Boeing blamed missing documents for the Alaska Air incident, prompting NTSB condemnation

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This photo from the National Transportation Safety Board shows the exterior of the fuselage plug area of ​​Alaska Airlines Flight 1282 Boeing 737-9 Max in Portland, Oregon, after the door plug exploded 10 minutes into the Jan. 5 flight.


Renton, Washington
CNN

With documents missing from the 737 Max that lost a door plug on an Alaska Airlines flight in January, it’s not hard to figure out who made the near-tragic mistake. The documents may have caused the problem in the first place, Boeing revealed this week.

It is already known that no documents have been found to show who worked on the door plug. What was revealed this week at a press conference at Boeing’s 737 Max factory in Renton, Washington, was a lack of paperwork that required four bolts to hold the door insert in place before the plane left the factory in October. There was no work order telling the workers who had to reinstall the bolts what work to do.

Without the bolt, the door plug incident was inevitable. Fortunately, it’s not dangerous.

This is a sign of problems with the quality of work on Boeing assembly lines. Those problems have become the focus of several federal investigations and whistleblower disclosures, and the reason delays in jet deliveries are causing headaches for airlines and passengers around the world.

But Boeing still ran into trouble with regulators for releasing details at this point. The National Transportation Safety Board (NTSB) on Thursday reprimanded Boeing for releasing “non-public intelligence information” to the media. It said in a statement that the company had “flagrantly violated” the agency’s rules.

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“During a media briefing Tuesday about quality improvements … a Boeing executive provided investigative information and an analysis of previously released factual information. Both actions are prohibited,” the NTSB said.

Boeing no longer has access to information generated by the NTSB during its investigation, the agency said, referring Boeing’s conduct to the Justice Department.

“As a party to many NTSB investigations over the past decades, few companies know the rules better than Boeing,” the NTSB said.

Boeing did not immediately respond to CNN’s request for comment outside regular business hours.

During Tuesday’s briefing, there was a particular problem with the Boeing Alaska Air door plug, as two different crews at the plant were accused of performing the task, one removing and the other reinstalling the door plug while the plane was in transit. Assembly tax.

First team crews removed the door insert to address problems with some rivets made by supplier Spirit Aerosystems. But in order to do that work, they didn’t produce documentation indicating that the door insert was removed, along with the four bolts needed to hold it in place.

When a different crew put the plug back in place, Boeing says they didn’t think the plane would fly in that condition.

Instead, the hole was sealed with a plug to protect the interior of the fuselage from the weather as the aircraft moved outside. That group of employees often makes those kinds of ad hoc fixes.

“The doors crew closes before moving the airplane out, but it’s not their responsibility to install the pins,” said Elizabeth Lund, senior vice president of quality for Boeing’s commercial aircraft division.

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Those employees may have assumed that there was paperwork showing that the plug and bolt had been removed, and that the paperwork would prompt someone else down the line to install the bolts.

But without documentation, Lund said, no one else on the assembly line had a door plug removed or its bolts missing. Lund added that removing a door insert after a flight from Spirit Aerosystems is rare. So no one knows that the door insert needs attention.

“(Permanent) reinstallation is done by another team based on documentation that shows what work has not been completed,” Lund said. “But there was no documentation, so no one knew what was going on.”

The plane actually flew for about two months with the door plug on despite the lack of bolts. But minutes after an Alaska Airlines flight took off from Portland, Oregon on Jan. 5, a door plug exploded, leaving a gaping hole in the side of the plane. Passengers’ clothes and phones were ripped from them and sent flying into the night sky. But luckily none of the passengers were seriously injured and the crew was able to land the plane safely.

The National Transportation Safety Board’s preliminary findings identified the missing bolt, but the report did not assess blame for the crash. And the final report is not expected for another year or so. A spokeswoman for the NTSB said the safety agency was continuing its investigation and would not comment on Boeing’s explanation for how the mistake was made.

The board issued a preliminary report in February that said it discovered the bolts were missing as they left the Boeing factory, but it did not assess culpability. A final report is not expected for another year or so.

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NTSB Chairman Jennifer Homandy has testified at congressional hearings about the missing documents.

Boeing is solving the problem by slowing down the speed at which planes move along assembly lines, and making sure planes don’t move forward with problems under the assumption that those problems will be fixed later in the assembly process, Lund said.

“We have slowed down our factories to ensure it is under control,” he said.

“I am very confident that the measures we have taken will ensure that every aircraft that leaves this factory is safe,” he added.

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