 53, Chugiak 29

Mt. Edgecumbe 59, Sitka 50

Wednesday

Shishmaref 82, Aniguiin 34

Shaktoolik 73, Anthony Andrews 25

Savoonga 61, White Mountain 56

Glennallen 68, Nenana 26

Seward 72, Houston 8

Service 65, South 26

Brevig Mission 65, Koyuk Malimiut 47

Chief Ivan Blunka 67, Manokotak 30

Thursday

White Mountain 76, Anthony Andrews 50

Hoonah 44, Skagway 21

Koyuk Malimiut 53, Aniguiin 51

Nunamiut 74, Kali 17

Glennallen 25, Delta 20

Birchwood Christian 42, Nanwalek 24

Ninilchik 33, Lumen Christi 30

Dimond 59, Chugiak 54

Shaktoolik 57, Savoonga 24

Colony 43, Mountain City Christian 41

Alak 67, Meade River 66

Lathrop 42, West Valley 34

Seward 78, Nikiski 32

Grace Christian 56, Soldotna 41

Kenai Central 56, Houston 10

Wasilla 72, Palmer 27

Bristol Bay 55, Chief Ivan Blunka 30

Nome-Beltz 33, Bethel 24

Scammon Bay 46, Ignatius Beans 28

Aniak 83, Akiachak 45

Shishmaref 53, Brevig Mission 51

Metlakatla 64, Haines 21

Friday

Chief Ivan Blunka 68, Togiak 38

Meade River 80, Nuiqsut Trapper 34

Nunamiut 68, Alak 50

Cook Inlet Academy 33, Birchwood Christian 32

Meade River 71, Kali 46

Kalskag 62, Akiachak 47

Hoonah 39, Kake 37

Soldotna 36, Palmer 23

Delta 54, Valdez 45

Unalakleet 61, Chevak 45

Minto 46, Hutchison 26

West 71, Bartlett 65

Seward 63, Homer 19

North Pole 61, West Valley 25

Newhalen 78, Chief Ivan Blunka 40

Birchwood Christian 43, Nanwalek 28

Bethel 42, Nome-Beltz 35

Aniak 65, Tuluksak 50

Scammon Bay 49, St. Mary’s 38

Monroe Catholic 84, Galena 42

Ketchikan 57, Redington 24

Meade River 69, Alak 62

Fort Yukon 60, Jimmy Huntington 19

Grace Christian 50, Kenai Central 45

Shaktoolik 44, Shishmaref 34

Wrangell 44, Petersburg 31

Saturday

Unalakleet 41, Chevak 37

Meade River 54, Nunamiut 51

Monroe Catholic 68, Galena 32

Newhalen 32, Bristol Bay 26

Cook Inlet Academy 65, Birchwood Christian 32

Soldotna 55, Palmer 42

Nunamiut 48, Meade River 46

Boys

Sunday

SISD 51, Yakutat 18

Monday

Eagle River 54, Birchwood Christian 52

Colony 69, Grace Christian 64

Kenai Central 68, Nikiski 30

Tuesday

Susitna Valley 48, Lumen Christi 46

Dimond 54, Service 47

South 50, East 46

Houston 53, Redington 40

Wasilla 63, Mountain City Christian Academy 50

Kenai Central 74, Homer 47

Chugiak 66, Bartlett 45

Wednesday

SISD 59, Yakutat 17

Shishmaref 85, Savoonga 45

Hydaburg 58, Hoonah 51

Shaktoolik 103, Martin L Olson 49

Skagway 68, Gustavus 24

Davis-Romoth 108, Kobuk 31

Klawock 68, SISD 27

Glennallen 61, Nenana 57

Gambell 46, James C Isabell 31

South 63, Service 60

Seward 81, Houston 73

Bristol Bay 80, Chief Ivan Blunka 61

Mt. Edgecumbe 68, Sitka 59

Scammon Bay 79, Ignatius Beans 34

Brevig Mission 73, Aniguiin 67

Thursday

Savoonga 69, James C Isabell 61

Hoonah 64, Yakutat 45

Alak 88, Meade River 38

Shaktoolik 110, Brevig Mission 30

Chief Ivan Blunka 62, Tanalian 39

Nunamiut 66, Kali 48

Davis-Romoth 91, Buckland 45

Ninilchik 83, Lumen Christi 38

Monroe Catholic 43, North Pole 42

King Cove 57, Bristol Bay 41

Metlakatla 52, Haines 46

Nome-Beltz 62, Bethel 45

Skagway 79, Angoon 30

Birchwood Christian 69, Nanwalek 63

Dimond 60, Chugiak 57

Colony 75, Mountain City Christian Academy 49

Wasilla 66, Palmer 40

Klawock 63, Hydaburg 49

Shishmaref 58, Gambell 47

Grace Christian 63, Soldotna 52

Seward 66, Nikiski 51

Kenai Central 61, Houston 48

Nuiqsut Trapper 64, Alak 51

West Valley 51, Lathrop 44

Akiachak 83, Akiak 64

Scammon Bay 62, Marshall 54

Friday

Hoonah 71, SISD 38

Hydaburg 61, Kake 50

Chief Ivan Blunka 73, Bristol Bay 68

Kali 63, Meade River 45

Nunamiut 80, Nuiqsut Trapper 62

Service 58, East 50

Angoon 61, Hoonah 56

Cook Inlet Academy 73, Birchwood Christian 34

King Cove 75, Newhalen 39

Petersburg 53, Wrangell 20

Skagway 46, Klawock 43

Metlakatla 50, Haines 42

Nome-Beltz 71, Bethel 43

Juneau-Douglas 67, Tri-Valley 45

Wasilla 73, Chugiak 43

West 83, Bartlett 36

Colony 73, Kodiak 32

Delta 62, Valdez 54

West Valley 72, North Pole 46

Palmer 57, Soldotna 47

Nenana 55, Cordova 53

Chief Ivan Blunka 63, Manokotak 48

Scammon Bay 67, St. Mary’s 54

Unalakleet 87, Chevak 64

Shaktoolik 73, Shishmaref 54

Saturday

Unalakleet 95, Chevak 44

Cook Inlet Academy 95, Birchwood Christian 50

South 73, Eagle River 35

Palmer 45, Soldotna 40

• • •

College

Hockey

Friday

UAF 2, UAA 0

Saturday

UAA vs. UAF (Late)

• • •

Women’s basketball

Thursday

UAA 79, Western Oregon 58

Saint Martin’s 99, UAF 59

Saturday

Western Oregon 73, UAF 58

UAA vs. Saint Martin’s (Late)

• • •

Men’s basketball

Thursday

Saint Martin’s 77, UAF 65

UAA 80, Western Oregon 59

Saturday

UAF 82, Western Oregon 74

UAA vs. Saint Martin’s (Late)

• • •

NAHL

Friday

Anchorage Wolverines 5, Chippewa Steel 4

Saturday

Anchorage Wolverines vs. Chippewa Steel (Late)

• • •

2026 Fur Rondy Frostbite Footrace

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2.5K Women

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