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.

Alaska Airlines will serve as the presenting sponsor of international call-ups, highlighting Reign players representing their countries on the world stage. The partnership will launch with storytelling and content campaigns celebrating these international achievements.

Fans can also look forward to surprise experiences during Reign FC home matches throughout the remainder of the season, including exclusive seat upgrades, giveaways and chances to win travel rewards to explore Alaska’s list of growing global destinations. Additionally, new programs launched by Alaska Airlines later this season will offer exciting ways for supporters to get rewarded.

As part of the partnership, Reign FC’s home match against San Diego Wave FC on August 29 will be presented by Alaska Airlines, showcasing the collaboration to fans and celebrating the shared commitment to growing the game and engaging the Seattle community.

The attention focused on the spectacle of state wildlife biologists flying around in helicopters shooting every grizzly bear they can find (186 killed so far plus 5 black bears and 20 wolves) on the calving grounds of the Mulchatna Caribou Herd in Southwest Alaska should not obscure the geographically much larger campaign against grizzly bears being conducted by the Alaska Department of Fish and Game and the Alaska Board of Game.

This war, often termed “intensive management,” is being conducted through decades of liberalized bear hunting regulations motivated by the desire to reduce bear numbers in the hope this will result in more moose and caribou for harvest by hunters (most of whom live in urban areas).

The Mulchatna program is officially defined as being “predator control” because it involves aerial shooting of bears by Fish and Game staff. The geographically much larger effort to reduce bear abundance using regulation liberalizations is not defined as predator control. This lawyerly sleight-of-hand by definition allows Fish and Game to misleadingly claim that predator control on bears (and wolves) is occurring only in the relatively small portions of Alaska where aerial shooting of bears is ongoing. The opposite is true using a commonsense definition of predator control, which is to achieve declines in predator numbers.

We are four retired Alaska Department of Fish and Game biologists who have published one or more peer-reviewed papers documenting this effort to reduce grizzly abundance through regulation liberalizations. We documented this in an area that represents approximately 76% of Alaska; the area where liberalizations of bear hunting regulations are most aggressive. This is everywhere except in Southeast Alaska, Kodiak, Prince William Sound and the Alaska Peninsula, where bears are large and are still managed for sustainable trophy harvests. It includes all areas where moose and/or caribou are common. Some elements of the liberalizations in this area include:

• Liberalized regulations in a Game Management Subunit a total of 253 times and made more conservative only six times. This contrasts dramatically with the pattern prior to passage of the Intensive Management law in 1994, when regulation changes were equally balanced between small tweaks in either direction.

• Increasing the bag limit from one bear every 4 years (everywhere in 1980) to 1 or two bears per year. In 2005, 5% of the area had an annual bag limit of 2 per year but this increased to 45% by 2020 and to 67% by 2025.

• Longer open hunting seasons to include periods when hides are in poor condition and bears are in dens. The whole area had hunting seasons totaling less than 100 days in 1975; by 2015, 100% of the area had seasons longer than 300 days (20% longer than 350 days).

•Grizzly bears could not be baited anywhere in 2010 but, by 2022, grizzlies could be baited in 75% of the area (essentially everywhere except north of the Brooks Range).

• In 1975, all resident hunters were required to purchase a $25 tag prior to hunting grizzly bears but this is now routinely waived everywhere.

• Regulations designed to incentivize killing more grizzlies even include allowing hunters to sell the hides and skulls of bears they kill (nowhere prior to 2010, 26% of the area in 2016 and 67% in 2025). Allowing these sales is, effectively, a bounty on bears and is contrary to one of the basic principles of the North American Model of Wildlife Conservation against the commercialization of hunted wildlife.

Throughout this entire area of our analysis, there has been only one scientific study with new information on grizzly bear numbers or trends. In Subunit 13A, Fish and Game biologists reported a decline in bear density of 25%-40% during 1998-2012; results from a follow-up ADFG study in the same area 5 years ago have not been analyzed. It is scientifically irresponsible to conduct a study like this with (in all likelihood) more than $200,000 of public funds expended and not analyze and report the results. Declines in grizzly bear density similar to or greater than those found in 13A have probably occurred throughout Alaska correlated with the regulation liberalizations (and documented increases in grizzly bear harvests). Nobody can say this for sure however, because the state has not done any studies. Short of avoiding extirpation, it is hard not to conclude that the BOG and the leadership of ADFG does not care what is happening to grizzly bear populations in most of Alaska.

This aggressive management of bears is largely driven by the 1994 Intensive Management Law (IM). This law set a wildlife management priority for human consumptive use of moose, caribou, and deer. Under the IM law, state managers are effectively required to conduct predator reduction efforts wherever hunter demands for more moose or caribou harvests exceed the supply.

Nowhere in Alaska since the passage of the IM law has there been any scientifically-documented “success” showing increased hunter harvests of moose, caribou or deer that is significantly correlated with the predator reduction programs. One of us (Sterling Miller) co-authored the only peer-reviewed paper on this topic since passage of the IM law; this paper concluded that 40 years of wolf and bear reduction efforts in GMU 13 were not correlated with increased hunter harvests of moose. We are saddened to see the agency in which we once proudly served the Alaska public now reduced to shooting bears (and wolves) from helicopters in some areas while misleading Alaskans about the true extent of the war on bears that is occurring in Alaska and its “effectiveness”.

Sterling Miller, PhD; John Schoen, PhD; Charles C. Schwarz, PhD; and Jim Faro, MS are retired research and management biologists for the Alaska Department of Fish and Game’s Division of Wildlife Conservation who have conducted research on bears and other topics in Alaska and elsewhere.

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