“Federal investigators said that Boeing's failure to provide adequate training, guidance and oversight for its manufacturing operations was to blame for the door plug that flew off a Boeing 737 MAX plane last year.
The National Transportation Safety Board also found that ineffective regulatory enforcement contributed to the accident, which terrified passengers and crew on an Alaska Airlines flight year but didn't result in any deaths or serious injuries.
Boeing is still grappling with fallout from the incident, which led to more stringent federal oversight of Boeing's manufacturing operations and leadership changes at the company.
The NTSB held a public meeting Tuesday to share findings of its investigation into the door plug blowout.
"An accident like this only happens when there are multiple system failures," NTSB chairman Jennifer Homendy said at the meeting.
The door plug left Boeing's factory in Renton, Wash., without four bolts needed to keep its fuselage panel in place.
The panel had shifted upward during prior flights the aircraft made after it went in service, but not enough for crew to notice during preflight walkarounds, NTSB investigators said. They determined that even one properly installed bolt at the bottom of the panel would have held it in place. It was supposed to have four for redundancy.
The investigators noted problems with several of Boeing's processes, including worker training and repair documentation. For example, workers didn't document the door plug work, so there is no final determination on who removed the panel, investigators said.
At the time of the accident, Boeing had 24 technicians working on doors at its Renton factory, investigators found. Of those technicians, only one had experience opening a door plug in the past, and he was on vacation during the time of the service.
The NTSB also highlighted ineffective oversight from the Federal Aviation Administration. At the time of the accident, the FAA only maintained records dating back five years, which meant it wasn't properly auditing systemic issues related to removals, the investigators said.
The investigation didn't find any issues with Alaska Airlines' preflight inspections.
The FAA said it has fundamentally changed how it oversees Boeing since the door-plug incident and will continue aggressive oversight, including weekly meetings with the company to review progress.
Boeing said it would review the NTSB's final report and recommendations as it keeps making improvements. "We at Boeing regret this accident and continue to work on strengthening safety and quality across our operations," the company said.” [1]
1. Boeing And FAA Faulted in Door-Plug Blowout. Pohle, Allison. Wall Street Journal, Eastern edition; New York, N.Y.. 25 June 2025: B1.
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