​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.

​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.

It's time for Boeing to end.
It's a hazardous organization. The more they get away with, the more they are going to cut corners.

​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.

​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.

​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.

​FAA cited for ineffective oversight of Boeing’s known recordkeeping issues

WASHINGTON (June 24, 2025) — The National Transportation Safety Board Tuesday said the probable cause of last year’s in-flight mid-exit door (MED) plug blowout on a Boeing 737 MAX 9 was Boeing’s failure to “provide adequate training, guidance and oversight” to its factory workers.

The NTSB also found the Federal Aviation Administration was ineffective in ensuring Boeing addressed “repetitive and systemic” nonconformance issues associated with its parts removal process.

The NTSB also concluded that in the two years before the accident, Boeing’s voluntary safety management system, or SMS, was inadequate, lacked formal FAA oversight, and did not proactively identify and mitigate risks. The investigation found that accurate and ongoing data about overall safety culture is necessary for an SMS to be successfully integrated into a quality management system.

On Jan. 5, 2024, the Boeing 737-9, operated as Alaska Airlines flight 1282, was climbing through 14,830 feet about six minutes after takeoff from Portland, Oregon, when the left MED plug departed the airplane. During the rapid depressurization, some passengers’ belongings were sucked out of the airplane, oxygen masks dropped from the overhead passenger service units, and the door to the flight deck swung open, injuring a flight attendant. In addition to the flight attendant, seven passengers received minor injuries. The two pilots, the other three flight attendants and the remaining 164 passengers were uninjured. The flight was destined for Ontario, California.

“The safety deficiencies that led to this accident should have been evident to Boeing and to the FAA — should have been preventable,” NTSB Chairwoman Jennifer Homendy said. “This time, it was missing bolts securing the MED plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.”

The MED plug was found in a Portland neighborhood two days after the accident. When investigators examined the recovered plug, they found evidence that the four bolts needed to secure the plug were missing before the accident occurred. Without the bolts, NTSB investigators found the unsecured plug “had moved incrementally upward during previous flight cycles” until it departed the airplane during the accident flight.

The airplane had been delivered to Alaska Airlines three months earlier. Investigators determined that the door plug was opened without the required documentation in Boeing’s Renton, Washington, factory on Sept. 18, 2023, to perform rivet repair work on the fuselage. The door plug was closed the following day. While Boeing’s procedures called for specific technicians to open or close MED plugs, none of the specialized workers were working at the time the door plug was closed. The absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred.

The investigation also highlighted the need for additional training on flight crew oxygen masks and their communication systems and the need for greater voluntary use of child restraint systems by caregivers of those under two years of age.

The NTSB issued new safety recommendations to the FAA and Boeing. Previously issued recommendations were reiterated to the FAA, Airlines for America, the National Air Carrier Association and Regional Airline Association.

The executive summary of the report, including the findings, probable cause and safety recommendations, is available online​. Additional material, including the preliminary report, previously issued safety recommendations, news releases, the public docket, investigative updates and links to photos and videos, is available on the accident investigation webpage.

The final report will be published in the coming weeks on NTSB.gov.