Boeing blames lack of paperwork for Alaska Air incident, prompting NTSB rebuke

Renton, Washington
CNN
–

For months, a lack of paperwork has hampered the investigation into how a door plug exploded on a 737 Max on an Alaska Airlines flight in January, making it difficult to figure out who made the near-tragic mistake. This week, Boeing revealed that the paperwork may have caused the problem in the first place.

It was already known that no documentation was found to show who worked on the door plug, which left the plane after reaching around 16 thousand feet in height, causing an uncontrolled decompression, which injured some passengers and even tore their shirts. .

But at a briefing for reporters at Boeing’s 737 Max factory in Renton, Washington, Boeing said a lack of paperwork is why the four bolts needed to hold the door plug in place were never installed before the plane left the factory in October. Workers who needed to reinstall the bolts never had the work order telling them the work needed to be done.

Without the bolts, the door plug incident was practically inevitable. Fortunately, it was not fatal.

It’s a sign of the quality problems on Boeing’s assembly lines that have become the focus of multiple federal investigations and whistleblower revelations, and the cause of delays in jet deliveries that are causing headaches for airlines and passengers around the world.

But Boeing may have faced even more trouble with regulators for releasing the details at this stage. The National Transportation Safety Board (NTSB) reprimanded Boeing on Thursday for releasing “nonpublic investigative information” to the media. It said in a statement that the company “flagrantly violated” the agency’s rules.

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

Boeing will no longer have access to information generated by the NTSB during its investigation, the agency said, adding that it was referring Boeing’s conduct to the Justice Department.

“As part of many NTSB investigations over the past decades, few entities know the rules better than Boeing,” the NTSB said.

In a letter sent to Boeing CEO Dave Calhoun on Thursday, NTSB Office of Aviation Safety Director Timothy LeBaron said this week’s media briefing was done without the regulator’s consent or knowledge.

“Boeing must take all reasonable steps to ensure that investigative information is protected from public disclosure,” he wrote. “Such disclosure or withholding of critical information from our investigators are flagrant violations of NTSB regulations.”

Boeing responded that it held the briefing in an effort to “take responsibility” and be transparent about its role in the incident. It said it “shared context on the lessons we learned from the January 5 accident.”

“We deeply regret that some of our comments, intended to clarify our responsibility for the accident and explain the actions we are taking, went beyond the NTSB’s role as a source of investigative information,” Boeing’s statement said. “We apologize to the NTSB and stand ready to answer any questions as the agency continues its investigation.”

The NTSB also criticized Boeing for declaring earlier this month that a rare and unsafe roll during a Southwest 737 Max flight in May was not due to a design or manufacturing error. The NTSB, which is investigating the incident, told Calhoun on Thursday that it had not yet made a decision and that Boeing and the NTSB should speak with one voice when making public statements.

Boeing said during Tuesday’s briefing that the reason Alaska Air’s door plug likely wasn’t stuck was because two different groups of factory workers were tasked with doing the work, with one removing and the other reinstalling the door plug as the plane was moving down the assembly line.

The first group of workers removed the door plug to fix problems with some rivets that were made by a supplier, Spirit AeroSystems. But they did not generate paperwork indicating that they had removed the door plug, along with the four screws needed to hold it in place, to do that work.

When a different group of workers put the plug back in place, Boeing said the workers did not think the plane would actually fly under those conditions.

Instead, they were just blocking the hole with the plug to protect the inside of the fuselage from the weather while the plane moved outside to a different area of ​​the factory complex. This group of employees usually does this type of temporary repair.

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

These employees probably assumed that documentation existed showing that the plug and screws had been removed and that the documentation would lead someone else down the line to install the screws.

But without the paperwork, no one on the assembly line knew that the door plug had already been removed, or that its screws were missing, Lund said. Removing a door plug after a plane arrives from Spirit AeroSystems rarely happens, Lund added, so no one knew the door plug needed attention.

“(The) permanent reinstallation is done by another team based on paperwork that shows what work is unfinished,” Lund said. “But there was no paperwork, so no one knew how to proceed.”

In fact, the plane flew for about two months with the door cover in place, despite the missing screws. But minutes after the Alaska Airlines flight took off from Portland, Oregon, on Jan. 5, the door plug blew, leaving a hole in the side of the plane. Passengers’ clothes and phones were ripped from them and thrown into the night sky. But fortunately, no passengers were seriously injured and the crew managed to land the plane safely.

The missing bolts were identified in preliminary findings by the National Transportation Safety Board, but that report did not assess blame for the accident. And a final report is not expected for a year or more. An NTSB spokesperson said the safety agency is continuing its investigation and will not comment on Boeing’s explanation for how the error was made.

The board released a preliminary report in February that said it found the screws were missing when it left the Boeing factory, but did not assess culpability. A final report is not expected for a year or more.

NTSB Chairwoman Jennifer Homendy testified about the lack of documents in congressional hearings since the preliminary report was released.

Boeing is addressing the problem by slowing down its assembly lines and ensuring that planes don’t move forward with problems, assuming those problems will be resolved later in the assembly process, Lund said.

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

“I am extremely confident that the actions we take” will ensure that every plane leaving this factory is safe, she added.

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