The National Transportation Safety Board has issued new safety recommendations to the Federal Aviation Administration and Boeing following the 2024 incident in which a door plug flew off in the middle of an Alaska Airlines flight.

“An accident like this only happens when there are multiple system failures,” NTSB chair Jennifer Homendy said at a meeting on Tuesday, partly blaming Boeing’s safety processes for the incident.

Homendy led the investigation into what happened before the door panel blew out six minutes into Alaska Flight 1282 that took off from Portland on Jan. 5, 2024. The aircraft was at about 16,000 feet over Oregon during a trip to California when it had to make an emergency landing. Four bolts meant to hold the Boeing 737 Max 9 door plug in place were missing, the NTSB discovered after the fact.

“The safety deficiencies that led to this accident should have been evident … to Boeing and to the FAA … and were therefore preventable,” Homendy said at the meeting Tuesday.

The accident left a gaping hole in the plane that had 177 people on board; eight of them suffered minor injuries.

In the NTSB’s report, investigators said the incident’s probable cause was in the in-flight separation of the left mid exit door plug, blaming “Boeing‘s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that 4 the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled.”

Investigators also faulted the FAA for the agency’s oversight.

“Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process,” the report said.

In a statement, the FAA said it is taking the NTSB’s safety recommendations seriously and will carefully evaluate the ones issued Tuesday.

“The FAA has fundamentally changed how it oversees Boeing since the Alaska Airlines door-plug accident and we will continue this aggressive oversight to ensure Boeing fixes its systemic production-quality issues,” the FAA’s statement said. “We are actively monitoring Boeing’s performance and meet weekly with the company to review its progress and any challenges it’s facing in implementing necessary changes.”

The FAA also said its safety inspectors are in Boeing’s facilities conducting more targeted audits and inspections. However, the agency said it has not lifted the 737 monthly production cap it has placed on Boeing until the FAA can confidently say Boeing can maintain the safety and quality of its aircraft.

“We at Boeing regret this accident and continue to work on strengthening safety and quality across our operations. We will review the final report and recommendations as we continue to implement improvements,” a spokesperson for Boeing said Tuesday following the NTSB meeting.

When the 737 Max involved in the accident was being manufactured, Boeing removed the door panel to make repairs to rivets nearby, according to the NTSB’s report. Paperwork that would have triggered additional inspections was never created and the panel was reinstalled without its bolts — and the team that did the work had never opened that type of door panel.

When asked whether all of it can be blamed on human error on the manufacturing floor at Boeing, Homendy told CBS News there needed to be a design change or a better process.

“It is due to a process issue, a process failure. A lot of people have focused on one or two Boeing personnel or door plug personnel. I think we have to really step back and look at the entire process was reliant on humans to set to put in a record that the door needed to be removed and put back in place,” she said.

Shandy Brewer was sitting in Row 10 on the flight when the door blew off. It was an experience that stuck with her 18 months later.

“All of a sudden, just this huge bang happened. It sounded like a firework going off, like right in your ears, just like so loud,” she recalled. “As soon as I step onto an airplane, tears start pouring down my face every single time. I haven’t been on a flight where that doesn’t happen.”

Brewer is among a group of 35 passengers who have filed a lawsuit against Boeing and Alaska Airlines in King County, Washington, where Boeing is headquartered. The companies have previously declined to comment on other lawsuits over the incident.

“The NTSB confirmed what we already suspected – Boeing’s quality control was woefully sloppy, and the FAA failed as a watchdog,” Brewer’s lawyer, Mark Lindquist, told CBS News in a statement. “Now it’s time for Boeing to accept responsibility, fix their issues, and move forward. We all want to feel safe when we board a Boeing plane.”

Despite the failure, Homendy said she feels like Boeing airplanes are safe, adding that she has “no concerns” about that. However, she said there are ways to improve safety.

“We found that in our investigation and we hope to help them close any gaps that remain,” Homendy said.

The NTSB’s new safety recommendations to the FAA include:

• Revising its compliance enforcement surveillance system, audit planning activities, and records systems
• Developing guidance and provide recurrent training to managers and inspectors
• Retaining historical compliance enforcement and audit records older than 5 years
• Convening an independent third-party panel to conduct a comprehensive review of Boeing’s safety culture

In a statement, U.S. Transportation Secretary Sean Duffy blamed the prior administration and Boeing for taking “their eye off the ball.”

“They were distracted and safety was put at risk. That can never happen again,” Duffy said. “Under this new administration, safety is paramount and it drives everything we do. Whether it’s building an all-new air traffic control system or ensuring Boeing and other manufacturers are delivering safe products, we will not hesitate to implement changes.”

In response to the NTSB meeting Tuesday, Alaska Airlines said: “We look forward to reviewing the final report in the weeks ahead. We remain deeply grateful for the heroic actions of the crew of Flight 1282 and will continue ensuring safety is always Alaska Airlines’ highest priority.”

Sarah Ploss

contributed to this report.